1. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Improving Care of Adult Patients Undergoing Cardiac Surgery LUMC CV-Surgical Team

2. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM LUMC CV-Surgical Team Surgeons Nurse Practitioners CV Anesthesia CV O.R. Staff 2-Surgical ICU-Staff 3 NEWS-Telemetry Staff Cardiac Rehab Staff Positive Surgical Outcomes Respiratory Care

3. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Identify the Problem……. Historical trend of coronary artery by-pass (CABG) surgery complication and mortality rates that were higher than desired, even after the data was adjusted for the severity of the patients’ illness..

4. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Solutions Implemented Aggressive Education of CV – Team –Physicians, Nurses, Respiratory Therapists Implementation of standing orders and integration into Electronic Medical Record (EMR) and Physician Order Entry (POE) Systems Monitoring and sharing of results with all team members Early ambulation after surgery Early extubation protocol Nurse Practitioner coordination of project

5. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Solutions - Example: Early Extubation Protocol Extubation protocol was developed to establish common team expectations Patients were re-warmed after surgery by the OR team Use of sedation medication was reduced so that patients were more alert Pain management was improved

6. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Solutions – Example - Early Extubation Results CABG Patients on a Ventilator for 4 hours or less

7. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Solutions – Example - Early Extubation Results UHC CABG Time on a Ventilator

8. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Keys to Success Multidisciplinary QI Team DRG Specific Cost Initiatives Post-op Primary CV Surgical Service Dedicated Nurse Practitioner Model Consolidated Patient Placement 3W Telemetry Dedicated Anesthesiology – 24 Hr. ICU Post-Operative Patient Management Early Awareness, Recognition and Prevention of Post-Op Complications Ventilator Weaning/Early Extubation Protocol Resident Accountability

9. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Results

10. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Results Significant improvement from 4Q 1999 – 3Q 2000 to 3Q – 4Q 2001 Mean LOS – 9.49 Days Mean Cost per Case - $24,511 Mortality – 0.6% (0/E 0.15) identified as best performer in institutions performing >100 CABG procedures

11. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Coronary Artery By-Pass Surgery Length of Stay, Case Cost and Mortality Observed to Expected (O/E) Ratios O/E Ratio of less than 1.0 is desirable

12. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Coronary Artery By-Pass Surgery Risk Adjusted Operative Mortality Trends

13. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Cardiac Surgery Pre-procedure Co-morbidity CY 2001 Higher percent of co-morbidities indicates patients who were sicker prior to surgery

14. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Cardiac Surgery Pre-procedure Co-morbidity CY 2001

15. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM What are our ongoing challenges? Managing 100% patient census and capacity issues Monitoring quality outcomes Keeping abreast of new technology in cardiovascular surgery Maintaining cost effectiveness Meeting the expectations of our patients