Hospitals tune up cardiac care through blind dates’
Learning from facilities that aren’t a perfect match
Most benchmarking programs allow hospitals the freedom to compare themselves to facilities that are like them in some way. They might serve similar size communities or do procedures in about the same proportions.
Perhaps, one hospital looks at another because they treat the same percentages of Medicare patients. But in Minnesota, a statewide peer review program links up hospitals randomly, and the results have been just as positive.
Sandee Carlson, RN, MA, director of cardiothoracic surgical services at SMDC Health System and St. Mary’s Hospital in Duluth, is going through its third such blind date. And there is probably little chance that the hospital it is paired with this year will be like it. "We are the third-largest heart center in the state," she explains.
The peer review program started through the Minneapolis-based Minnesota Society of Thoracic Surgeons six years ago. "Part of it was that we compare our data blinded. But then they decided to do site visits. Each hospital in Minnesota is assigned a partner every two years."
The hospitals’ staff sit down in advance of the visits and talk about issues they want to explore. The last time Carlson went through the process, one issue St. Mary’s wanted to investigate was intubation times. "We knew from the blinded data that our times were longer than anywhere else, and we had known that for a couple years."
Although administrators and physicians knew it was something they wanted to work on, "we didn’t realize immediately that if you want to make a change, you need a process. We thought by just concentrating on it, it would get better," says Carlson.
Other issues to cover in the last site visit were wounds and same-day admissions. "The nice thing was that the other hospital was interested in some of the same things," says Carlson. "It was also working on turnaround times in the operating room [OR] and had already started working on extubation."
That facility was at six hours and wanted to get to four, she adds. "We were at 17 hours, had declined to 13, and wanted to get to six."
Despite the fact that the hospitals are not handpicked, the site visits bring an element of peer pressure to physicians who might not have embraced process changes as enthusiastically as some might wish, Carlson says. "That can help to reinforce data."
Revamping extubation
The whole cardiac team went to the site visit: the lead physician, Carlson, an anesthesiologist, a surgical assistant, a member of the OR staff, and a member of the inpatient unit. There were 10 people on the trip. "It’s very helpful. Trying to sell someone on change with words isn’t as instructive as a field trip."
After watching how others ran their show, Carlson says her team returned and created a quality improvement steering committee. It flowcharted the processes and looked at how things were done currently. "Then we identified the issues we wanted to concentrate on, such as extubation times."
To revamp the extubation protocol at St. Mary’s, Carlson put together a team that included herself, a respiratory therapist, a surgical ICU nurse, and an anesthesiologist. The goal was to create, present, and implement the change within 60 days.
In the old process, a patient underwent surgery, stayed overnight, and had the tube removed the next morning. "No one wants to wake a patient up in the middle of the night for extubation," Carlson explains. "That is the most unstable time for a patient."
But as part of the old process, anesthesiologists medicated patients, and the nurses gave pain medication after surgery — a sure recipe for a sound sleep. "We had to change the way medications were delivered, opting for less and shorter-acting mediations," she says. "We worked hard with anesthesiologists to get them to standardize their practices. We asked the nurses to use less morphine. Now, patients are awake within a couple hours of surgery."
The team also created a tool for nurses to use that would report variances from the six-hour goal. The tool allows Carlson to look at variances by physician or by patient group, or those that occur due to systemic issues.
The tool includes what drugs were administered, how much, and when. There is also a space for the nurses to explain reasons why extubation didn’t occur — for instance, if a patient was hemodynamically unstable or too sleepy, or if there was no respiratory therapist available.
Once implemented, the change in extubation came fairly fast, says Carlson. "The new protocol was implemented in March 1997. By the next month, it was down from 13 hours to 9.2." Currently, the number is at 6.6 hours. "Once you make that first big leap, it takes a little longer to work the numbers down."
Carlson does have a reason for being above the goal. "We are seeing more and more sicker patients. We actually feel pretty comfortable where we are, and I don’t think we can push ourselves much lower. Perhaps if we sorted out those who were less sick, we could get it down to four hours. But I don’t want to better our time at the expense of what is best for patients."
Another statistic, re-intubation, helps Carlson stay positive about where the hospital is. "Our rates are less than 1% for re-intubation, and that is very very low."
The whole peer review process has been a positive experience, says Carlson. "There is always something to learn from our partners." What they will study this year remains up in the air. "We are implementing some new pathways soon, so maybe [we’ll study] that. Maybe, we’ll focus on cost or length of stay. Actually, our length of stay is fine, but you always wonder where you can improve."
[For more information, contact:
- Sandee Carlson, RN, MA, Director of Cardio-thoracic Surgical Services, SMDC Health System, Duluth, MN. Telephone: (218) 786-3670.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content