Knoxville facilities attain extubation goal, save $2.5 million
Overall quality of open-heart services improved along the way
The cardiology teams serving two Knoxville, TN, facilities learned recently that through sharing information with other organizations they were able to attain major breakthroughs in the overall quality of their open-heart services.
According to Pauletta Thomas, RN, senior nursing executive in the Cardiac Special Services department of Fort Sanders Parkwest Medical Center in Knoxville, these facilities’ improvements are a direct result of the information and experience gained by her team through Fort Sanders Parkwest’s participation in a program run by the Institute for Healthcare Improvement (IHI) in Boston.
Fort Sanders Parkwest and Fort Sanders Regional Medical Centers, two major hospitals within the Covenant Health System, are anticipating saving $2.5 million due to the extubation project. "We could end up showing a savings of about $1.5 million after the first year," says Thomas.
The project paid off in terms of patient satisfaction as well, because the length of time that patients stay in the ICU is important to them.
"One of patients’ greatest fears when they contemplate CABG surgery," says Thomas, "is being intubated, because they cannot communicate. They are so glad when we remove their tubes!"
Also the patients feel better hemodynamically when they are taken off weaning drugs. Prior to the project, patients were on dopamine or dobutamine, or combinations, and nitroglycerine. Most of the patients are coming back now with just nitroglycerine.
Thomas, along with open-heart surgeons Michael Maggart and Robert Helsel, compared notes with 40 other organizations late last fall on how to accelerate efforts to improve outcomes in cardiac surgery. "We learned how to identify needs, recognize and handle obstacles, and rapidly implement changes," says Thomas. She says they learned from the successes and failures of others.
Maggart and Helsel practice at Fort Sanders Parkwest and Fort Sanders Regional. Both facilities were involved in the study, but it started at Parkwest with an initial goal of improving the quality of care for open-heart patients, therefore reducing costs. Both physicians benefited from working together and participating in this project, says Thomas — it gave them good publicity and increased their referrals.
"We attended the IHI conference where 240 participants from 44 institutions shared information. Beginning with the plan-do-study-act’ model, we broke out into planning sessions. Then, on an ongoing basis, we reported our progress and shared information," she says. The groups met three times over an 18-month period and developed an understanding of the model — how to use and expand on it.
Goal: Extubate in less than six hours
The main objective of the Fort Sanders project was to extubate all CABG patients in less than six hours. Along the way, the team accomplished significant related improvements, including a reduction in length of stay in intensive care, a reduction in surgical complications, and improvements in the management of pain.
"To extubate patients in under six hours," says Thomas, "was a simple, direct, clear, and measurable goal." When they started, the team consisted of Thomas and the two surgeons, then they added an anesthesiologist, a couple of ICU nurses, and lab personnel. They began by defining extubation time as the average time from the moment a patient is admitted to the ICU to the moment tubes are removed. They realized they also needed to look at reintubations and pulmonary complication rates.
Thomas says their first test of change related to anesthesia management. Patients cannot be extubated when they are sedated, so the team had to establish a protocol on lowering sedative dosages. That anesthesia piece is especially important, says Kathy C. Fox, MSN, RN, the cardiac service line director at St. Francis Hospital in Beech Grove, IN. She says six hours is a reasonable goal.
Debra Caskey, RN, administrative director of cardiovascular services for The Jewish Health System of Cincinnati, agrees.
"Some institutions have brought extubation time down to as short as four hours," she says, "but they are probably pushing the envelope."
Fox says when some teams have tried to take patients below six hours, they found some were having surgery recall — they remembered some things that happened on the operating table. "That should not happen," she says. "The type of anesthesia you use determines success in short extubation, she says. Both Fox and Caskey say that their facilities extubate at six hours now, too, except when there are extenuating circumstances. (See article at left on late arrivals.)
"The patient’s comfort level and history add into this as well," says Caskey. "If they are smokers or have a history of respiratory problems, we keep them intubated overnight and extubate early in the morning."
"Once we had the anesthesia piece under control," Thomas says, "we had to deal with the pain control piece." If patients are extubated early, their pain needs special management. "Nurses, physicians, and anesthesiologists all worked together to come up with a plan for the pain management piece and the weaning protocol."
Last came the education piece. "Because patients were leaving the hospital earlier than before, we needed to make sure they had the information they needed," says Thomas. She explains that Knoxville’s average literacy rate is about sixth-grade level, so the team developed a picture pathway for in-house education.
The team met on a monthly basis to discuss various issues and concerns and establish roles, responsibilities, and accountabilities. "If there was a problem, we took care of it," says Thomas. "We were doing wonderfully well."
At first the project included only elective coronary artery bypass graft (CABG) patients, but "they were doing so well that we included everyone in the study. We began managing all CABG patients alike and tried to extubate them early regardless of whether or not they were elective."
Managing resistance: Send them on a trip
Cost Management in Cardiac Care asked Thomas how they dealt with any obstacles to the project, whether there were hesitation on the part of the staff or other problems. She says when the team encountered resistance to the project, they would hold a special meeting with the cardiac nursing staff, administration, physicians, open-heart surgeons, and anesthesiologists, and talk over the problem.
"The collaboration of administration is very important," she says. Attract their attention, and keep them interested. "Senior-level administration has to be on board or it won’t work."
Apparently, the team did that well because members of Fort Sanders’ quality council said they believed in the project and that it was "near and dear to their hearts." Periodically, the council wrote letters and stayed close to the project. "Physicians knew the administration was looking at them in this project," says Thomas, "and they need that — they need to know administration is watching."
At their meetings, the team encouraged everyone to talk openly about their concerns and the group would discuss them. All the team members went away with a clear understanding of where they were and where they were headed. Everyone knew they were all working together.
The team held a lot of informal meetings, too. "We’d gather around some new data and talk about our outcomes," Thomas says. "We posted data on an ongoing basis. That way the anesthesiologists and physicians and nurses had constant feedback on the project."
There was some staff resistance to the project’s goal. Some thought it might not be achievable. "One special way we dealt with that," explains Thomas, "was to show that extubation in under six hours was possible. We sent a couple of nurses, anesthesiologists, and a surgeon to an institution in Temple, TX, that was extubating early."
Scott & White Clinic and Hospital in Temple, TX, is one of America’s largest multispecialty group practices with a 515-physician clinic, a 486-bed hospital, and a health plan that supervises the care of more than 163,000 central Texans.
After that site visit, the team members became excited about being a part of the project. They saw it could work, and that patients weren’t going to die or even have to be reintubated. "In fact, they saw that patients do really well on short extubation," says Thomas.
The project involved totally changing some standards of care. "We looked at our existing standards of care and saw that there was some miscommunication about them," says Thomas. "We talked about that. We said, Here are the ways that you as nurses should treat these patients. Let’s change the standard of care. Let’s change the routine orders.’"
Once they had the new standards in place and saw that they worked, they realized the new approach was better.
What is the most important factor when you want to make changes? Thomas offers this recipe for success: "A mixture of open, honest communication, frequent meetings, talking about issues and concerns, finding ways to solve problems, and not taking forever to do it. People need to have a clear understanding of where they’re at, where they’re going, and who’s responsible for getting them there."
She says sometimes it helps not to have a perfect process in mind at the beginning. "Go slow. You begin to make small, safe tests of change so everybody is comfortable. Study what you’ve done. Study your process and take action and improve based on what you find. Every time you study the results, you’ll find another avenue and process of improvement. They build on one another."
Thomas says to develop a plan you should ask, How can we address these issues? Who’s accountable?’
"You can’t develop a perfect pathway right away," she says. "Sometimes, when you try to do things too quick, even if you know it doesn’t work, you’ve spent so much energy, no one wants to change it. Instead, begin basic. Build on it, and you could end up with a perfect product."
Fort Sanders Accomplishes Extubation Goal
Bypass graft patients extubated within 6 hours
• Length of stay in the intensive care unit (ICU) was reduced by 36%.
• Anesthesia protocol and sequencing are standardized. Smaller, more frequent morphine doses are given by ICU nurses to avoid oversedation.
• Extubation process is standardized through rapid weaning.
• Post-op pain management standards were revised. Pulmonary complications were reduced by 12% overall.
• Patients are reintubated less than 24 hours after extubation.
Pauletta Thomas, RN, senior nursing executive in the Cardiac Special Services department of Fort Sanders Parkwest Medical Center in Knoxville, TN, points out, "It’s very important to us to maintain our gains, and we’ve been successful."
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