Article

Cardiothoracic Surgeon Management of Postoperative Cardiac Critical Care

Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Blalock 618, 600 N Wolfe St, Baltimore, MD 21287, USA.
Archives of surgery (Chicago, Ill.: 1960) (Impact Factor: 4.93). 11/2011; 146(11):1253-60. DOI: 10.1001/archsurg.2011.298
Source: PubMed

ABSTRACT

To determine whether postoperative cardiac care by cardiothoracic surgeons in a semiclosed intensive care unit model could be distinguished from that given by intensivists who are not board certified in cardiothoracic surgery.
From January 2007 to February 2009, we retrospectively examined data on patients after cardiac operations from 2 consecutive periods during which full-time management of intensive care was changed from noncardiothoracic intensivists (period 1, 168 patients) to cardiothoracic surgeons (period 2, 272 patients).
Variables measured included Society of Thoracic Surgeons observed and expected mortality, central venous line infections, ventilator-acquired pneumonia, red blood cell exposure, adherence to blood glucose level target at 6 am on the first and second postoperative days, length of stay, and intensive care unit pharmacy costs. Results were compared using a 2-sample t test or 2-tailed Fisher exact test.
In similar populations, as witnessed by equivalent Society of Thoracic Surgeons operative risk, cardiothoracic surgeons providing postoperative critical care led to a mean (SD) decrease in hospital length of stay from 13.4 (0.9) to 11.2 (0.4) days (P = .01) and decreased drug costs from $4300 (1000) to $1800 (200) (P < .001). These improvements occurred without losing benefits in other quality measures.
By virtue of their cardiac-specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. In a semiclosed unit where care of the patient is codirected, the improvements noted may have been facilitated by the commonalities between surgeons and intensivists associated with similar training and experiences.

Full-text

Available from: Hitoshi Hirose, Nov 09, 2015
ORIGINAL ARTICLE
Cardiothoracic Surgeon Management
of Postoperative Cardiac Critical Care
Glenn J. R. Whitman, MD; Michel Haddad, MD; Hitoshi Hirose, MD;
Jeremiah G. Allen, MD; Margaret Lusardi, BA; Maura A. Murphy, BA
Objective: To determine whether postoperative car-
diac care by cardiothoracic surgeons in a semiclosed in-
tensive care unit model could be distinguished from that
given by intensivists who are not board certified in car-
diothoracic surgery.
Design: From January 2007 to February 2009, we ret-
rospectively examined data on patients after cardiac op-
erations from 2 consecutive periods during which full-
time management of intensive care was changed from
noncardiothoracic intensivists (period 1, 168 patients)
to cardiothoracic surgeons (period 2, 272 patients).
Main Outcome Measures: Variables measured in-
cluded Society of Thoracic Surgeons observed and ex-
pected mortality, central venous line infections, ventilator-
acquired pneumonia, red blood cell exposure, adherence
to blood glucose level target at 6
AM on the first and sec-
ond postoperative days, length of stay, and intensive care
unit pharmacy costs. Results were compared using a
2-sample t test or 2-tailed Fisher exact test.
Results: In similar populations, as witnessed by equiva-
lent Society of Thoracic Surgeons operative risk, cardio-
thoracic surgeons providing postoperative critical care
led to a mean (SD) decrease in hospital length of stay from
13.4(0.9) to 11.2 (0.4) days (P=.01) and decreased drug
costs from $4300(1000) to $1800 (200) (P.001). These
improvements occurred without losing benefits in other
quality measures.
Conclusions: By virtue of their cardiac-specific opera-
tive and nonoperative training, cardiothoracic surgeons
may be uniquely qualified to provide postoperative car-
diac critical care. In a semiclosed unit where care of the
patient is codirected, the improvements noted may
have been facilitated by the commonalities between
surgeons and intensivists associated with similar train-
ing and experiences.
Arch Surg. 2011;146(11):1253-1260
E
VIDENCE SUGGESTS THAT CRITI-
cal care physicians (intensiv-
ists) make a significant differ-
ence in the care of the critically
ill, with reported
1
decreased
mortality, time to extubation, infectious
complications, and length of stay (LOS), as
well as increased use of quality indicators.
Furthermore, Leapfrog,
2
an organization
dedicated to ensuring patient safety and
evidence-based quality care, considers use
of intensivists to be one of their 7 key indi-
cators of hospital quality, reporting that hos-
pitals with intensivist-managed intensive care
units (ICUs) have as much as a 40% reduc-
tion in ICU mortality. However, not all stud-
ies have had similar findings, most notewor-
thy the report by Levy et al,
3
in which the
odds of hospital mortality were higher for
patients whose care was managed by criti-
calcare physicians. Specifically regardingcare
in the cardiac ICU, board-certified intensiv-
ists rarely have formal surgical training;
rather, their training is heterogeneous, with
specialty training in pulmonology, internal
medicine, emergency medicine, anesthe-
siology, and trauma. As surgeons of all
specialties would attest, postoperative man-
agement of a patient’s care begins in the op-
erating room, and complications can often
be best understood in the context of the spe-
cific operation performed. Therefore, it seems
reasonable that as intraoperative complex-
ity increases, the importance of surgical train-
ingfor postoperative care would also increase.
The field of cardiothoracic surgery is
notable for its protracted period of surgi-
cal training and unparalleled intraopera-
tive complexity. A tenet of the specialty
is that this training is necessary to learn
preoperative assessment, operative tech-
nique, and intricate postoperative man-
agement. Furthermore, public reporting
See Invited Critique
at end of article
Author Affiliations: Division of
Cardiothoracic Surgery,
Department of Surgery,
The Johns Hopkins Hospital,
Baltimore, Maryland
(Drs Whitman and Allen); and
Division of Cardiothoracic
Surgery, Department of Surgery,
Thomas Jefferson Medical
College, Philadelphia,
Pennsylvania (Drs Haddad and
Hirose and Mss Lusardi and
Murphy).
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has led to increased scrutiny of individual surgeons’ re-
sults, and although they cannot realistically control all
aspects of care (let alone ensure outcomes), surgeons are
held accountable. Cardiac surgeons have traditionally ac-
cepted this responsibility, overseeing their patients’ en-
tire hospital course. However, with the advent of inten-
sivist-staffed ICUs, much of the minute-to-minute decision
making has been taken out of the surgeon’s hands. In-
tensive care units previously under cardiac surgical su-
pervision have been converted to “closed” or “semi-
closed” units wherein patient care is either totally directed
or codirected by an intensivist. Despite reports
1
of ben-
efits associated with intensivist care, lack of cardiac sur-
gical training may represent an inherent flaw in this pa-
tient care model. Intensivists without cardiothoracic
training may be at a disadvantage when managing post-
operative care for these patients because of the unique
pathophysiologic factors resulting from complex opera-
tions, hematologic and metabolic perturbations that re-
sult from cardiac arrest and cardiopulmonary bypass, and
the myriad life-threatening perioperative complications
that manifest themselves rapidly.
In 2007, Thomas Jefferson University Hospital changed
management of postoperative care from pulmonary/
trauma critical intensivists to board-certified cardiac sur-
gery physicians in the surgical cardiac care unit (SCCU).
The purpose of this study was to determine whether this
change was associated with a measurable effect on post-
operative outcomes. The study was presented to the
Thomas Jefferson University institutional review board,
considered exempt, and approved.
METHODS
We conducted a retrospective analysis of data on patients re-
ceiving care after a cardiac operation in 2 consecutive periods
during which full-time intensive care management changed from
noncardiac surgeons (period 1 [P1], January 2007 to Septem-
ber 2007; 168 patients) to cardiac surgeons (period 2 [P2], Oc-
tober 2007 to February 2009; 272 patients). Analysis included
patients’ risks stratified by the Society of Thoracic Surgeons da-
tabase, including all coronary bypass, mitral and aortic valve, and
combined bypass/valve operations. Baseline preoperative pa-
tient characteristics showed no significant differences (
Table 1).
Comparisons included mortality; central venous line infection
(CVLI) and ventilator-acquired pneumonia (VAP), defined as
the number of infections per 1000 device-days; percentage of pa-
tients with red blood cell exposure (ie, receipt of packed red blood
cells [PRBCs]); 6
AM blood glucose level less than 200 mg/dL
(to convert to millimoles per liter, multiply by 0.0555) on post-
operative day (POD) 1 and POD2; postoperative and total LOS;
and ICU pharmacy cost per patient (drug cost).
Throughout the 26 study months, the SCCU was semi-
closed, with care codirected by intensivists and operating sur-
geons. During P1, SCCU intensivists included 3 pulmonary phy-
sicians and 1 surgical critical care physician. During P2,
intensivist care changed to 3 board-certified cardiac surgeons
(G.J.R.W., M.H., and H.H.); one of these surgeons (M.H.) is
also board certified in critical care.
During P1, the patient care team comprised 3 junior resi-
dents, which changed to 2 residents and a physician assistant
during P2. The residents, the physician assistant, the post-
graduate-year-4 resident rotating on the cardiothoracic ser-
vice, or a research resident provided night coverage. Over-
sight at night was conducted by telephone or direct supervision,
shared between intensivists and operating surgeons.
During P2, with the change in intensivists came a concerted
effort to improve the quality of care in the SCCU. Although qual-
ity assurance/performance improvement (QA/PI) had been an on-
going hospital process, a specific SCCU QA/PI initiative was spear-
headed by the SCCU director (G.J.R.W.) throughout P2. This plan
included monthly multidisciplinary meetings with representa-
tion from risk management, hospital administration, cardiac sur-
gery, anesthesiology, intensivists, pharmacy, respiratory therapy,
physical and occupational therapy, dietary, SCCU nursing, data
management (M.L.), and performance improvement (M.A.M.).
An agenda was determined and minutes were kept and distrib-
uted at each meeting; action items were delegated to specific mem-
bers of the team (
Figure 1).
A dashboard (given in the following tabulation) was created
by the QA/PI committee to highlight variables related to quality
within the SCCU to which metrics could be applied, allowing
quantitative assessment of the effect of various initiatives.
Length of stay (intensive care unit and total)
Cost of drugs (albumin, argatroban hydrate, darbepoetin alfa, recombinant
human b-type natriuretic peptide)
Packed red blood cell exposure
Coagulation factor exposure
Ventilator-acquired pneumonias
a
Central venous line–associated bloodstream infections
a
Checklist adherence
Hand washing adherence
a
http://www.cdc.gov/ncidod/dhqp/pdf/NNIS/NosInfDefinitions.pdf.
Dashboard maintenance was the responsibility of one per-
son (M.A.M.), who was given access to hospital databases and
appropriate personnel to ensure timely collection and report-
ing. Data on CVLI and VAP rates came from the hospital’s In-
fection Control Department, PRBC exposure from the Society
of Thoracic Surgeons database, blood glucose levels from the
hospital report for the Surgical Care Improvement Project, and
pharmaceutical costs from the pharmacy data system.
At the beginning of P2, a bedside checklist was introduced,
based on a postoperative pathway that described nursing care,
laboratory and other testing, medications, documentation, and
quality metrics (
Figure 2). The checklist was completed by
the intensivist team with the bedside nurse on admission of any
patient postoperatively and the morning and evening of each
POD. This checklist was designed by the QA/PI team to en-
sure uniform, high-quality care and was reviewed twice daily
(
AM and PM). For example, the checklist was used to deal with
Table 1. Patient Characteristics for Periods 1 and 2
Characteristic
No. (%)
P Value
Period 1
(n=168)
Period 2
(n= 272)
Male sex 125 (74) 190 (70) .42
Diabetes mellitus 53 (32) 89 (33) .68
CABG 102 (61) 188 (69) .09
Valve 44 (26) 57 (21) .25
Combined 22 (13) 27 (10) .30
Ejection fraction, mean 49.8 50.7 .55
BMI, mean 28.7 29.1 .60
Abbreviations: BMI, body mass index (calculated as weight in kilograms
divided by height in meters squared); CABG, coronary artery bypass graft.
Combined, combined bypass/valve operations; Valve, mitral and aortic valve
operation.
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the problem of infections, addressing VAP by including “HOB
[head of the bed] up 30°” and antacid therapy as checklist items,
having respiratory therapy develop a standard rapid weaning
protocol to decrease ventilator time, and instituting routine
mouth care and “sedation vacations.”
4
Our method to dimin-
ish CVLIs was to place on the checklist removal of the CVL
introducer on POD1.
Commercial software (SAS, version 9.1; SAS Institute, Inc,
Cary, North Carolina) was used for statistical analysis. The
2-sample t test was used for comparing continuous variables,
and
2
analysis and the 2-tailed Fisher exact test were used for
categorical variables, as appropriate.
RESULTS
MORTALITY
Mortality rates did not change significantly from P1 to
P2, with a mean (SD) of 3.1%(4.5%) vs 2.5%(2.8%)
(P =.15). Furthermore, the Society of Thoracic Sur-
geons observed to expected mortality ratio remained con-
stant at 1.17 (P=.80) between the 2 periods.
THE QA/PI COMMITTEE MEETINGS
A typical agenda (Figure 1) addressed issues for which re-
sponsible parties had been identified. Meetings occurred
biweekly until the group felt comfortable that progress
would continue with monthly meetings. The initiatives of
P1 invariably had an associated metric. For example,
Figure 3 shows our success with using the checklists dur-
ing rounds. Consistently collecting checklists proved to
be impossible, but the data showed that, although recov-
ery of checklists was variable, their use appeared to be im-
mediate between 80% and 100% of the time.
VAP AND CVLI
Although the difference was not significant, VAP rates
dropped from 7.6 per 1000 device-days to 4.2 per 1000
device-days (P=.19).The incidence of CVLIs (incidence
per 1000 device-days) also did not change significantly
between P1 and P2 (1.3 vs 1.6; P = .83) (
Figure 4).
PRBC EXPOSURE
We attempted to create a guideline whereby postopera-
tive administration of PRBCs would occur only if the he-
matocrit was less than or equal to 24% (to change to a
proportion of 1.0, multiply by 0.01). We recognized that
a better metric existed, eg, adherence to our protocol, as
measured by the incidence of PRBC transfusions when
the hematocrit was higher than 24%. However, re-
sources prevented that type of data capture. The post-
operative exposure to PRBCs between P1 and P2 was 32%
vs 37% (P=.28).
BLOOD GLUCOSE TARGET ADHERENCE
Our hospital’s Insulin Infusion Protocol was imple-
mented in the SCCU in June 2006, targeting a blood glu-
cose level between 100 and 140 mg/dL. Our improve-
ment between P1 (83%) and P2 (88%) was nonsignificant
(P=.19). We were troubled by our inability to better con-
trol hyperglycemia, as it was the only Surgical Care Im-
provement Project metric that did not improve to the top
10% of hospitals in the United States. This poor perfor-
mance was evaluated during P2 and resulted in an Insu-
lin Infusion Protocol modification to account for cer-
tain patient risk factors and to require its continuation
through POD2 if patients still required intravenous in-
sulin to maintain glucose control rather than transition
to subcutaneous insulin as a sliding scale, as deter-
mined by the caring intensivist on POD1.
5,6
PHARMACEUTICAL COSTS
At the commencement of P2, the QA/PI committee de-
termined that cost of care should be a quality measure.
With use of the hospital pharmacy database, we identi-
fied the following drugs as representing the greatest cost
with the greatest opportunity to minimize expenditures
without jeopardizing high-quality care:
1. albumin: routinely used for volume resuscitation;
2. recombinant human b-type natriuretic peptide:
treatment initiated occasionally as therapy for postop-
erative advanced heart failure;
3. argatroban hydrate: prescribed for postoperative an-
ticoagulation to avoid heparin-induced thrombocytope-
nia or to treat postoperative thrombocytopenia; and
4. darbepoetin alfa: used to decrease postoperative
transfusion rates.
SCCU QA/PI Committee
Typical agenda
Review of the minutes
1. CABG/valve checklist:
(a) Combine
(b) Collection
(c) Collate the data
G.J.R.W./M.A.M.
9. Dashboard:
CLV infections
VAP
SCIP data
Blood utilization
Time from transfer order to transfer of patient
Metrics from the pathway
SCD utilization
Time to extubation
M.A.M./E.M.
2. Implementation of new order sets in Last Word J.R./B.B./G.J.R.W.
3. Fentanyl drips after OHS S.G.
5. Extubation protocol B.G.
6. Postoperative transport and line management D.C.
7. Aspirin/clopidogrel bisulfate and Afib protocols M.D./G.J.R.W.
8. Nutrition initiation G.J.R.W.
4. Argatroban use: changing concentration to decrease waste
No. of patients and treatment days
S.G.
E.M.
Party responsible
Figure 1. Typical agenda of the SCCU QA/PI Committee with delegation of
projects to specific committee members. Afib indicates atrial fibrillation;
CABG, coronary artery bypass graft; CVL, central venous line; OHS, open
heart surgery; QA/PI, quality assurance/performance improvement;
SCCU, surgical cardiac care unit; SCD, sequential compression device;
SCIP, Surgical Care Improvement Project; and VAP, ventilator-acquired
pneumonia.
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Not a permanent part of the patient record
Privileged and confidential information
OPERATIVE DAY Patient plate
Date:
7a-7p
RN INITIALS
7p-7a N/ACABG CLINICAL PRACTICE GUIDELINE
Goals:
Normal thermic, No evidence of excessive bleeding, hemodynamically stable,
CT drainage within limits & adequate respiratory parameters.
Initials denote completion of intervention, Circled initials indicates intervention not completed.
Please return completed pathway to Abhi Rastogi in the Care Management Department
Goals:
Labs, EKG, X-rays within expected limits. Diabetics: glucose controlled
Cardiac & hemodynamic monitoring
Nasogastric/Oralgastric tube to suction
Notify house officer if temp >
101.5
Warming blanket for temp <
96 degrees F
SICU CT weaning/extubation protocol
Pulse check upon arrival and every 4 hours
CT output every 15 minutes
×
4 then every hour
Notify surgeon if CT drainage >
150cc/hr
If restrained, is physician order written?
Sequential compression device in place
Defibrillator pads removed
Pacer, Swan, A-line & chest tubes checked and proper working order
Dressings dry and intact (change dressings if saturated)
Chest x-ray upon arrival
EKG upon arrival
CBC, platelets, basic met, CK, PT, PTT, post-op
ABG and mixed venous gas upon arrival to the SICU
Glucose monitoring every 4 hours if on Epi. or PMH DM
H&H, PLT, PT, PTT PRN if bleeding
Continuous pulse oximetry
ABG 2 hours post-op and with any changes in minute ventilation
ASA 6 hours post-op as ordered
Nitroglycerin drip infusing
Vasopressor drips as ordered
Insulin drip as ordered glucose check every hour till stable
Prophylactic antibiotic given immediately post-op
250cc Normal saline IV bolus if MAP <
60, while notifying MD
D5W @ 10cc/hr via cordis
Analgesics as ordered
H2 blocker as ordered
Goals:
Teaching
RN Signatures
RN Signatures
RN Signatures
RN Signatures
RN Signatures
Maintain hemodynamic stability with meds as needed, afebrile, & pain free.
Review clinical practice guide with family
Daily contact made with family
Explain all procedures to patient/family
Correlate manual BP to A-line every shift, and document.
Epicardial pacing wires to pacer & tested in OR.
Head of bed elevated 30 degrees
VS every 15 minutes till stable then every 1 hour and as needed
Hemodynamic profile upon arrival and then every hour until stable.
(If PAD outside parameters, MAP <
60 or >
90, or CI <
2.2 call surgeon)
Urine output >
0.5cc/kg/hour: Notify surgeon if urine output less than this amount
times 2 hours.
AssessmentTestsMedications
Figure 2. The checklist: a tool to be used on rounds as a guideline for patient care, to standardize and maintain quality. ABG, arterial blood gases; ASA, aspirin;
BP, blood pressure; CABG, coronary artery bypass graft; CBC, complete blood cell count; CI, cardiac index; CK, creatine kinase; cordis, side port of the central
venous cannula; CT, chest tube; D5W, 5% dextrose and water; DM, diabetes mellitus; EKG, electrocardiogram; Epi, epinephrine; H&H, hemoglobin and hematocrit;
IV, intravenous; MAP, mean arterial pressure; MD, physician; met, metabolic panel; N/A, not applicable; OR, operating room; PAD, pulmonary artery diastolic
pressure; PLT, platelet; PMH, past medical history; post-op, postoperative; PRN, as occasion requires; PT, prothrombin time; PTT, partial thromboplastin time;
RN, registered nurse; SICU, surgical intensive care unit; VS, vital signs.
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During P2, the savings that resulted from targeting
these drugs was approximately $1600 per patient and rep-
resented 64% of the $2500 per patient in pharmacy sav-
ings (
Table 2 ). Although we did not break down costs
beyond the 4 drugs listed, it is remarkable that during
P2 an additional decrease of $892 in other pharmaceu-
tical expenses occurred.
LENGTH OF STAY
Our mean (SD) total hospital LOS for P2 decreased by
2.2 days, from 13.4(0.9) to 11.2(0.4) days (P=.01). Our
postoperative LOS, which dropped from 9.8(0.7) to 8.3
(0.3) days (P=.04), contributed 1.5 of these 2.2 days.
COMMENT
This study examined a variety of quality indicators com-
paring care between 2 consecutive cohorts of patients who
underwent open heart surgery when noncardiothoracic in-
tensivists vs intensivists board certified in cardiothoracic
surgery provided attending supervision. The hypothesis
questioned the impact of the specialty training of inten-
sivists caring for patients in SCCUs, with all 3 intensivists
being board certified in cardiothoracic surgery during P2.
Overall, the care provided did not differ significantly with
respect to mortality, CVLI, VAP, PRBC transfusions, or
blood glucose control. Significant differences were found
in postoperative LOS, as well as the cost of drugs. How-
ever, there were confounding differences in the focus of
care delivered between the 2 periods.
The SCCU QA/PI committee was instituted simulta-
neously with the change in intensivist leadership. Al-
though the hospital collected outcome measurements dur-
ing both periods, only during P2 was a concerted effort
made to present these data formally as part of the SCCU
dashboard. The committee involved a variety of hospi-
tal departments and was diligent regarding its agenda and
the assignment of specific individuals to their action items.
Most important, all areas of focus had associated met-
rics allowing assessment of performance improvement.
The committee recognized that continuous review of the
data was the sine qua non of performance improve-
ment
7-12
and that presentation of quantified outcomes is
a powerful tool in manipulating behavior.
8,13-16
A checklist used during rounds has been shown to be
a simple but effective tool in standardizing high-quality
care.
16-19
To improve the quality of care, the use of such
a checklist was instituted during P2. The dashboard met-
rics dealt with outcomes and the checklist addressed spe-
cific care issues (eg, keeping the head of the bed el-
evated 30°, twice-daily oral care while receiving
mechanical ventilation, early elimination of CVLs, or use
of the Insulin Infusion Protocol.
20
Nevertheless, as dem-
onstrated in Figure 3, simply making the checklist avail-
able at the bedside did not guarantee its use. However,
over time, with consistent presentation of quality met-
rics, the relevance of the checklist became apparent and
its use became routine. Although adherence to use of the
checklist was 100% on POD1, it did not reach that level
at ICU admission. This was almost certainly the result
of late night or weekend admissions, when upper level
residents, not fully oriented to its use, staffed the unit.
Unfortunately, the checklist did not lead to signifi-
cant benefit regarding VAP, CVLIs, transfusions, or ad-
herence to Surgical Care Improvement Project guide-
lines for blood glucose control, although performance with
VAP and blood glucose control did improve. This lack
8
4
6
2
0
CVLI VAP
P
=
.83
P
=
.19
Rate/1000 Device-days
Period 1
Period 2
Figure 4. Incidence of central venous line infection (CVLI) and ventilator-
acquired pneumonia (VAP) in period 1 vs period 2. Prevention of CVLI and VAP
was a process improvement specifically addressed by the checklist.
100
90
80
70
60
50
40
30
20
10
0
Oct 2007 Dec 2007 Feb 2008 Apr 2008 Jun 2008 Aug 2008 Oct 2008 Dec 2008 Feb 2009
Month
Adherence, %
Checklists turned in Operation day POD shift 1 complete
Figure 3. Surgical cardiac care unit checklist adherence. POD indicates postoperative day.
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of significance was likely the result of the relatively small
sample size during each period, leading to insufficient
power to identify statistical significance. However, the
relative decrease of 50% in VAP rates between the 2 pe-
riods was notable.
LENGTH OF STAY
During the entire study, LOS was a crucial focus for the
hospital. During P2, LOS decreased by 2.2 days. The ef-
fect of the intensivist on LOS would have been more con-
vincing had we shown that SCCU LOS decreased, but it
did not. However, it became apparent during P2 that our
inability to transfer patients to the step-down unit or ward
at the time of the actual transfer order was contributing to
the problem. This wait-to-transfer time averaged up to 22
hours per patient. Consequently, in early 2008, we modi-
fied our 9 SCCU beds to allow telemetry. This enabled pa-
tients to be mobile, allowing the unit to rehabilitate pa-
tients through assisted or independent ambulation. Second,
in concert with the operating surgeon, the intensivists be-
gan to inform patients of their expected hospital dis-
charge dates at the time of SCCU discharge. By setting an
expected date of discharge with patients and families, we
attempted to manage expectations. In this way, we hoped
that the decision to discharge would not be a surprise. Al-
though we did not measure the effectiveness of this spe-
cifically, we believe that, when forewarned, patients are more
accepting of discharge timing.
The dollar value that one can ascribe to the decrease in
LOS is derived from 2 considerations. First, discharging pa-
tients earlier leads to an absolute decrease in hospital re-
source units expended per patient. Second, a reliable de-
crease in LOS across a large hospital-based population, such
as patients who have undergone cardiac operations, in-
creases bed availability. If these days can be “back filled”
with new admissions, they represent added revenue to the
hospital. When applied to a population of approximately
300 patients per year who undergo open heart surgery, a
2.2-day decrease in LOS translates into as many as 660 new
inpatient-days. With an average hospital LOS of 6 days, as
seen at our institution, this represents approximately 110
new admissions per year. At current reimbursement lev-
els, this would increase the hospital’s contribution margin
by approximately $800 000.
PHARMACEUTICAL COSTS
Targeting pharmaceutical costs of care has recently be-
come a focus
21-23
and is generally not included in rou-
tine performance improvement. Notably, the cost of simi-
lar care delivered by different physicians has been shown
to vary significantly.
24
During P2, the intensivists took
it upon themselves to control costs as a group. They de-
termined which drugs led to the greatest expenditures,
focusing on possible alternatives to decrease overall costs.
If one takes a data-driven approach to determine accept-
able interventions, many costly therapies can be elimi-
nated. For example, there is no benefit of albumin vs crys-
talloid for the resuscitation of hypovolemia,
25,26
and there
are no data supporting the short-term use of darbepo-
etin alfa to improve reticulocytosis and diminish the need
for PRBC transfusions.
27,28
Although costly at $800 per
day, recombinant human b-type natriuretic peptide is a
recognized, effective pulmonary and systemic vasodila-
tor that improves ventricular stroke volume and diure-
sis; however, there is no evidence to support its use in
postoperative decompensated heart failure.
29,30
Simi-
larly, use of a direct thrombin inhibitor for postopera-
tive anticoagulation to avoid the possibility of heparin-
induced thrombocytopenia, although theoretically
reasonable, is an extremely expensive solution to an un-
common problem (argatroban costs $800-$1000 per day).
The 60% reduction in pharmaceutical costs seen be-
tween the 2 periods represented a savings of more than
$2500 per patient.
ORGANIZATIONAL STRUCTURE
The crux of the issue regarding the improvement in LOS
and cost savings is whether they are attributable to the in-
sight and teamwork resulting from similarly trained sur-
geons working together or simply because of the effi-
ciency measures that were concurrently implemented at
the commencement of P2. This study simply docu-
mented improvement to care that resulted from a change
in ICU staffing to intensivists trained in cardiothoracic sur-
gery while simultaneously implementing a formal, metric-
driven performance improvement initiative. Could simi-
lar results have been achieved if the noncardiothoracic
intensivists from P1 attempted to manage the quality im-
provement program? Specifically, would cardiac sur-
geons easily accept a perceived “outside” specialty iden-
tifying patient care efficiency opportunities and changing
the delivery of care to address those opportunities?
A recent article by Hewett et al
31
highlights the diffi-
culties associated with communication between differ-
ent caregivers within the health care profession and il-
lustrates the obstacles to care facing patients who require
attention from multiple specialties. As anyone who has
Table 2. Pharmaceutical Costs for Period 1 and Period 2
Period
Cost, Mean (SD), $
Albumin
Argatroban
Hydrate
Darbepoetin
Alfa
Recombinant
Human b-Type
Natriuretic Peptide Other Overall
a
1 153 2800 54 180 1113 4300 (1000)
2 34 1450 39 56 221 1800 (200)
a
P .001 (period 1 vs period 2).
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cared for patients in a large university health care sys-
tem can attest, orchestration of patient care via commu-
nication between house officers, referring physicians, and
consultants can be overwhelmingly difficult.
32,33
Many in-
efficiencies, waste, and preventable errors stem from dif-
ficulties with intergroup communications. This is quite
problematic in the SCCU when one considers that in-
tergroup dynamics are constantly at play, with difficul-
ties increasing in concert with the complexity of the pa-
tient’s condition. Furthermore, in postoperative care, the
surgeon-patient bond that results from the preoperative
consent process may not be fully appreciated by physi-
cians from other specialties.
34,35
No one feels the com-
mitment to his or her patient more poignantly than the
cardiac surgeon who routinely obtains consent for op-
erations that pose a substantial risk to life.
In a semiclosed unit where care is codirected, an ap-
preciation of this commitment by the cardiothoracic sur-
geon intensivist may have provided a sense of trust and
comfort that allowed the performance improvement pro-
cess to proceed successfully. Although its contribution
to ICU care may be difficult to assess, the bond between
cardiothoracic surgeons as a result of their arduous train-
ing, the intensity of the operations they perform, and their
common experience with critically ill postoperative pa-
tients cannot be denied. It is possible that this sense of
belonging to the same group felt by the surgeons and in-
tensivists present during P2 enabled the intensivists to
address apparent opportunities for improvement and in-
stitute new plans for patient care. The improvement in
performance seen during P2 may be as much an out-
come of group identification resulting from similar train-
ing, education, experiences, and sense of patient “own-
ership” as from the specific medical knowledge that came
from the years of training that are required to become a
cardiac surgeon.
In conclusion, a change in cardiac ICU staffing to the
use of intensivists specialized in cardiothoracic surgery
was associated with significant efficiencies in postopera-
tive care relating to a decrease in LOS and the cost of drugs
used postoperatively. Should even a portion of these sav-
ings be generalizable to the 500 000 patients who un-
dergo open heart surgery each year in the United States,
the money saved could be on the order of hundreds of
millions of dollars. The change in group dynamics,
wherein both surgeons and intensivists were similarly
trained and board certified, may have been responsible
for the success of the performance improvement initia-
tives that was associated with increased efficiency of care
delivered.
Accepted for Publication: July 11, 2011.
Correspondence: Glenn J. R. Whitman, MD, Division of
Cardiothoracic Surgery, Department of Surgery, Johns
Hopkins Hospital, Blalock 618, 600 N Wolfe St, Balti-
more, MD 21287 (gwhitman@jhmi.edu).
Author Contributions: Study concept and design:
Whitman, Hirose, and Murphy. Acquisition of data:
Hirose and Murphy. Analysis and interpretation of data:
Haddad, Hirose, Allen, Lusardi, and Murphy. Drafting of
the manuscript: Whitman, Haddad, Hirose, and Allen.
Critical revision of the manuscript for important intellec-
tual content: Hirose, Allen, Lusardi, and Murphy. Statis-
tical analysis: Haddad, Hirose, Allen, and Murphy. Ad-
ministrative, technical, and material support: Whitman,
Hirose, Lusardi, and Murphy. Study supervision: Whitman.
Financial Disclosure: None reported.
Previous Presentation: This study was presented at the
46th Annual Meeting of the Society of Thoracic Sur-
geons; January 25-28, 2010; Fort Lauderdale, Florida.
REFERENCES
1. Fuchs RJ, Berenholtz SM, Dorman T. Do intensivists in ICU improve outcome?
Best Pract Res Clin Anaesthesiol. 2005;19(1):125-135.
2. Traynor K. Latest Leapfrog survey finds hospitals lagging in quality goals. Am J
Health Syst Pharm. 2009;66(11):972-973.
3. Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Associa-
tion between critical care physician management and patient mortality in the in-
tensive care unit. Ann Intern Med. 2008;148(11):801-809.
4. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative in-
fusions in critically ill patients undergoing mechanical ventilation. N Engl J Med.
2000;342(20):1471-1477.
5. Murphy M, Whitman I, Moxey E, Campfield A, Haddad M, Whitman G. Intense
implementation of a strict insulin infusion protocol does not guarantee postop-
erative glycemic control. J Am Coll Surg. 2010;211(4):465-469.e3. doi:10.1016
/j.jamcollsurg.2010.06.003.
6. Whitman IR, Murphy M, Campfield A, Moxey E, Haddad M, Whitman G. Surgical
Care Improvement Project blood glucose compliance and insulin infusion pro-
tocols: one size doesn’t fit all. In: Proceedings from the 39th Critical Care Con-
gress; January 2010.
7. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to
surgical quality and safety: from concept to measurement. Ann Surg. 2004;
239(4):475-482.
8. Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review
of research and implications for patient safety. J Crit Care. 2008;23(2):188-
196.
9. Fackler JC, Watts C, Grome A, Miller T, Crandall B, Pronovost P. Critical care
physician cognitive task analysis: an exploratory study. Crit Care. 2009;13(2):
R33. doi:10.1186/cc7740.
10. Levy MM, Dellinger RP, Townsend SR, et al; Surviving Sepsis Campaign. The
Surviving Sepsis Campaign: results of an international guideline-based perfor-
mance improvement program targeting severe sepsis. Crit Care Med. 2010;
38(2):367-374.
11. Eachempati SR, Hydo LJ, Shou J, Barie PS. Implementation of tight glucose con-
trol for critically ill surgical patients: a process improvement analysis. Surg In-
fect (Larchmt). 2009;10(6):523-531.
12. Campbell DA Jr, Kubus JJ, Henke PK, Hutton M, Englesbe MJ; Michigan Surgi-
cal Quality Collaborative. The Michigan Surgical Quality Collaborative: a legacy
of Shukri Khuri. Am J Surg. 2009;198(5)(suppl):S49-S55.
13. Sevdalis N, Brett SJ. Improving care by understanding the way we work: human
factors and behavioural science in the context of intensive care. Crit Care. 2009;
13(2):139. doi:10.1186/cc7787.
14. Luckett T, Butow PN, King MT. Improving patient outcomes through the routine
use of patient-reported data in cancer clinics: future directions. Psychooncology.
2009;18(11):1129-1138.
15. Nagy PG, Konewko R, Warnock M, et al. Novel, Web-based, information-
exploration approach for improving operating room logistics and system processes.
Surg Innov. 2008;15(1):7-16.
16. Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RD. Benchmarking surgical
incident reports using a database and a triage system to reduce adverse outcomes.
Arch Surg. 2008;143(12):1192-1197.
17. Hales BM, Pronovost PJ. The checklist—a tool for error management and per-
formance improvement. J Crit Care. 2006;21(3):231-235.
18. DuBose JJ, Inaba K, Shiflett A, et al. Measurable outcomes of quality improve-
ment in the trauma intensive care unit: the impact of a daily quality rounding
checklist. J Trauma. 2008;64(1):22-29.
19. Dubose J, Teixeira PG, Inaba K, et al. Measurable outcomes of quality improve-
ment using a daily quality rounds checklist: one-year analysis in a trauma inten-
sive care unit with sustained ventilator-associated pneumonia reduction. J Trauma.
2010;69(4):855-860.
20. Goldberg PA, Sakharova OV, Barrett PW, et al. Improving glycemic control in
the cardiothoracic intensive care unit: clinical experience in two hospital settings.
J Cardiothorac Vasc Anesth. 2004;18(6):690-697.
ARCH SURG/ VOL 146 (NO. 11), NOV 2011 WWW.ARCHSURG.COM
1259
©2011 American Medical Association. All rights reserved.
on November 21, 2011 www.archsurg.comDownloaded from
Page 7
21. MacLaren R, Bond CA. Effects of pharmacist participation in intensive care units
on clinical and economic outcomes of critically ill patients with thromboembolic
or infarction-related events. Pharmacotherapy. 2009;29(7):761-768.
22. Pittoni GM, Scatto A. Economics and outcome in the intensive care unit. Curr
Opin Anaesthesiol. 2009;22(2):232-236.
23. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump in-
hibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol.
2009;104(suppl 2):S27-S32.
24. Garland A, Shaman Z, Baron J, Connors AF Jr. Physician-attributable differ-
ences in intensive care unit costs: a single-center study. Am J Respir Crit Care
Med. 2006;174(11):1206-1210.
25. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study In-
vestigators. A comparison of albumin and saline for fluid resuscitation in the in-
tensive care unit. N Engl J Med. 2004;350(22):2247-2256.
26. Liberati A, Moja L, Moschetti I, Gensini GF, Gusinu R. Human albumin solution
for resuscitation and volume expansion in critically ill patients. Intern Emerg Med.
2006;1(3):243-245.
27. Corwin HL, Gettinger A, Fabian TC, et al; EPO Critical Care Trials Group. Efficacy
and safety of epoetin alfa in critically ill patients. N Engl J Med. 2007;357(10):
965-976.
28. Zarychanski R, Turgeon AF, McIntyre L, Fergusson DA. Erythropoietin-receptor
agonists in critically ill patients: a meta-analysis of randomized controlled trials.
CMAJ. 2007;177(7):725-734.
29. Noviasky JA. Controversy and conflict in the treatment of acute decompensated
heart failure: limited role for nesiritide. Pharmacotherapy. 2007;27(5):626-
632.
30. Yancy CW. Benefit-risk assessment of nesiritide in the treatment of acute de-
compensated heart failure. Drug Saf. 2007;30(9):765-781.
31. Hewett DG, Watson BM, Gallois C, Ward M, Leggett BA. Intergroup communi-
cation between hospital doctors: implications for quality of patient care. Soc Sci
Med. 2009;69(12):1732-1740.
32. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious
contributor to medical mishaps. Acad Med. 2004;79(2):186-194.
33. Epstein RM. Communication between primary care physicians and consultants.
Arch Fam Med. 1995;4(5):403-409.
34. Cassell J, Buchman TG, Streat S, Stewart RM. Surgeons, intensivists, and the
covenant of care: administrative models and values affecting care at the end of
life—updated. Crit Care Med. 2003;31(5):1551-1559.
35. Penkoske PA, Buchman TG. The relationship between the surgeon and the in-
tensivist in the surgical intensive care unit. Surg Clin North Am. 2006;86(6):
1351-1357.
INVITED CRITIQUE
Critical Care Competence
W
hether or not intensivists improve out-
comes is debatable. Lost in this debate, how-
ever, is the fact that many surgical subspe-
cialists are, in fact, well-trained critical care physicians.
Obvious examples include trauma surgeons, burn sur-
geons, and cardiothoracic surgeons. The educational para-
digms of these subspecialties, the inherent nature of the
diseases, and the high acuity of the patients these surgi-
cal subspecialists treat demand that they be critical care
physicians.
Critical care is intrinsic to cardiothoracic surgery. As
defined by the American Board of Medical Specialties, a
cardiothoracic surgeon “provides the operative, peri-
operative care and critical care of patients with acquired
and congenital pathologic conditions within the chest.”
1
The program requirements and curricula of thoracic sur-
gery residencies accredited by the Accreditation Coun-
cil for Graduate Medical Education demand an immer-
sion into the critical care of cardiothoracic surgical
patients; completion of these programs requires an at-
testation of resident competence by the program direc-
tors. The 2 largest professional societies of cardiotho-
racic surgery, the Society of Thoracic Surgery and the
American Association for Thoracic Surgery, dedicate large
portions of their annual meetings to critical care. The
American Board of Thoracic Surgery specifically exam-
ines candidates on critical care as part of its determina-
tion of board certification. Cardiothoracic surgeons are,
in fact, specialized critical care physicians.
Therefore, Whitman and colleagues
2
are to be con-
gratulated for this study. Their data clearly demonstrate
that the critical care provided by cardiothoracic sur-
geons contributed to excellent surgical outcomes. One
must conclude that the professional backgrounds in car-
diothoracic surgery of these critical care physicians al-
lowed them to improve the processes of care of cardiac
surgical patients. In turn, this led to greater efficiency in
the care provided and substantial financial savings. As
Whitman and colleagues continue their research in this
area, I am confident that these investigators will con-
tinue to affirm the competence of cardiothoracic sur-
geons as critical care physicians.
Author Affiliation: Department of Cardiothoracic Sur-
gery, University of Colorado School of Medicine, Aurora.
Correspondence: Dr Fullerton, Department of Cardio-
thoracic Surgery, University of Colorado School of Medi-
cine, 12631 E 17th Ave, Room 6602, Mail Stop C-310,
Aurora, CO 80045 (david.fullerton@ucdenver.edu).
Financial Disclosure: None reported.
1. American Board of Medical Specialties Web site. http://www.ABMS.org/who
_we_help/consumers/about_physician_specialties/thoracic.aspx. Accessed Au-
gust 25, 2011.
2. Whitman GJR, Haddad M, Hirose H, Allen JG, Lusardi M, Murphy MA.
Cardiothoracic surgeon management of postoperative cardiac critical care. Arch
Surg. 2011;146(11):1253-1260.
David A. Fullerton, MD
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