Targeted efforts reduce time on ventilators
Washington University cardiac surgeons have significantly reduced the amount of time patients are on ventilation after surgery, an important measure of surgical care quality.
“Evidence suggests that the longer patients stay on ventilation, the higher their chances of getting a ventilator-associated pneumonia,” says cardiac surgeon Spencer Melby, MD. “The risk goes up about 10 percent every day patients are ventilated after surgery. Prolonged ventilation also keeps the patient sedated longer and slows the recovery process.”
Melby and a multidisciplinary quality-improvement team have spent the past two years working to reduce prolonged ventilation — defined by the Society of Thoracic Surgeons as longer than 24 hours — in patients undergoing coronary artery bypass graft (CABG) and aortic valve replacement (AVR). As a result, CABG patients experiencing prolonged ventilation decreased from 15 percent in 2014 to 12.8 percent in 2016, and in AVR patients, the rate decreased from 11.7 percent to 8.7 percent. The average hours spent on ventilation also decreased — from 42.1 hours to 33.7 hours in CABG patients and from 41.2 to 16.7 hours in AVR patients.
Melby, cardiac surgeon Keki Balsara, MD, anesthesiologist Charl De Wet, MD, and cardiothoracic surgery intensive care unit (CT ICU) clinical nurse manager Elaine Thomas-Horton, RN, accomplished the reductions largely through education of physicians, nurses and nurse practitioners about the importance of removing patients from ventilation as soon as possible. Staff in the eICU, a remote monitoring facility, also assist by reminding the CT ICU team when 12 and 18 hours have gone by — logical intervals at which to reassess the need for ventilation.
Washington University cardiac surgeons and anesthesiologists are ahead of the curve on taking patients off ventilators in the operating room before moving them to the CT ICU. At Barnes-Jewish Hospital, about 30 percent of CABG and AVR patients are extubated, or removed from ventilation, in the operating room, compared with about 3 percent of cardiac surgery patients nationally.
“To extubate in the operating room, you have to be comfortable your patient is doing well and that the surgery went well,” says Melby.
Melby and colleagues are now working with surgeons at Christian Hospital and Missouri Baptist Hospital to improve surgical outcomes.
Highlights
CARDIAC SURGEONS PERFORMED more than 1,200 major cardiac procedures in 2016 — the most in the division’s history. They also extended services into central Illinois and southern Missouri through collaborative agreements with UnityPoint Health – Methodist | Proctor hospitals in Peoria, Ill., and SoutheastHEALTH system in Cape Girardeau, Mo.
The section also collaborates with Blessing Hospital in Quincy, Ill., and Good Samaritan Hospital in Mount Vernon, Ill. High-risk patients gain greater access to advanced open-heart surgery and clinical trials, and the institutions’ surgeons benefit from on-site training, Washington University educational seminars, consultation services and quality-assurance input.
HERSH MANIAR, MD, was the senior author of studies suggesting that preoperative pulmonary function tests should be a part of the workup for surgical or transcatheter aortic valve replacement (TAVR) and on evaluating the learning curves for surgeons using alternative methods to gain vascular access for TAVR. The Journal of Thoracic and Cardiovascular Surgery and Annals of Thoracic Surgery published the papers. Maniar is co-principal investigator of the PARTNER (Placement of AoRTic traNscathetER) III clinical trial, which studies the use of minimally invasive surgical techniques to place aortic valve devices vs. open-heart aortic valve replacement in low-risk patients.
“IN THE WORDS OF THE PRESIDENTS,” a book by cardiac surgery Chief Marc Moon, MD, presents interviews of all 29 living past presidents of the American Association
for Thoracic Surgery (AATS). Five past presidents were Washington University faculty, including Alec Patterson, MD, who was president in 2009-2010.