A Relentless Focus on Improving Cardiac Care
Date: April 23, 2012
Providing the best care for patients in an intensive care unit—and finding ways to improve it even more—is a large and never-ending responsibility. In the cardiovascular surgery intensive care unit (CVSICU) at The Johns Hopkins Hospital, the focus includes a wide range of targets, from early weaning of patients from ventilators and appropriate blood utilization to improved communication with families.
“Our job requires constant review and measurement,” says Glenn Whitman, director of the CVSICU since summer 2009. “We continually look at our performance and try to apply metrics to all of it. Over the years it has become apparent to all of us that if you don’t measure it, you can’t improve it.”
Whitman is unique in being a cardiac surgeon with oversight of an ICU. He and the unit’s multidisciplinary Performance Improvement Committee have been concentrating on the full range of quality issues, including enabling patients to get off of ventilators sooner, care of central lines, preventing surgical-site infections, adhering to safety checklists, reducing the cost of drugs, and improving communication not only with physicians and staff in other units but with patients and their families. The unit has made progress in these areas by instituting some simple yet effective strategies.
“One of our goals is to have as many patients as possible weaned from the ventilator within six hours after surgery in order to speed up recovery and prevent complications,” says Whitman.
“We developed a new protocol involving nursing and respiratory therapy and took the simple step of posting a sign in each patient’s room that shows the time surgery ended and the time six hours later. That way, everyone caring for that patient can see the target time for extubation and work toward achieving it.”
The result: 50 percent of patients are now able to be removed from the ventilator within that time window, compared to less than 20 percent a few years ago.
Another priority is reducing surgical-site infections. To that end, heart surgery patients are tested preoperatively for the presence of staph. “If test results are positive, we prescribe a nasal antibiotic ointment before the operation as well as an antiseptic body wash,” says Whitman. This began almost two years ago, and compliance is close to 100 percent.
The rate of postoperative infections in cardiac surgery has dropped to an all-time low and is now one of the lowest in the country. “Over the past two years,” Whitman says, “we have reduced the rate from 4 percent to well under 2 percent, and we continue to strive for further improvement.”
Whitman and the ICU team have also found ways to cut costs without compromising patient care. For example, some expensive drugs routinely used in the CVSICU have been replaced with less costly but effective alternatives, for an estimated savings of $300,000 during the first year of the initiative. The unit cares for 1,200 patients annually.
“Nationally, critical care patients account for nearly one-third of all inpatient costs,” says Whitman, “and hospitals are not being fully reimbursed for these high levels of care. We need to find ways to lower costs while maintaining excellent clinical quality.”
Improving patient care in the CVSICU takes another leap forward this spring, when Johns Hopkins opens a new 1.6 million-square-foot hospital building that houses the Heart and Vascular Institute as well as the Children’s Center and other services.
As with all patient rooms in the new building, the 18 CVSICU beds are all private and spacious, with bathrooms and sleeping accommodations for family members. The unit is located next to the six new operating rooms dedicated to cardiac and vascular procedures and also on the same floor as the cardiac care unit, making all services and specialists close by and easily accessible.
“The unit is equipped with the latest technology, and it is clearly designed for the comfort of our patients and their family members,” says Whitman. “We think the new environment will help us continue to make measurable improvements in the care of our patients.”