Adopting airline protocol helps improve clinical outcomes
For the past four years, the Cincinnati Children’s Heart Institute has achieved above average outcomes for length of stay (LOS) and mortality in a national database of cardiac surgical procedures. According to James S. Tweddell, MD, executive co-director of the Heart Institute, factors at play in these results include the team’s ongoing focus on multidisciplinary care, combined with a resolute dedication to seeking opportunities for improvement.
The risk-adjusted multi-institutional database results show that the Heart Institute is below the 25th percentile for most benchmark operations and has had superior results with the Norwood procedure. The Heart Institute’s LOS for the Norwood is 27 days, compared to a median of 48.9 days. Average mortality for the same procedure is 8.5 percent in Cincinnati compared to a national average of 14.9 percent. Other diagnoses in the lowest quartile for LOS included:
- Coarctation of the aorta (4.5 days for the Heart Institute vs. the 25th percentile of 10)
- Atrioventricular septal defect (6.5 vs. 12.4)
- Ventricular septal defect (4 vs. 6.6)
- Tetralogy of Fallot (6 vs. 9)
As director of Cardiothoracic Surgery for the institute, Tweddell emphasized that realizing these results is challenging. Both mortality and LOS are affected by several variables, and many disciplines need to be involved in solutions. Better survival and lower length of stay are markers of excellent multi-disciplinary team performance and require accurate diagnosis, excellent intraoperative and postoperative care. Tweddell says the team approach to care within the Heart Institute has helped bring about this success.
Assessing patients pre- and post-operatively
The Heart Institute’s multidisciplinary care is a method that emphasizes collaboration among team members and across disciplines. Tweddell stresses that this strategy is employed before, during and after surgery within the Heart Institute. Pre-operative study of cases includes review by critical care specialists, non-invasive cardiologists, invasive cardiologists, and surgeons, allowing the team to make fully informed decisions together.
Post-operatively, the group has recently adopted the use of “flight plans” for reviewing patient cases. This approach was first implemented at The Hospital for Sick Children (SickKids) in Toronto and is based on a “threat and error” safety protocol originally developed by NASA for airline pilots. The premise behind these flight plans is to look at a pilot’s entire flight and learn lessons to make flying safer—or in the case of healthcare, to review a patient’s surgical path through the hospital and identify areas that can be improved upon.
The goal of presenting these flight plans within the Heart Institute each week is to enable blameless but accountable work and close the loop of awareness for each patient’s clinical course. The team has found them to be of great benefit.
Awareness across all team members
“The flight plans provide a very realistic assessment of the patient course and outcome. They allow us to review every surgical patient so the whole team has awareness,” explains Tweddell. “They help us gauge both outcome and team performance and uncover areas where we can do better.”
That idea of constantly looking at where they can do better permeates the Heart Institute. The team’s culture is one of continuous improvement. “These achievements are not necessarily due to any one specific initiative, but to the fact that we have created a system that permits ongoing innovation as a standard of care,” Tweddell says.
Improving always a priority
Ongoing quality improvement initiatives allow the Heart Institute’s team to make strides in patient care. A recent example was aimed at reducing the length of time for chest tube duration. For most patients, removing the chest tubes is the last event before discharge and earlier chest tube removal will lead to lower length of stay. The Pediatric Acute Care Cardiology Collaborative, lead by Nicolas Madsen, MD, MPH, is a nationwide multi-institutional quality improvement effort and recently looked at chest tube removal practices across the country. They found that early chest tube removal was not associated with adverse outcomes, and as a consequence of these findings, we began adopting a strategy of early chest removal here in Cincinnati. It has resulted in shorter LOS for routine cases.
The chest-tube initiative is an example of the big role Acute Care Cardiology plays in achieving these better-than-average LOS outcomes. Led by Madsen, this group is responsible for getting patients from the ICU phase of care to discharge. Says Tweddell, “They are very effective at quickly identifying barriers to discharge and then addressing them. This contributes to discharging patients when it’s the right time and safe for the patients.”
Beyond simply proposing and supporting quality improvements, the Heart Institute focuses on sustaining the results they’ve achieved and encouraging the use of improvement science throughout all aspects of their care. They take pride in what they accomplish. And then they ask, “What’s next?”
