BestPractice
January 4, 2016

In 2005, only 8 percent of patients undergoing cardiac artery bypass grafting at The Johns Hopkins Hospital were removed from the ventilator less than six hours after surgery. Such early extubation is desirable because patients sit up faster, eat solid food sooner, and lower their risk of ventilator-associated pneumonia and other complications.

The national average for early removal, at the time, was 30 percent.

“We knew we could do better,” says Glenn Whitman, director of the cardiovascular surgical intensive care unit and adult heart transplants at The Johns Hopkins Hospital. So in 2009, a performance improvement committee came together that included representatives from several departments, including cardiology and anesthesiology, along with an intensivist, advanced care practitioner, respiratory therapist and nurse. Its aim was to develop a standard clinical pathway for getting patients off the ventilator.

Now 55 percent of patients undergoing cardiac artery bypass grafting at The Johns Hopkins Hospital are removed from the ventilator less than six hours after leaving the operating room, Whitman says.

Clinical pathways are designed, first, to improve patient care, but they are also about increasing the efficiency of care delivery. Under the terms of the Maryland Medicare waiver, surgical procedures are reimbursed at a set rate, regardless of the patient’s length of stay, medications given or labs ordered.

Becoming more efficient is an institutional priority because, as Whitman says, “it’s not like we get extra money for performing procedures less efficiently and extending the patient’s stay with us.

”Says Lisa Ishii, a facial plastic and reconstructive surgeon who co-leads the Clinical Communities Project Management Office, which supports the pathways initiative: “A lot of variation in care is unintentional. Generally speaking, the more variation, the more dissatisfaction among staff and the greater the chance of complications.” For example, she says, it would happen that “Dr. Smith wants patients on oxycodone for pain, no solid food for two days and discharge on day five. Dr. Jones prefers hydromorphone for pain and has patients eating one day postop, discharging on day four. All the variation caused confusion among the nurses and residents,” requiring them to memorize algorithms specific to each surgeon’s patients.

By contrast, says colorectal surgeon Jonathan Efron, who is part of the colorectal clinical pathway committee, “with standardization, you have fewer errors. Plus, not every surgeon is perfectly up to date on what best practices are. With a set process in place to continually update best practice protocols, it allows everyone to stay current, and it improves efficiency.”

Developing a pathway takes anywhere from three months to a year. Ten pathway teams are running now:

• Coronary artery bypass grafting/aortic valve replacement
• Anterior cervical discectomy and fusion
• Laparoscopic donor nephrectomy
• Live donor renal transplant
• Mastectomy with tissue expanders
• Gynecologic oncology enhanced recovery after surgery  (ERAS)
• Cystectomy ERAS
• Colorectal ERAS
• Liver ERAS
• Pancreas/Whipple ERAS

The enhanced recovery after surgery model originated out of work done by the colorectal committee to speed postoperative recovery. The ERAS pathway has reduced length of stay for colorectal surgery by as much as 60 percent.

Other practices the coronary arterial bypass grafting and aortic valve replacement committee has examined include using cost-effective pharmaceuticals, saving up to $700,000 annually; setting bed angle in the intensive care unit to 30 degrees to minimize the risk of ventilator-associated pneumonia; and expediting transfer from the operating room to intensive care so that the operating room is available for the next patient.

Inspired by those results, the liver ERAS committee developed an ERAS pathway for liver resection over the last year, focusing on perioperative care and encompassing patient education materials, nourishment prior to surgery, and pain management in and after surgery. Patient education materials set appropriate expectations and make patients more engaged in their care. Patients are allowed to drink carbohydrate drinks, such as Gatorade, before surgery, which keeps them more comfortable. Epidural use has jumped from 12 percent to 75 percent, reducing the amount of opioid pain medication patients take while keeping their pain scores unchanged. Length of stay has dropped, on average, from six days to five, and medical supply and laboratory costs have been reduced.

Tim Pawlik, chief of the Division of Surgical Oncology, attributes the pathway’s success to surveying care providers, with the aim of understanding the barriers to implementing the liver ERAS pathway. “We asked questions such as, ‘Is it important to drive down opioid use? What is the most important part of the pathway? The least important?’ Only by understanding people’s attitudes could we get everyone on board.”