Achieving Three Stars for CABG Surgery

Preop Clinic Helps Good Samaritan Add a ‘Star’ to Its STS Quality Score

Achieving the best possible patient outcomes is an ongoing challenge for cardiothoracic surgery programs around the country, and a stretch goal would be the coveted three-star quality award ranking from the Society of Thoracic Surgeons (STS). Roughly three-quarters of all participants in the adult cardiac surgery database maintained by STS rate two stars (average), and the remainder fall more or less equitably in the one-star (lower than average) or three-star (higher than average) category. Among HCA’s hospitals nationwide, six—including Good Samaritan Hospital in San Jose, California—achieved three-star status for coronary artery bypass graft (CABG) surgery in calendar year 2016.

The STS star rating system for CABG surgery begins by assuming all providers are average, and then calculates if an individual hospital’s composite score is significantly different from the majority in the middle across 11 process and outcomes measures approved by the nonprofit National Quality Forum. Pulling away from the pack is a notoriously difficult feat to attain and sustain, and the precise STS weighting formula is proprietary. Good Samaritan Hospital gives a large share of the credit to a standardized preoperative evaluation clinic (PEC) that is mandatory for all patients undergoing highly invasive cardiothoracic surgery.

It is not uncommon for patients to arrive at PECs (aka “surgery assessment clinics” or “perioperative surgical homes”) with an undiagnosed or previously untreated condition, such as diabetes, obstructive sleep apnea, nicotine dependency or morbid obesity. PECs have repeatedly demonstrated their ability to identify potential uncontrolled medical issues earlier so that appropriate testing and mitigating treatments get initiated, heading off potential complications. That also translates into fewer last-minute “surprises” that can delay or cancel surgery. Multiple reports have also linked PECs to shorter hospital lengths of stay and improved patient satisfaction.

The hallmarks of PECs for patients needing CABG surgery include evidence-based testing, “optimization” of medical comorbidities, and management of surgery-related medications. Although PECs may be most cost effective at large tertiary care centers dealing with high volumes of medically complex patients for a wide variety of surgeries, the experience of Good Samaritan Hospital suggests that smaller community hospitals with a cardiothoracic surgery program can benefit both clinically and financially from such a clinic.

A PEC is Born

The cardiothoracic surgery program at Good Samaritan Hospital had plateaued for several years with an STS two-star ranking, despite multiple isolated attempts at improvement. That all changed in 2014, when a task force of cardiac anesthesiologists created a physician-led PEC. In partnership with the department of cardiovascular services and the department of anesthesia, task force members first developed a standard, evidence-based guideline for preoperative testing and optimization, along with a clinical care pathway to help guide the care of cardiac surgery patients throughout the perioperative period. They volunteered their time to evaluate patients and coordinate a multidisciplinary workup that included assessments by primary care physicians, internists, cardiovascular specialists, pulmonary intensivists and others as needed.

The PEC assesses all cardiac surgery patients, as well as other high-risk patients scheduled for non-cardiac surgery, starting a week or more prior to their procedure. Staffing includes a physician anesthesiologist who sees patients on weekday afternoons, assisted by existing preoperative staff, and a full-time nurse practitioner.

Risk-scoring Patients

Most physicians are aware of the STS cardiac surgery risk calculator that “scores” a patient as being at low, intermediate or high risk of mortality and morbidities from a planned procedure. But in actual practice, physicians tend to rely disproportionately on their clinical intuition. To better educate physicians on the value of formal risk stratification, Good Samaritan Hospital hosted a series of conferences where the STS tool—available as a web- or smartphone-based application—was applied to medically complex cardiovascular cases. STS risk scores also became a mandatory part of patients’ medical record, in full view of all providers along the care continuum.

Risk scores are derived from 33 differentially weighted clinical and demographic factors, such as surgery type and patient’s age, gender, cardiac history and comorbidities. Patients falling in the intermediate- to high-risk range (upwards of 40 percent of the cardiothoracic surgery caseload) would then get focused attention on any medically addressable condition, such as uncontrolled hypertension or diabetes, chronic heart failure, obstructive pulmonary disease, renal insufficiency or anemia. Optimizing patients in this way helps ensure planned surgeries are done in a timely manner.

Cardiac Surgery Care Pathway at Good Samaritan: The Preoperative Phase

Education and Teaching
Baseline assessment (e.g., pre-illness abilities and discharge needs)
“Preparing for Your Surgery” video, “Moving Right Along” booklet, incentive spirometer, continuous deep breathing, what to expect
Preop clinic visit
STS risk calculation added to history and physical documentation

Diet
No solid food within eight hours of surgery and no water within two hours of surgery

Diagnostics
Complete blood count, chemistry panel, type and cross for blood bank, and (if indicated) coagulation studies
Urinalysis
Screen for methicillin-resistant Staphylococcus aureus
Electrocardiogram
Chest X-ray
Echocardiogram
Cardiac catheterization
Bedside pulmonary function tests
Carotid Doppler test (looking for narrowing or blockages)
Radial artery duplex ultrasound (if indicated)
Five-meter walk test

Medications
Continue home meds as instructed
Temporarily hold anticoagulants as instructed
ACE inhibitors and angiotensin receptor blockers held for 48 hours
Continuation of aspirin unless otherwise instructed
Preop beta-blocker

Treatments and Assessments
Chlorhexidine shower night prior to surgery and morning of surgery; bed bath if on bed rest
Surgery prep with clippers only (for hair removal)
Preop weight on scale
Blood pressure check on both arms; notify M.D. if difference >20 mmHg
Patient on oxygen after premeds given
Consent for all surgical procedures

EXPECTED OUTCOMES: Patient demonstrates use of incentive spirometer and continuous deep breathing, understands what to expect postop, and gets appropriate preoperative studies and medication management

Specific Tests and Instruction

A study published in Surgery, Gynecology & Obstetrics estimates that more than 60 percent of preoperative tests ordered are in fact medically unnecessary. To help ensure that doesn’t happen at Good Samaritan Hospital, physicians follow appropriateness guidelines contained in the Practice Advisory for Preanesthesia Evaluation of the American Society of Anesthesiologists (ASA). Doing so helps ensure all preoperative lab, imaging and stress studies—and subspecialty consults—are medically justified.

The ASA Task Force recommends that such tests be performed on a selective basis to guide or optimize perioperative management, and that the rationale be documented. Following their preoperative evaluation, patients are given specific instructions on which medications to take or hold prior to surgery, based on established guidelines. Timing of fasting with explicit definitions for solids and clear liquids is emphasized, as well as where to come and what to bring on the day of surgery. Full preoperative instructions, in easy-to-understand language, are also printed out and handed to patients to reference through their care journey.

Managing Expectations

The more involved and educated patients are about the natural progression of their disease, and its symptoms and treatment, the more engaged they become in their care process. Mental preparedness assists in reducing their anxiety level. Good Samaritan Hospital’s goal is to ensure surgical candidates know exactly what to expect from a procedure—what the operation entails, if they will experience any pain or discomfort (and how the hospital plans to minimize it), if cardiac rehab or a stay in a skilled nursing facility is anticipated, and when they’ll be able to resume normal activities. The hospital also seeks to learn their expectations of a full recovery, so it can clear up any misconceptions. Direct-to-consumer advertising, online research and conversations with friends, family and co-workers can all lead to mistaken beliefs.

Physicians address any and all questions patients and families may have so risks of the planned procedure are understood, as well as other treatment options that may be available. Any significant concerns are communicated back to patients’ primary care physician or cardiovascular specialist. The value of patients’ peace of mind during the preoperative phase of their care cannot be underestimated.

Good Samaritan’s patient-focused perspective doesn’t end with surgery. CareAssure, HCA’s discharge program, utilizes a dedicated nurse navigator who makes patients’ follow-up appointments and confirms their medications have been called or faxed in to the pharmacy before they leave the hospital, automatically refers them to cardiac rehab, verifies that medications have been picked up, and makes reminder phone calls about upcoming physician visits. The idea is to remove as many outpatient hurdles as possible so patients don’t get needlessly readmitted.

Entire episodes of care—starting preoperatively and extending for months after surgery—get recognized all at once. Patients know exactly what is going to happen when. Because STS risk calculations get documented in their medical chart, patients and caregivers start having more honest conversations about recovery realities and prospects. Good Samaritan has found that these personal touches help alleviate the stress surrounding a surgery. Patients and physicians also appreciate the care coordination and opportunity for open collaboration through improved communication.

Back to ‘Average’

Good Samaritan Hospital achieved its 2016 three-star status over two years by improving all four of the major factors accounting for the STS CABG ranking—mortality, major morbidity, internal mammary artery (IMA) use and perioperative medication administration. These improvements are due in large part to PEC. In addition to improvements in patient outcomes, the hospital is realizing other benefits from the PEC. Among patients seen in the clinic, compared to those who were not, physicians have documented a greater than 50 percent reduction in surgery delays and cancellations.

The last-minute cancellation of a surgery is a huge burden for patients and everyone involved in their care. Patients have already requested time off from work, coordinated with family members for transportation to and from the hospital, and made arrangements for their aftercare. Hospital schedulers have also made provisions for holding and staffing an operating room and postoperative care bed.
Maintaining three-star status is always a challenge, because the STS scoring system includes unplanned surgeries, when use of a PEC might not be an option, as well as planned ones. Patients admitted acutely, in poor health, do not always survive emergency surgery. Good Samaritan Hospital recently lost its STS three-star ranking by the smallest of margins, so it remains laser-focused on process improvements that will earn back the coveted third star.

Author Information

William Ennen

William Ennen

William Ennen, M.D. is medical director for cardiac surgery at Good Samaritan Hospital, where he is chair of the department of anesthesia. He also serves as medical director of CEP South Bay Cardiac Anesthesia Service in San Jose, California. More Articles by This Author »

Henry Kamali

Henry Kamali

Henry Kamali, M.D. is medical director for surgical services at Good Samaritan Hospital. He also serves as assistant medical director of CEP Anesthesia in San Jose, California. More Articles by This Author »

Felix Lee

Felix Lee

Felix Lee, M.D., medical director of cardiovascular services at HCA’s Good Samaritan Hospital in San Jose, California, as well as a partner in cardiovascular medicine, nuclear cardiology and interventional cardiology at Heart Associates of Northern California, Palo Alto Medical Foundation, Sutter Health. He also serves as cardiovascular service line director for HealthTrust. Dr. Lee earned his medical degree from the University of Pennsylvania School of Medicine in Philadelphia. More Articles by This Author »

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