The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery.

OBJECTIVE: Although associations between transfusion and inferior outcomes have been documented, there is a lack of blood transfusion standardization in cardiac surgery. At the Inova Heart and Vascular Institute, a multidisciplinary, criterion-driven algorithm for transfusion management was implemented. We examined the effect of our blood conservation protocol on transfusion rates and outcomes after cardiac surgery and on stability of transfusion over time. METHODS: Patients undergoing first-time cardiac surgery from 2006 (full year before protocol) were compared with those in 2009 (after protocol) and propensity score matched to improve balance. Data were prospectively collected. Stability of transfusion incidence also was compared (2005-2006 vs 2008-2014). RESULTS: After matching, 890 patients from each year were included. Use of blood products decreased from 54% in 2006 to 25% in 2009 (P < .001). Patients in 2009 had a lower incidence of postoperative renal failure (2.6% vs 4%, P = .04), reoperations for bleeding (2% vs 4%, P = .004), and readmissions at less than 30 days (6% vs 12%, P < .001). No differences were found for operative mortality, deep sternal wound infection, or permanent strokes. Patients in 2009 had greater improvement in physical (P = .001) and mental (P = .02) quality of life than patients in 2006. Reduction of blood products led to significant cost savings for packed erythrocytes (P < .001) and platelets (P < .001). After protocol implementation, transfusion incidence remained 30% or less, with less than 28% in most years. CONCLUSIONS: A multidisciplinary blood conservation program can significantly control blood transfusion rates, improve outcomes, and be sustained over time. Efforts are needed to implement evidence-based protocols to standardize and decrease blood use in cardiac surgery to improve outcomes and reduce cost.

Patient disposition and long-term outcomes after valve surgery in octogenarians.

BACKGROUND: Valve surgery is performed routinely in octogenarians. This study explored variables affecting patient discharge disposition (home versus other facility) and whether patient disposition was related to long-term survival. METHODS: Patients 80 years or older who presented for aortic valve or mitral valve surgery from 2002 to 2010 were included. Baseline demographic, perioperative, and long-term outcomes were captured. Disposition was categorized into 2 groups; home (n=184) or other facility (n=123). The National Death Index and Social Security Death Index verified deaths. RESULTS: Mean age was 82.9±2.5; 46% (140 of 307) were female. Discharge location logistic regression, adjusted for gender (odds ratio [OR]=1.45, p=0.17) and European System for Cardiac Operative Risk Evaluation score (OR=1.09, p=0.10), predicted that older (OR=1.18, p<0.001), unmarried (OR=2.07, p=0.006) patients with at least 1 major complication (OR=3.86, p<0.001) were more likely to be not discharged home. Kaplan-Meier analysis found significantly lower 1- and 2-year (85.8% vs 94.6%, p=0.009; 80.1% vs 90.3%, respectively, p=0.01) cumulative survival in patients not discharged home. A multivariate Cox proportional hazards model demonstrated poorer 1- and 2-year survival (hazard ratio [HR]=2.56, p=0.04; HR=2.06, p=0.05, respectively). Predictors of follow-up mortality for patients not discharged home were length of stay (OR=1.06, p=0.03) and any major complication (OR=6.90, p=0.002); lower body mass index was marginally significant (OR=1.12, p=0.06). The significant predictor for patients discharged home was length of stay (OR=1.17, p=0.002). CONCLUSIONS: Octogenarians can expect excellent survival after valve surgery. Those not discharged home had poorer long-term survival. Therefore, adequate resources should be secured so sicker patients receive the appropriate level of care.

Survival and quality of life following elective open-heart surgery.

Eight hundred thirty-six patients who had open-heart surgery were available for analysis of health-related quality of life (HRQL) data and survival at the 1-year follow-up. Elective open-heart surgery patients with decreasing HRQL at 1 year following surgery may experience a survival disadvantage in comparison with those patients experiencing positive gains. Clinical care should extend beyond the immediate postoperative period.

Public health reporting: the United States perspective.

The release of 2 landmark reports by the Institute of Medicine titled, "To Err Is Human: Building a Safer Health System" and "Crossing the Quality Chasm" were instrumental in the identification of safety and quality issues. Since their release, federal and state programs of public reporting of performance measures have attempted to close the quality gap of care that is inappropriate, not timely, or lacking an evidence base. Cardiac surgery has long been the focus of public scrutiny, and now, as we move from an era of managed care to public reporting, reimbursement for cardiac surgery procedures will be tied to performance. However, the question is whether public reporting and pay for performance will ultimately improve the quality of patient care, safety, and provide the consumer with enough information to make surgeon and institutional choices. Will the cost and focus of achieving perfection with performance standards overshadow any real improvement in clinical outcomes?

Gender differences for Rapid After Bypass Back Into Telemetry tract following cardiac surgery.

The Rapid After Bypass Back Into Telemetry program is based on a simple clinical algorithm to predict same-day transfer of patients to the cardiac telemetry unit following cardiac surgery. This program proved to be an excellent predictor for decreased postoperative complications, shorter intensive care unit and hospital stay, and lower costs. We believe that any candidate for cardiac surgery should be screened for eligibility to participate in the program with special focus on female patients to further improve their outcomes.

Guided imagery in cardiac surgery.

Clinical research has demonstrated that guided imagery, a simple form of relaxation, can reduce preoperative anxiety and postoperative pain among patients undergoing surgical procedures. In 1998, the cardiac surgery team implemented a guided imagery program to compare cardiac surgical outcomes between two groups of patients: with and without guided imagery. Data from the hospital financial cost/accounting database and patient satisfaction data were collected and matched to the two groups of patients. A questionnaire was developed to assess the benefits of the guided imagery program to those who elected to participate in it. Patients who completed the guided imagery program had a shorter average length of stay, a decrease in average direct pharmacy costs, and a decrease in average direct pain medication costs while maintaining high overall patient satisfaction with the care and treatment provided. Guided imagery is now considered a complementary means to reduce anxiety, pain, and length of stay among our cardiac surgery patients.