Standardized practice design with electronic support mechanisms for surgical process improvement: reducing mechanical ventilation time.

BACKGROUND: Hospital surgical care is complex and subject to unwarranted variation. OBJECTIVE: As part of a multiyear effort, we sought to reduce variability in intraoperative care and management of mechanical ventilation in cardiac surgery. We identified a patient population whose care could be standardized and implemented a protocol-based practice model reinforced by electronic mechanisms. METHODS: In a large cardiac surgery practice, we built a standardized practice model between 2009 and 2011. We compared mechanical ventilation time before (2008) and after (2012) implementation. To ensure groups were comparable, propensity analysis matched patients from the 2 operative years. RESULTS: In 2012, more than 50% of all cardiac surgical patients were managed with our standardized care model; of those, 769 were one-to-one matched with patients undergoing surgery in 2008. Patients had a mix of coronary artery bypass grafting, valve surgery, and combined procedures. Our practice model reduced median mechanical ventilation duration from 9.3 to 6.3 hours (2008 and 2012) (P < 0.001) and intensive care unit length of stay from 26.3 to 22.5 hours (P < 0.001). Reintubation and intensive care unit readmission were unchanged. Variability in ventilation time was also reduced. CONCLUSIONS: We demonstrate that in more than 50% of all cardiac surgical patients, a standardized practice model can be used to achieve better results. Clinical outcomes are improved and unwarranted variability is reduced. Success is driven by clear patient identification and well-defined protocols that are clearly communicated both by electronic tools and by empowerment of bedside providers to advance care when clinical criteria are met.

Regioselective and controlled-density branching in amylose esters.

Herein, we report creation of methodology for one-pot synthesis of 2,3-O-acetyl-6-bromo-6-deoxy (2,3Ac-6Br) amylose with controlled degree of substitution of bromide (DS(Br)) followed by quantitative azide substitution as a route to branched polysaccharide derivatives. This methodology affords complete control of "tine" location, and strong control of degree of branching of comb-structured polymers. In this way, we achieved bromination strictly at C6 and esterification at the other hydroxy groups, where the DS(Br) at C6 was well-controlled by bromination/acylation conditions in the one-pot process. Azide displacement of all C6 bromides followed by copper-catalyzed azide-alkyne cycloaddition (CuAAC) click reaction with the small molecule tert-butyl propargyl ether (TBPE) demonstrated the potential to create such branched structures. This synthetic method has broad potential to generate well-defined polysaccharide-based comb-like structures, with a degree of structural control that is very unusual in polysaccharide chemistry.

The value of a web-based interactive regional health scorecard in setting public health priorities.

INTRODUCTION: Community-based health improvement efforts sometimes focus on emerging health issues rather than following a more proactive planning process. Although there is an abundance of easily accessible data on state and national websites, community leaders frequently don't know where to find data that will help them to prioritize local efforts. METHODS: The La Crosse Medical Health Science Consortium (LMHSC) is a formal collaborative of the 2 major health care providers and 3 higher education institutions in La Crosse, Wisconsin, and covers 20 counties in western Wisconsin, southeastern Minnesota, and northeastern Iowa. To help prioritize regional health improvement efforts, we developed an interactive scorecard for each county, which allows for tracking indicators (ie, leading causes of death, accidents, cancer, health and behaviors, heart disease, infectious diseases, maternal and child health, sexually transmitted infections, and substance use/abuse) and monitoring health improvement efforts. The website www.communityscorecard.com allows the user to examine a county's statistics over time (as far back as 1998) and compare data among LMHSC's 20 counties, the state, and the nation as a whole. To aid prioritization, a grading schema allows each county to grade itself compared with selected health indicator benchmarks, like the Healthy People 2010 goals. RESULTS: Since going public in March 2007, the website has received more than 10,500 visits by more than 2300 unique users from 48 states and 46 countries. CONCLUSIONS: Prioritization and engagement of the community in health promotion activities requires quick access to accurate data that have been translated into information. We describe the development of a web-based population health scorecard for this purpose.

Surgical Process Improvement: Impact of a Standardized Care Model With Electronic Decision Support to Improve Compliance With SCIP Inf-9.

The absence of standardization in surgical care process, exemplified in a "solution shop" model, can lead to unwarranted variation, increased cost, and reduced quality. A comprehensive effort was undertaken to improve quality of care around indwelling bladder catheter use following surgery by creating a "focused factory" model within the cardiac surgical practice. Baseline compliance with Surgical Care Improvement Inf-9, removal of urinary catheter by the end of surgical postoperative day 2, was determined. Comparison of baseline data to postintervention results showed clinically important reductions in the duration of indwelling bladder catheters as well as marked reduction in practice variation. Following the intervention, Surgical Care Improvement Inf-9 guidelines were met in 97% of patients. Although clinical quality improvement was notable, the process to accomplish this-identification of patients suitable for standardized pathways, protocol application, and electronic systems to support the standardized practice model-has potentially greater relevance than the specific clinical results.

From 'solution shop' model to 'focused factory' in hospital surgery: increasing care value and predictability.

The full-service US hospital has been described organizationally as a "solution shop," in which medical problems are assumed to be unstructured and to require expert physicians to determine each course of care. If universally applied, this model contributes to unwarranted variation in care, which leads to lower quality and higher costs. We purposely disrupted the adult cardiac surgical practice that we led at Mayo Clinic, in Rochester, Minnesota, by creating a "focused factory" model (characterized by a uniform approach to delivering a limited set of high-quality products) within the practice's solution shop. Key elements of implementing the new model were mapping the care process, segmenting the patient population, using information technology to communicate clearly defined expectations, and empowering nonphysician providers at the bedside. Using a set of criteria, we determined that the focused-factory model was appropriate for 67 percent of cardiac surgical patients. We found that implementation of the model reduced resource use, length-of-stay, and cost. Variation was markedly reduced, and outcomes were improved. Assigning patients to different care models increases care value and the predictability of care process, outcomes, and costs while preserving (in a lesser clinical footprint) the strengths of the solution shop. We conclude that creating a focused-factory model within a solution shop, by applying industrial engineering principles and health information technology tools and changing the model of work, is very effective in both improving quality and reducing costs.

Recovery bed planning in cardiovascular surgery: a simulation case study.

Recovery beds for cardiovascular surgical patients in the intensive care unit (ICU) and progressive care unit (PCU) are costly hospital resources that require effective management. This case study reports on the development and use of a discrete-event simulation model used to predict minimum bed needs to achieve the high patient service level demanded at Mayo Clinic. In addition to bed predictions that incorporate surgery growth and new recovery protocols, the model was used to explore the effects of smoothing surgery schedules and transferring long-stay patients from the ICU. The model projected bed needs that were 30 % lower than the traditional bed-planning approach and the options explored by the practice could substantially reduce the number of beds required.

Functional recovery in the elderly after major surgery: assessment of mobility recovery using wireless technology.

PURPOSE: Hospitalization and surgery in older patients often leads to a loss of strength, mobility, and functional capacity. We tested the hypothesis that wireless accelerometry could be used to measure mobility during hospital recovery after cardiac surgery. DESCRIPTION: We used an off-the-shelf fitness monitor to measure daily mobility in patients after surgery. Data were transmitted wirelessly, aggregated, and configured onto a provider-viewable dashboard. EVALUATION: Wireless monitoring of mobility after major surgery was easy and practical. There was a significant relationship between the number of steps taken in the early recovery period, length of stay, and dismissal disposition. CONCLUSIONS: Wireless monitoring of mobility after major surgery creates an opportunity for early identification and intervention in individual patients and could serve as a tool to evaluate and improve the process of care and to affect postdischarge outcomes.

Improving affordability through innovation in the surgical treatment of mitral valve disease.

OBJECTIVE: To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses. PATIENTS AND METHODS: We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect. RESULTS: Baseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P=.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P=.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P=.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P=.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001). CONCLUSION: Following the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes.