Standardizing Patient Care to Improve Outcomes in Cardiac Surgery
By the OhioHealth Process Excellence Department
Mediastinitis is a rare surgical site infection that occurs after cardiac surgery. It is a deep infection below the sternum and into the chest cavity. Mediastinitis has devastating consequences for the patient including increased risk of mortality, longer length of stay, and re-operation. Patients also experience significant financial and psychosocial burdens as a result of mediastinitis.
Mutiple organizations have focused efforts on reducing surgical site infections such as mediastinitis. National Patient Safety Goal No. 7 from The Joint Commission (2010) is to reduce the risk of healthcare associated infections. In addition, The Centers For Medicare and Medicaid Services has assigned mediastinitis as a “Never Event” for which hospitals receive reduced reimbursement.
Serving Columbus, Ohio, Riverside Methodist Hospital is a 650 bed nonprofit teaching facility. In November 2008, the Surgical Heart Team at Riverside Methodist Hospital identified the prevention of mediastinitis as one of the focus areas for improving the quality of their cardiac surgery program. Further, they recognized that the key driver was to lower the rate of mediastinitis to 0 percent, below the national benchmark. The objective was to implement evidence-based practices and standardize hospital processes.
The Surgical Heart Team partnered with the Process Excellence Department of OhioHealth. A multi-disciplinary team participated in a 3 day Kaizen event, a methodology used for rapid process improvement. The team included representatives from hospital administration, nursing management, bedside nursing, infection prevention, pharmacy and surgeons and physician assistants. The project was facilitated by a Process Improvement Specialist and an Outcomes Manager. The project spanned the departments of Surgery, Critical care, Pre-admission Testing, and the surgeons’ offices.
The project’s scope included all patients undergoing elective and urgent cardiac surgery. Pre-operative, intra-operative, and post-operative phases of care were deemed within scope. Emergent cardiac surgery cases and surgeon operating techniques were deemed out of scope. The key metric was the rate of mediastinitis in patients undergoing isolated coronary artery bypass grafting (CABG), one type of cardiac surgery.
Using process mapping, the team completed a current state assessment for each phase of the patient’s care: pre-operative, intra-operative, and post-operative. The current state assessment revealed multiple variations in processes. In addition, the team identified an opportunity to implement additional evidence-based practices for the prevention of mediastinitis.
The team reviewed cardiac surgery literature and benchmarked against higher performing cardiac surgery programs to identify evidence-based practices. They developed a process map for future state which incorporated 26 practices for infection prevention (Figure 1). Because consistency was paramount, Standard Work and preprinted orders were used to make the evidence-based practices both effective and efficient.
Metrics were established in a dashboard format for the 26 practices. The Dashboard signaled the occurrence of a problem and acted as a communication tool as well. In addition, a process was set up so that when a patient was re-admitted to the hospital with mediastinitis, the team was notified and a case review completed immediately
From November until the end of January, the team finalized Standard Work and pre-printed physician orders. In addition, supplies were ordered to operationalize each practice. Frequent meetings ensured collaboration as the team prepared for implementation and regular updates were given to hospital administration. The team held inservices and staff meetings 2 weeks prior to implementation to train all staff. The new process for the prevention of mediastinitis was implemented on February 9, 2009 with much excitement.
The Process Improvement Specialist and Outcomes Manager performed daily Gemba walks in the surgeons’ offices and pre-operative, intra-operative, and post-operative areas. The purpose of the Gemba walk was to observe standard work, identify and resolve opportunities for improvement, and to resolve change management issues with staff and surgeons. Dashboard metrics were obtained from observation during Gemba walks and daily chart audits while the patient was hospitalized. Opportunities for improvement were identified and resolved immediately with the health care providers at the bedside. This real time approach to the evaluation of care allowed the team to make real time adjustments to the care being delivered to cardiac surgery patients.
The overall rate of mediastinitis in isolated CABG patients was reported monthly in a control chart format. The rate of mediastinitis has decreased by 35 percent since implementation of the project in February 2009. Dashboard metrics for the 26 different practices run close to 100 percent on a weekly basis. The project’s success has been most beneficial to cardiac surgery patients. Experiencing the Kaizen approach to process improvement has benefited the hospital staff, leadership, and physicians as well. The team’s emphasis on quality has become a very high priority on a daily basis.
* Process Excellence (PEx) is an OhioHealth Corporate Department. Its mission is to drive improvement throughout OhioHealth by focusing on process using Lean / Six Sigma methodology.