Improving Clinical, Operational, and Financial Performance inCardiovascular Surgery

Cardiovascular surgery is one of the highest revenue-producing specialties in U.S. healthcare. When combined with cardiology, it isestimated to contribute approximately one-fifth of revenues to not-for-profit hospital coffers. The successful planning and imple-mentation of data-driven process improve-ment initiatives in cardiovascular surgery thusare critical for most acute care hospitals.Although many improvement opportunitiesexist, we focus here on two key opportunities—the first with coronary artery bypass graft(CABG) patients and the second with suspect-ed heart attack patients.

Opportunity: Standardize and improvetreatment of CABG patients to reducetheir LOS

Problem: Approximately one-third of CABGpatients experience atrial fibrillation, adisturbance in the rhythm of the heartbeat,which delays their discharge, therebyextending their length of stay (LOS).

Increased LOS decreases an organization’sthroughput and increases its costs, resulting indecreased financial performance. Further-more, patients with atrial fibrillation are atincreased risk for further complications ofcare, including increased risk for stroke.

Strategy 1: Implement preventive atrialfibrillation medication protocols.

Multiple studies have been completed in thepast decade demonstrating the efficacy of several pharmacologic agents, includingamiodarone, in reducing the risk of atrialfibrillation when administered prophylactically.Typically these agents have decreasedpostoperative atrial fibrillation rates by 10 to20 percent.1 Hospital physician leaders couldconsider developing and implementing aprotocol for the prophylactic administration ofamiodarone for CABG patients. Standardiza-tion of this preventive approach could reducevariation in care outcomes and LOS.

Performance measures:

• LOS by DRG

• Costs by DRG

• Total CABG patients

• Total elective CABG patients receiving andnot receiving prophylactic amiodarone

• Percentage of elective CABG patients withprophylactic amiodarone who developedatrial fibrillation (compared with percentageof elective CABG patients with prophylacticamiodarone who did not develop atrial fibrillation)

HFMA and McKesson have collaborated on a four-part series ofeducational reports focusing on opportunities for process improvementin hospitals. This is the second report in that series.

The first report, “Key Strategies for Sustained PerformanceImprovement,” presented three broad strategies that can be used toimprove overall performance. It appeared in the November 2004 hfm,and can be found on the HFMA web site at http://www.hfma.org/performance.

Watch the HFMA web site for the third and fourth reports, which willpresent specific opportunities for performance improvement inorthopedic surgery (report to be released in May) and laparoscopiccholecystectomy (report to be released in August).

Strategy 2: Ensure effective heart-ratestabilization and antithrombolyticmedication therapy.

Patients who are experiencing atrialfibrillation are at increased risk for stroke, as mentioned earlier. They require rate-controlintravenous anticoagulant medications tostabilize their heart rates. A typical regimenbegins with heparin administration, followedin later days by administration of warfarin.Clinicians manage this complex medicalscenario to minimize risk of stroke. Ifmedications are provided in the right sequenceand duration, outcomes can be improved andLOS reduced.

Performance measures: • CABG LOS • CABG variable direct costs • Percentage of total CABG patients with atrial

fibrillation• LOS for CABG patients with atrial

fibrillation• Time between CABG procedure and first

evidence of atrial fibrillation, using rate-control medication administration as theproxy

• Percentage of atrial fibrillation patients suf-fering a stroke postoperatively

Opportunity: Improve the diagnosis ofpatients presenting with suspected acutemyocardial infarction to improve theirclinical outcomes and reduce their LOS

Problem: Rapid diagnosis of acutemyocardial infarction (AMI) is critical tooptimal patient outcomes.

Heart attacks are a high-volume health prob-lem worldwide, and nearly 5 millionAmericans suffer a heart attack each year.Individuals presenting to EDs with acute chest

pain and suspected AMI represent one of themost pressing diagnosis and care challengesfaced by acute care facilities. Every minutethat passes without medical treatment after aheart attack reduces patients’ survival rates.

The costs associated with diagnostic workupsare significant, yet at least one-third of pre-senting patients have not actually experiencedan AMI. Unfortunately, 5 to 8 percent ofpatients discharged from the ED are found tohave suffered an AMI.2 Failure to diagnose andtreat AMI patients in the ED results in largemalpractice settlements each year.

Strategy: Improve timeliness and accuracy ofdiagnostic workup.

If a heart attack is suspected, the ED physicianwill usually order tests to confirm or rule out aheart attack. Tests may include an electrocar-diogram, echocardiogram, cardiac enzyme lab-oratory studies, stress test, or coronarycatheterization. Timing of diagnostic tests andtheir accurate interpretation by ED staff arecritical. Standardization of the ordering oftests through use of clinical pathways canreduce costs per stay (for example, decreasewastage of nuclear cardiology and cardiac cathlaboratory materials) and LOS, while improv-ing patient satisfaction.

Performance measures: • Time from presentation in the ED and start

of cath laboratory procedure• Mortality• LOS• Timing, utilization, and outcomes of

coronary catheterization

1. Institute for Clinical Systems Improvement, “Atrial fibrillation,”Bloomington, Minn: Institute for Clinical Systems Improvement, 2003.

2. McCarthy, B.D., Beshansky, J.R., D’Agostino, R.B., et al. “Missed Diagnosisof Acute Myocardial Infarction in the Emergency Department,” Annals ofEmergency Medicine, 1993. 22:579-582.mington, Minn: Institute forClinical Systems Improvement, 2003.

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