Impact of Quality Improvement in the CICU

Santiago Borasino MD, MPHAssociate Professor of Pediatrics, Section of Cardiac Critical Care

University of Alabama at Birmingham

Standardization in Oncology: Quality and Research Hand by Hand

• Most patients enrolled• Meticulous Data

collection• Adjustment of

treatments as new therapies become available

• Comparison with previous protocol

STANDARDIZATIONCase for Standardization in the CVICU

Standardization: CVICU

• High complexity dynamic environment• Multiple decisions per day• Admission can be classified by their surgical

procedure and required similar care most of the time

• Multiple processes are performed in all patients at some point (feeds, ventilator weaning, etc.)

Standardization: Pro

• Simplification of Complex Processes– Time to concentrate on more important decisions

• Allow expert opinion to the bedside efficiently• Training and Retraining• Anticipatory care: all members of the team understand the

process and their role(s)• Detect protocol deviations and allow for corrections• Protocol adjustments and comparisons (QI)• Reduction of practice variation (care should change for the

patient, not the physician)• Research

Standardization: Cons

• “Loss” of physician’s judgment and experience– All patients are different– Decrease practice variation to adapt to the patient

(or is it to adapt to the physician?)• Rigidity

How to approach QI in the CVICU?• Have the Will Power• Tools

– LEAN, Six Sigma, etc.

• Include all the important stakeholders– Especially the frontline clinicians

(Nurse and bedside doctors)

• Use Data to create your guidelines– Internal/External– Evidence Based Medicine

• Have a plan to measure the effects

Quality Improvement in our Unit

Quality Improvement in our Unit

• Admission Order Sets (CPOE)• Feeding

– Pre-op Neonatal Feeding guidelines– Feeding guidelines – Swallowing and Aspiration Evaluation

• Potassium Management• Anticoagulation

– General – ECMO

• Postoperative Hemorrhage • Transport Check Off List

Quality Improvement in our Unit cont.

• Resuscitation– Debriefing– Resuscitation Committee evaluation– ASAP’s– RAP

• Respiratory– Intubation “kits”– Ventilator Weaning Protocol– 3 person ETT suction– Tracheostomy Care – Oxygen Management Guidelines

• Cardiac Echo – HLHS pre and postoperative imaging schedule

Quality Improvement in our Unit cont.

• Chylothorax• Laboratory Studies • CVL

– Placement (All US)– Maintenance (Access, dressing changes)

• Sedation weaning• HLHS• ECMO • Transport off Unit Check list

EXAMPLESQuality Improvement in our Unit

Potassium Replacement Protocol

• IV potassium is considered a high risk medication

• Appropriate threshold for K replacement is not clear in pediatrics

• Enteral potassium is a safe alternative

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35

30

25

20

15

10

5

0

Nu

mb

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Bo

luse

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_X=1.68

UCL=5.13

Pre Post

IV Potassium Bolus Pre and Post Intervention

Protocol implementation

Total intravenous KCL doses, n 336 47  

Total enteral KCL doses, n 1143 1733  

Intravenous KCL doses per 100 patient days, n 17.6 2.5 <0.01

Enteral KCL doses per 100 patient days, n 59.8 92.0 <0.01

Cost of KCL supplementation per patient admission, US dollar

36.23 15.66 <0.01

Total intravenous KCL fluid administration, ml 6226 3451  

Total enteral KCL fluid administration, ml 1070 3181  

Total KCL fluid supplementation per patient admission, ml

40.5 18.2 <0.01

Abbreviations: KCL, potassium chloride; ml, milliliters; US, United States

Outcomes: Doses, fluid and cost

 Before

ProtocolAfter Protocol p value

Episodes of serum potassium >6.0mEq/Lper 100 patient days

1.6 0.6 <0.01

Episodes of serum potassium <3.5mEq/L per 100 patient days

47.9 50.7 0.4

Average morning serum potassium level, mEq/L mean (SD)

3.5 (0.6) 3.4 (0.6) 0.49

Arrhythmias per 100 patient days, n 1.5 1.7 0.34

Abbreviations: SD, standard deviation

Outcomes: Clinical

Laboratory Use

• 2012 CPOE was introduced• Standardization through Order Sets• Recurrent Daily Lab orders entered on admission• Increase use of laboratory studies drive cost up

but does not necessarily increase quality of care• QI project : Decrease laboratory use by changing

Order Sets and asking Health Care Team to evaluate needs for labs each day

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9

8

7

6

5

4

3

2

1

0

Days

lab

dra

ws

_X=2.67

UCL=4.84

LCL=0.50

Baseline New Protocol

Total Lab Draws per Patient Days

X=3.56

Pre-Protocol Post-Protocol

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4

3

2

1

0

Days

lab

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raw

n

_X=0.809

UCL=1.698

Baseline New Protocol

VBGs drawn per Patient Day

X=1.564

Pre-Protocol Post-Protocol

Blood Product Utilization and Bleeding

• Multidisciplinary Effort– Anesthesia– CV surgery– CVICU

• Data Collection• Primary Drivers and secondary drivers

identified• Leading to Standardization

Blood Product Utilization and Bleeding

Ventilator Weaning Protocol

Total Intubation Times (Median)

1 2 3 40

5

10

15

20

25

30

1211

16

28.5

5

8.37.5

19.2

3.8

6.7 7

17

2012 VWP (Initial) VWP (Overall)

RACHS

Hou

rs

6

60

50

100

150

200

250224

72 72

Postoperative Feeding Protocol Improves Outcomes Following Arterial Switch Operation

Moellinger, A., Torsch, S., Abernathy, S., Borasino, S., Alten, J. 1. Department of Pediatrics, Division of Critical Care, 2. Department of Surgery,

Division of Cardiothoracic Surgery; University of Alabama at Birmingham

CURRENT QI PROJECTS DATA COLLECTION UNDERWAY, RESULTS PENDING

HLHS: Norwood/Sano

• Includes Daily Care plan– Standardization of Management and goals of Care

• Hemodynamic Data Collection- Trends• Algorithms

– Hypotension and Hypoxia• Allows for:

– Early recognition of deviation• Team meeting: Cardiologist, Intensivist and

Surgeon

Name____________________ Lesion __________________ Surgery__________________ Date_________________

Norwood Procedure Post Operative Hemodynamic Goals Worksheet

SEND VENOUS GAS FROM in ORDER of PREFERENCE: IJ > UVC > FEMORAL. DRAW ABG and SVO2 and RECORD NON-INVASIVE MEASURES at SAME TIME .

Lactate to be sent every 4 hours until normalized; goal: decreased in half at 12 hours – normal after 24 hours SVO2 should reach its nadir at 6-12 hours post-op

Other Goals for first 72 hours: HgB > 15; temperature 36 to 37 – turn down warmer and give Tylenol for any temp > 37.5; systolic BP 55 – 75; diastolic BP > 35; Heart Rate 120-170; PIP on vent < 35; iCa 1.2 to 1.4

Qp/Qs = (SaO2 – SvO2) / (97 – SaO2) Oxygen Excess Factor = SaO2 / (SaO2 –SvO2)

Hour postop Admit 2 hr 4 hr 6 hr 8 hr 12 16 20 24 30 36 42 48 54 60 66 72 Time

SaO2 (ABG) target 70-80

SvO2 target 45-55

Pulse Ox target 75-85

MAP target 45-55

CVP target 8-12

cNIRS target > 50

rNIRS target > 60

SaO2 – SvO2 target < 25

Qp/Qs target <1.5

Arterial pH 7.35-7.45

PaCO2 target 35-45

Hemoglobin target 14-16

Lactate

Cardiac Arrest

• Debriefing- Standardized Tool• Event Review

– Team of Nurses and Physicians• Resuscitation Committee

– Systems Problems– Education: ASAP (Arrest Summary and Action

Plan)• RAP (Resuscitation Action Plan)

Multicenter Collaboration

PC4Quality.org

Identify “Real”

Variation

Study High Performers

Identify Practices

Associated with

Performance

Disseminate best practices

Improve quality

PC4: Other Benefits

• Risk adjustment• Outcome Metrics• Real Time Feedback• Opportunities for Knowledge Sharing

– Multicenter QI initiatives

Conclusions

• Quality improvement is here to stay• Standardization as the base for QI is possible

in the CVICU • Measure, adjust and measure again• Publish results to share knowledge• Multicenter QI way of the future