Implementation of a high volume, complex clinical pathway for cardiothoracic surgery patients in the intensive care unit.

Transcription

1 Implementation of a high volume, complex clinical pathway for cardiothoracic surgery patients in the intensive care unit. Marion van der Kolk Surgeon/Intensivist UMC St Radboud, Nijmegen The Netherlands

2 Cardio thoracic surgery High volume, high risk Dedicated ICU/MC/Ward 68% of deaths in this patient group in post-op ICU ( v Heede etal 2009, Int J Nurse Stud 46(6) ) Clinical pathways rarely start in the ICU

3 Clinical Pathway Generally expressed as a day-to-day-care plan describing all multidisciplinary activities In the intensive care unit (ICU) a clinical pathway implicates an hour-to-hour care plan

4 The cardiothoracic ICU patient Starting a path

5 Pre-implementation Clinical Pathway ICU organization cardiothoracic surgery 16 beds: intensivists, fellows, residents, nurses, providers (surgeons, cardiologists) Barriers and opportunities Selection of key-nurses Education and training Heart surgery database (corrad)

6 Barriers and Risks Collaboration: Cardiothoracic surgeons vs Cardiologists vs Intensivists NICE: information of intensivists was not taken seriously Education aspect for residents Tradition: doctors autonomy Evidence was a turbulent time for our organization

7 Opportunities Head of the department of Intensive Care: total commitment Chances for nurses Radboud variance model made is possible to act fast (pro-active) The hour-to-hour care plan, together with the medical protocol made it possible that responsibilities could be taken by nurses within a legal setting

8 Method to build a clinical pathway 1 Population: Cardiothoracic Surgery 2 Literature review 6/8 Key nurses and intensivist: clinical activities and development of Radboud variance model Education Eight step method to build a pathway. Not in our minds at that time Lodewijckx etal trials :229

9 Clinical Pathway and Variance model

10 Variance report

11 Predefined goals Incidence of temperature drop >0.3 o C after arrival on the ICU Electrolytes in range Duration of weaning from the ventilator Extubation time Time to mobilization Nutrition intake

12 Overall variances measured Blood pressure and hemodynamic parameters Atrial fibrillation Thoracic drain output Diuresis Temperature Pain Sedation Start weaning Extubation Shivering Mobilisation etc etc.

13 Results Control N=53 Clinical Pathway N=53 Diff Male (n,%) 43 (81%) 44 (85%) 0.80 Age; years 65 [60-67] 64 [60-68] 0.33 Type of surgery (n,%) - Bypass - Valve and bypass - Valve single - Other 37 (70%) 5 (10%) 7 (13%) 4 (8%) 39 (74%) 1 (2%) 7 (13%) 6 (11%) 0.37 APACHE II** 14 [12-16] 13 [12-17] 0.55 Temp ICU admission** 35.9 [ ] 35.9 [ ] 1.0 **median [IQR]

14 Results Start weaning from ventilator (hrs)** Control N=53 Clinical Pathway N= [ ] 2.9 [ ] Extubation (hrs) ** 9.0 [ ] 6.5 [ ] 0.02 Mobilization day % < Mobilization within 24 hrs 0 66% < Lactate >2.0 mmol/l 21% 18% 0.48 Troponin > 2.0 mcg/l 64% 65% 0.51 Temp drop >0.3 0 C 17 % 19% 0.36 **median [IQR] p

15 Results Control N=53 Clinical Pathway N=53 Intensive insulin therapy 66% 85% 0.03 Potassium suppletion 2% 35% < Magnesium suppletion 6% 11% 0.30 Phosphate suppletion 8% 11% 0.51 Electr suppl according to protocol 6% 98 % <0.001 RR control according to protocol 9% 94% <0.001 Drain production: -No action needed -Action<30 minutes -Action >30 minutes 9 (32%) 0 (0%) 19 (68%) 46 (87%) 4 (8%) 3 (6%) p <0.001

16 Results Weaning time decreased significantly following the implementation of the clinical pathway Extubation time decreased significantly The day following surgery all included patients resumed normal nutrional intake and were mobilized, which was one day sooner than in the non-clinical Pathway group

17 Results: Clinical pathway group Over 90% of the control patients needed electrolyte or adequate blood pressure regulation, which was not started in time In contrast: Over 90% in CP group received timely and adequate treatment Nurses acted faster when abnormal drain production occured

18 Corrad : length of stay / Quarter Mean length of stay (per quarter) total

19 RISK-ADJUSTED MORTALITY ANALYSIS Cussum score Q1-Q3 2012

20 Conclusions Clinical pathway in the intensive care unit is feasible Adherence can be measured Radboud variance model enables nurses to act fast and within a save and legal setting Clinical benefits appear to be likely Hard data on morbidity and mortality will be difficult to correlate

21 Where do we stand and the future CP high volume high risk is used as blue print to develop CP s for low volume-high risk populations: Implementation of preoperative optimization of esophageal resection 2008 and 2011 was succesfull (ICU path) CP (Intensive care and Surgical ward) for esophageal resection with preoperative optimization has been implemented in september 2011 Post Anesthesia Care Unit/ICU/Ward implementation of peri-operative care for Whipple procedure is starting. HIPEC, Liver surgery, etc will follow Know the strengths and weaknesses of your wards

22 Special thanks Department Intensive Care Department Cardiothoracic Surgery Mark van den Boogaard, RN, PhD, research Corine Speelman-ten Brugge, RN, MSc Jeroen Hol, Medical Student Henry van Swieten MD PhD, cardiothoracic surgeon Luc Noyez, MD PhD, cardiothoracic surgeon Melissa Arron, Medical Student Suzanne Meijer-Wijting, Key-nurse Hans van der Hoeven MD PhD, Intensivist Peter Pickkers MD PhD, Intensivist