title: Implementing goal-directed protocols reduces length of stay after cardiac surgery.
abstract: OBJECTIVE
  To test the effect of a high reliability organization (HRO) intervention on patient lengths of stay in the CVICU and hospital. The authors proposed that (1) higher safety related evidence based protocol (SREBP) team compliance scores and (2) lower SREBP milestone scores are associated with shorter lengths of CVICU and hospital stay.
  
  
  METHODS
  A prospective, longitudinal observational evaluation was used to assess the effects of SREBP-focused rounding processes and a milestone-tracking tool.
  
  
  METHODS
  United States, university academic medical center's 27-bed CVICU.
  
  
  METHODS
  Six hundred sixty-five adult cardiac surgery patients and the CVICU care team (100 registered nurses and 16 clinical providers) participated.
  
  
  RESULTS
  Team compliance was the proportion of SREBP-related team behaviors exhibited during daily rounds. Patients' milestone scores were the cumulative difference between actual and expected times for 4 SREBP milestones over 48 hours. Milestones achieved earlier than expected indicated reduced complication risk, and milestones achieved later than expected indicated increased risk. As team compliance increased, CVICU length of stay decreased 0.66 (95% CI: -0.04 to 1.28; p = 0.08) days; hospital stay decreased 0.89 times (95% CI: 0.77-1.03; p = 0.008). As the mean milestone scores increased from -7 to 12, length of ICU stay increased 2.63 (95% CI: 1.66-3.59; p<0.001) days; hospital length of stay increased 1.44 times (95% CI: 1.23-1.7; p = 0.05).
  
  
  CONCLUSIONS
  A milestone-driven pathway supported by team rounding was associated with decreased lengths of CVICU and hospital stay. However, tracking patient trajectories by milestones suggests a more complex relationship than anticipated and presents new opportunities for SREBP implementation and research.
authors.affiliation: Departments of Anesthesiology and Critical Care.
authors.forename: Anne
authors.initials: A
authors.lastname: Miller
authors.affiliation: Departments of Anesthesiology and Critical Care. Electronic address: Chad.e.wagner@vanderbilt.edu.
authors.forename: Chad E
authors.initials: CE
authors.lastname: Wagner
authors.affiliation: Biostatistics.
authors.forename: Yanna
authors.initials: Y
authors.lastname: Song
authors.affiliation: Cardiovascular Intensive Care Unit.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Burns
authors.affiliation: Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN.
authors.forename: Rashid
authors.initials: R
authors.lastname: Ahmad
authors.affiliation: Departments of Anesthesiology and Critical Care.
authors.forename: C
authors.initials: C
authors.lastname: Lee Parmley
authors.affiliation: Departments of Anesthesiology and Critical Care.
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Weinger
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000379:methods*; D002985:Clinical Protocols; D003422:Critical Care; D019317:Evidence-Based Medicine; D005260:Female; D006040:Goals; D019983:Guideline Adherence; D006801:Humans; D007902:Length of Stay; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D061214:Patient Safety; D011446:Prospective Studies; D013318:Stroke Volume
keywords: bundled payment; cardiac surgery; high reliability organizations; intensive care; quality improvement