Standardized practice design with electronic support mechanisms for surgical process improvement: reducing mechanical ventilation time.
BACKGROUND
Hospital surgical care is complex and subject to unwarranted variation.


OBJECTIVE
As part of a multiyear effort, we sought to reduce variability in intraoperative care and management of mechanical ventilation in cardiac surgery. We identified a patient population whose care could be standardized and implemented a protocol-based practice model reinforced by electronic mechanisms.


METHODS
In a large cardiac surgery practice, we built a standardized practice model between 2009 and 2011. We compared mechanical ventilation time before (2008) and after (2012) implementation. To ensure groups were comparable, propensity analysis matched patients from the 2 operative years.


RESULTS
In 2012, more than 50% of all cardiac surgical patients were managed with our standardized care model; of those, 769 were one-to-one matched with patients undergoing surgery in 2008. Patients had a mix of coronary artery bypass grafting, valve surgery, and combined procedures. Our practice model reduced median mechanical ventilation duration from 9.3 to 6.3 hours (2008 and 2012) (P < 0.001) and intensive care unit length of stay from 26.3 to 22.5 hours (P < 0.001). Reintubation and intensive care unit readmission were unchanged. Variability in ventilation time was also reduced.


CONCLUSIONS
We demonstrate that in more than 50% of all cardiac surgical patients, a standardized practice model can be used to achieve better results. Clinical outcomes are improved and unwarranted variability is reduced. Success is driven by clear patient identification and well-defined protocols that are clearly communicated both by electronic tools and by empowerment of bedside providers to advance care when clinical criteria are met.
*Department of Anesthesiology and Center for the Science of Health Care Delivery, Division of Cardiovascular Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN †Department of Anesthesiology, Division of Cardiovascular Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN ‡United Surgical Partners Inc, Addison, TX §Department of Surgery, Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN ‖Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN ¶Health Services Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, Rochester, MN.
David J
DJ
Cook
Juan N
JN
Pulido
Jeffrey E
JE
Thompson
Joseph A
JA
Dearani
Matthew J
MJ
Ritter
Andrew C
AC
Hanson
Bijan J
BJ
Borah
Elizabeth B
EB
Habermann
D000368:Aged; D006348:Cardiac Surgical Procedures; D001330:Electronic Data Processing / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units; D007430:Intraoperative Care / Q000592:standards*; D007442:Intubation, Intratracheal; D008297:Male; D017410:Practice Guidelines as Topic; D012121:Respiration, Artificial / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome