From the moment a cardiac patient steps on our campus until their last follow-up call, Pennsylvania Hospital is committed to making their experience as positive and stress-free as possible. Still, no amount of hospitality from our staff can make up for how overwhelming a lengthy hospitalization can be. That’s where the PAH cardiovascular surgery team – and their winning 2017 Quality & Patient Safety project centered on expediting the process without compromising quality, safety, and comfort – come in.
From top: Theresa Ryan, RN; Satoshi Furukawa, MD; Katherine Hilliard, PA-C; and Bryan Blanchard, CRNP
Earlier this year, Penn Medicine’s five Cardiovascular surgical teams came together at the 2nd Annual Cardiac Surgery Symposium to discuss the strategic initiatives they have been implementing to improve outcomes, combine assets, and create a more unified, consistent protocol across the health system. When it came time for PAH’s team to present their findings, Satoshi Furukawa, MD, chief of Cardiovascular Surgery, Katherine Hilliard, PA-C, a physician assistant in Cardiovascular Surgery, and Jonathan Parmet, MD, chief of Cardiac Anesthesia, highlighted their three goals: decreasing the need for postoperative narcotics, utilizing “on-table” extubation, and condensing the length of stay.
PAH’s cardiac surgery program is smaller than those at other entities, but the size and the same relative level of sickness among the patients make initiating changes easier. As chief, Furukawa is dedicated to introducing new pilot programs, monitoring the results, and ensuring the best outcomes in the least amount of time. For his team, the goal is to start thinking about a patient’s hours at PAH, rather than about days.
Preemptive pain control is one focus. By setting pain control expectations with the patient, then providing them with a standardized regimen of oral painkillers, a spinal injection, and general anesthesia, the team is able to prevent pain more aggressively, all without introducing an excessive amount of narcotics into the mix. Fewer narcotics means fewer patients feeling nauseous, drowsy, “loopy,” or constipated, all of which can slow recovery, cause complications, and lengthen hospitalization. And while Furukawa notes that his team is not going to single-handedly end the opioid epidemic sweeping the nation, the ramifications of not sending patients home with narcotics are not lost on him.
“The fewer [narcotics] that are out there, the fewer issues there will be,” Furukawa said. “Taking this multimodal approach to pain control and reducing the administration of narcotics after 24 hours has significant implications for our patients, their families, and their communities, even after discharge.”
With good pain control also comes the ability to extubate – remove a patient’s breathing tube – in the operating room. Since 2014, the PAH CT surgery team has sought to increase their “on-table” extubations (OTE) rate to more than 50 percent, cutting the average length of stay for patients undergoing coronary bypass surgery from 9.2 days (no OTE) to 5.6 days (OTE). If it’s not necessary to remove the tube immediately, though, why make it such a priority, especially when the surgical team is also concerned with avoiding complications like excessive bleeding, pleural effusions (fluid buildup), and thrombosis?
“Why not?” Furukawa said. “Waking up with a breathing tube is a major fear for many patients. If there’s good pain control and if they’re breathing freely on their own, why risk that anxiety? It’s a psychological thing – for the family too. There’s a big difference between walking in and seeing your loved one with a breathing tube, and finding them sitting up in a chair, breathing comfortably. If you tell them, ‘Oh, he’ll be able to go home in three days,’ but the patient is still on a ventilator, they’re less likely to believe in a quick recovery.”
That quick recovery is the ultimate goal. “Early mobilization with the help of the nurses is key, and a physical therapy consult gets them back to baseline function quickly,” Hilliard said. “The team helps patients develop a clear plan for their care after discharge, and their families or caregivers are encouraged to be involved throughout the process.”
All of this helps to further condense the length of stay and prevent readmissions. This is not to say that the CT team is trying to churn out patients and move on; to the contrary, a personal connection remains even after discharge through phone calls from Theresa Ryan, RN, scheduled follow-up visits (as well as open office visits for any concerns), and easy communication through myPennMedicine. Instead, focusing on shortening stays as much as possible through efficient procedures and clear communication helps to reduce the risk of infection, cut costs, keep up with competitive cardiologists outside of the health system, and push Penn Medicine ahead.
“You may laugh, but I imagine there one day being a drive-through cardiac surgery program, and I’m going to be the one to do it!” Furukawa said. “We used to get patients home in a week, then five days, then three. If I can get you home and recovering in three days, I can get you there sooner. And that’s the beauty of academic medical centers, and especially a small one like Pennsy. If we can do these pilot programs successfully, then larger hospitals like HUP and PPMC can scale the program to fit them. Cardiac surgery has come such a long way, but we can push it so much further. So we will.”