Asian Cardiovasc Thorac Ann 2008;16:81-85
© 2008 Asia Publishing EXchange Ltd
Coronary Heart Disease Service Framework for Revascularization in Pakistan
Maqsood M Elahi, MRCS,
Jawad S Khan, FRCS
Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, Pakistan
For reprint information contact: Maqsood M Elahi, MRCS Tel: 92 79 2901 0164 Fax: 92 79 2901 0164 Email: manzoor_elahi{at}hotmail.com, Department of Cardiac Surgery, Punjab Institute of Cardiology, Jail Road, Lahore, Pakistan.
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ABSTRACT
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Many centers across the country have used collaborative techniques to identify problems and come up with innovative solutions. Excellent improvements have been made in every aspect of the patient’s journey through the cardiac surgery services, such as decreased length of stay, reduced clinical variation and costs, and improved outcome. We looked at how the cardiac surgical team at our center is helping to improve services for patients undergoing coronary revascularization. Improvements are not just focused on waiting lists or operating rooms but reflect the wider experience of patients and their families.
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INTRODUCTION
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Coronary artery disease (CAD) is by far the most common heart disease.1,2 It results in considerable morbidity and mortality worldwide.1,3 The Coronary Heart Disease (CHD) Collaborative is now well established, and one of its most important accomplishments has been the successful introduction of "process mapping" that sets out to determine what happens to patients.4,5 However, revascularization surgery is too complex to redesign as it has too many variables and interdependencies as well as a high proportion of emergency procedures. Yet work by the CHD Collaborative within our center has established it as an effective means of improving the revascularization surgery service.
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CONTEXT OF WORK STREAM
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The goal was to improve the experience and outcomes for patients with suspected or diagnosed CHD by optimizing the care delivery system across the whole integrated pathway of cardiac care. Drawing on work of the National Service Framework for CHD, we aimed to fundamentally redesign the systems for prevention, diagnosis, treatment, and care of CHD. This generated the basic knowledge for team building and understanding of the problems encountered by patients going through the pathway, and created new ways to solve problems from diagnosis to discharge, follow-up and rehabilitation. Under the guidance of the CHD Collaborative, many of the improvements have been made with few new resources. The main resource has been time and support so that teams can look at the way CHD care is delivered and see how the systems can be improved. Doctors, nurses, allied health professionals, managers and clerical staff have come together to examine the service they jointly provide. Such detailed analysis has enabled us to streamline the surgical pathway at our center.
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WHAT WAS THE PROBLEM?
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The model for improvement was designed to provide a framework for developing, testing and implementing changes to reduce the following problems identified at our center: waits of 14 months or more for routine coronary artery bypass grafting (CABG); delayed transfer times from cardiologist to surgeon; lack of certainty of the operation date for the patient, carer and relatives. Patients were frequently advised by their surgeon or cardiologist to improve their cardiovascular risk factors prior to surgery, but there was no formal support or monitoring. Those requiring cardiac surgery within 12 weeks were kept in primary care hospitals while waiting for a bed in the tertiary center. A robust system was needed to enable patients to wait at home for surgery. Furthermore, those detained in the intensive therapy or high-dependency unit postoperatively produced a backlog that resulted in canceled operations.
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HOW WERE PROBLEMS IDENTIFIED?
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A specialist registrar working across the cardiorespiratory directorate recognized the issues and brought them to the Collaborative for further investigation. The patient-centered issues were identified as part of a 3-year radical reorganization of cardiac surgery, which included centralized waiting list management, smart operating list planning, effective management of the information gap, and optimal use of beds if stable patients requiring early cardiac surgery were to be discharged home and admitted to the tertiary center for surgery within a 12-week period. A literature review indicated that patients on a waiting list for CABG experience anxiety, fear, depression, uncertainty, frequent episodes of chest pain and have a poor quality of life with high rates of hospital readmission.
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WHAT ARE THE IMPLEMENTED IMPROVEMENTS AND OUR PROGRESS?
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The first stage was to map in detail the processes by which patients were referred for surgery, hospital admission, treatment and discharge. In addition to mapping the patient pathway, it is also necessary to have an understanding of the time it takes to complete each step.
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REFERRAL OF THE PATIENT
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Currently, the patient’s journey begins when they suffer chest pain suggestive of acute myocardial infarction or acute coronary syndrome. Our aim was to improve the speed of access, diagnosis and treatment of patients with suspected angina. Thus an important aspect of our work was to create a good relationship between primary and secondary care providers. This was achieved by development of a rapid access chest pain clinic. Changes introduced included booking system, referral and management plan templates. We audited the last 12 months of our initiative and measured the extent to which the rapid access chest pain clinic successfully substituted for the cardiology outpatient clinic in assessing new-onset chest pain referrals. All 1,300 patients with chest pain who attended the rapid access chest pain clinic were seen within 24 hours of referral. On the other hand, the 250 patients who attended the cardiology outpatient clinic waited 77 ± 33 days (mean ± standard deviation) for an appointment. Only 30 (14%) cardiology outpatient clinic patients fulfilled the criterion of recent onset of chest pain (< 4 weeks duration) vs 845 (65%) rapid access chest pain clinic patients. Thus the rapid access chest pain clinic substituted for the cardiology outpatient clinic in 845/875 (97%) new chest pain referrals. Patients from the cardiology outpatient clinic were 4% (95% confidence interval: 1.85%–7.90%) more likely to be referred for a coronary angiogram compared to those attending the rapid access chest pain clinic. These findings demonstrate that the rapid access chest pain clinic provided an efficient and effective substitute for the cardiology outpatient clinic in assessing new chest pain referrals according to predefined criteria. Other changes include an improved referral system where patients can be contacted directly by fax or email. This progress has been further supplemented by the creation of a Clinical Decisions Unit where the local cardiologist reviews cases with the visiting surgeon before the patient is seen at the clinic. The cardiac rehabilitation nurses also see the patient at this time to offer advice and rehabilitation prior to the procedure. As well as rationalizing referrals and coordinator roles, reducing waiting time and establishing integrated care pathways, a review of transfer protocols was introduced.
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PREOPERATIVE ASSESMENT CLINICS
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Before the preoperative assessment clinics were launched at our center, patients entered hospital the day before their operation to be prepared and assessed. Some were regularly found to be unfit for surgery or requiring further tests. This caused a significant number of cancelations and many urgent demands for additional tests such as echocardiography, which put pressure on diagnostic departments. Now patients visit a pre-assessment clinic 2 weeks before surgery where all the necessary preoperative checks are performed, and any additional tests are organized before admission. A multidisciplinary team is available at the clinic, many problems such as urinary infections, raised blood pressure and dental treatment are tackled preoperatively; adherence eliminates delay. Patients can now come to the ward in the afternoon, and ward staff can deal with planned discharges in the morning making sure that beds are ready on time.
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OUTPATIENT CLINICS
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Improvements in outpatient clinics have been achieved by changes such as revision of clinical times and quick access to results. Other changes include a centralized system, pooling of lists, introduction of booking systems and pre-booking tests, selection for potential preoperative rehabilitation, progressive care unit candidates, patient choice and nurse practitioner wound clinics. An integrated care pathway system was introduced to plan stages of care and assess intensive therapy unit needs according to the degree of risk quoted by the surgeon. Patients are classified into 3 groups: not requiring overnight intensive therapy, probably requiring one night only and likely to need more than one night in the intensive therapy unit.
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REDUCING WAITING TIMES
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Previously, patients had to wait 2 to 6 weeks for a surgical outpatient appointment following angiography. The delay in undergoing treatment was associated with list size at registration; there being shorter times for shorter lists (log-rank test 1,198.3, p < 0.0001). When the list size at registration required clearance time of more than one week, patients had 38% lower odds of undergoing surgery compared to those on lists with clearance time < 1 week (odds ratio: 0.60%), after adjustment for age, sex, comorbidity, period and hospital. The number of new registrations exceeding weekly service capacity had an independent effect on lengthening service delays when the list size at registration required a clearance time < 1 week (odds ratio: 0.56%), but not for longer lists. Every time surgery was performed on a patient not registered on the waiting list, the odds of surgery for listed patients were reduced by 6%. Today, this is not the case. The scheme aims to ensure that patients are treated sooner and given more choice about where and when they have their operations. The process begins with patients > 6 months on the waiting list. The local Patient Care Adviser makes contact and explains the new scheme. The surgeon reviews the patient in the outpatient clinic with the Patient Care Adviser who then initiates the choice process. Patients undergo surgery after 6–7 months of waiting. The Patient Care Adviser remains in contact with the patient up to 30 days postoperatively. Despite huge progress nationally on waiting times for surgery, locally we decided to increase the draw on resources available alongside with the large capital and revenue investment in surgical capacity by engaging surgeons and other clinicians with regard to the patient choice initiative over the previous 3 years. Many surgeons and other clinicians are already leading the way in the redesigning efforts and improvements. This has provided a new forum for networking and sharing ideas.
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SCHEDULING
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We have introduced surgical coordinators who have the trust and respect of the surgeons, to manage waiting lists as a whole rather than as individual lists. Their task is to help balance the relative priorities of urgent patients and find a suitable case mix to ensure targets are met. They are there to introduce many of the benefits of a common waiting list yet still allow surgeons control over workload, and to act as a referral point for urgent cases.
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PROGRESSIVE CARE UNIT
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A Progressive Care Unit was developed at our center primarily to reduce the number of cancelations due to the cardiac intensive care unit bottleneck. Higher-risk procedures in seriously sick patients cause greater demand for scarce resources. The aims of the Progressive Care Unit are to remove the need for admission to the cardiac intensive care unit from the patient journey, to fast tract patients to recovery (first stage) and the move to a high-dependency unit (second stage). Nursing staff assess all patients for early extubation before transfer to the high-dependency unit. Improvements were brought about with support of the multidisciplinary team. Patient selection criteria include age > 75 years, moderate to good left ventricular function, serum creatinine < 125 mol·L–1 and controlled diabetes. Recently, we audited our progress in this category and compared 2 groups of patients submitted to early and late extubation protocols after CABG with cardiopulmonary bypass, in terms of duration of ventilation and intubation and complication rates in the postoperative period. The 179 consecutive patients with poor left ventricular function (ejection fraction < 30%) scheduled for isolated CABG with cardiopulmonary bypass were audited over 6 months. There were 79 patients excluded due to preoperative inotropic hemodynamic support, low body mass index (
18–20 kg·m–2), reoperations for acute surgical complications, off-pump CABG, severe respiratory disease, recent myocardial infarction ( 7 days) or absence of relevant data. Thirty-four consecutive patients who underwent anesthesia with an early extubation protocol were compared with 66 who had anesthesia by a conventional anesthetic protocol in the same period. Demographic data, previous medical and cardiac history, preoperative medication and operative data were similar in both groups. The overall surgical mortality rate was 1.5%. Early extubation led to decreased time of intubation (0.8 vs 8.1 hours; p < 0.001) and incidence of atrial fibrillation (1 vs 7; p = 0.003) compared to the late extubation group. The findings suggest that early extubation can be safely implemented without increased risks in elderly patients with ejection fractions < 30% undergoing CABG with cardiopulmonary bypass.
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REDUCING DELAYS IN DISCHARGE
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Delays in discharge lead to delays in admissions and returns from the cardiac intensive care unit, which in turn affect operating room scheduling. After process mapping, the local team identified several issues regarding discharge, which were causing delays. They looked at several elements across the patient journey to smooth the flow of patients through the cardiac intensive care unit, high-dependency unit, ward beds and to streamline the discharge process. Nurse-coordinated discharges have greatly improved all aspects of patient discharge.
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EARLY WARNING SYSTEM
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Early identification and appropriate treatment of ill patients improves their outcome, and with this in mind, we introduced an early warning system to the cardiac surgical ward. Any patient whose parameters fall outside predetermined values triggers a warning: respiratory rate < 8 or > 30 per min; oxygen saturation < 93% or PaO2 < 8 kPa despite 
60% oxygen or CO2 > 7.0; new episode of pulse < 40 or > 130·beat–1 systolic blood pressure < 90 mm Hg or mean arterial pressure < 55 mm Hg; pH < 7.28 or bicarbonate < 20 mmol·L–1 or base excess below -5 mmol·L–1; urine output < 1–2 mL·kg–1·h–1 for 2 consecutive hours or patient not responding to commands. Once a warning is triggered, a series of medical interventions are initiated until the parameters return to the predetermined range. Following introduction of the early warning system, a significant reduction in morbidity and mortality and fewer returns to the cardiac intensive care unit were noted.
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NEAR-PATIENT TESTING
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Also known as point-of-care testing, near-patient testing is the term used for any analytical process performed for or by a patient outside the hospital clinical laboratory.6 The policy relates to point-of-care testing of arterial blood gases using an i-STAT 1 analyzer (Heska, Loveland, CO, USA) to determine blood gas profile, electrolytes, urea, creatinine, glucose and hemoglobin, in the recovery area and cardiac surgery wards. This includes patients who have undergone revascularization surgery according to set protocols. The system is not applicable to high-risk patients with blood-borne viral infections. The advantages of point-of-care testing include rapid availability of results, which leads to efficient discharge. This policy has been devised to ensure the maintenance of practice standards in accordance with clinical risk management and clinical governance issues.
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CARDIAC REHABILITATION
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Our basic aim is to create the conditions for local CHD Collaborative programs to improve the outcome and experience of patients and their carers along the rehabilitation pathway. Phase 1 occurs during the inpatient stage or after a significant change in the patient’s condition. Phase 2 is the early post-discharge period when many patients feel isolated and insecure, and support is provided by home visits or telephone contact. Phase 3 includes a structured exercise program in a hospital or community setting, with education and physiological support and advice on risk factors. Phase 4 involves long-term maintenance of physical activity and lifestyle change. One exciting area under consideration is what we describe as a menu-driven approach to cardiac rehabilitation. This recognizes that patients and carers are individuals with their own needs; a view that is supported by many health professionals (Table 1
).
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SECONDARY PREVENTION
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Simple treatments and important lifestyle changes can substantially reduce the risks of worsening CAD, and evidence shows that such measures can slow and even reverse the progression of established CAD. Subsequent work with the CHD Collaborative has allowed the exploration of exercise training and lifestyle modification prior to surgery, and now patients are selected by cardiac surgeons as suitable to undergo a period of supervised exercise training.
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PUTTING IDEAS INTO PRACTICE
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The busy last 3 years has seen increased activity; however, much has yet to be accomplished, and comparisons supported by the upcoming data audit over the 12-month period before and after implementation of the protocol are awaited. So far, patients who are clinically suitable for rapid access surgical procedures can wait at home, but with a good support system should their condition alter. The beds they would have occupied are now freed up. This makes is less likely that other coronary patients will be nursed on outlying wards. Patients are now waiting on average only 4 months for routine elective CABG, during which time they are fully supported to reduce risk factors and ensure they are as fit as possible for surgery. This reduction in waiting time has enabled the unit to begin to look at piloting a new booking system. Routine elective surgery patients will be offered a partial booking, whereby they confirm a mutually convenient date approximately 4 to 6 weeks before surgery. Patients now have a direct link with our center via a specialist cardiac nurse who maintains contact throughout the waiting period. The cardiac outreach sister has identified and corrected a number of administrative errors that may have resulted in delays in surgery. Patients now get individualized patient-focussed care based on clinical priority. This has avoided unnecessary inpatient waits with the associated anxiety for patients and carers. As a result, patients now have shorter waits, a vastly improved personal experience, and a degree of certainty and choice about their arrangements for surgery.
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IS THE IMPROVEMENT SUSTAINABLE?
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Having initially cleared the backlog, both the extra slots and improved scheduling arrangements have been successfully maintained. Centralized waiting lists have been in operation for over 2 years and yield many other benefits in the management of patient care. The booking system for CABG has now passed the early pilot phase, and the improved method of communication has ensured that all staff and patients are aware of the times. This has led to certainty for all concerned, resulting in fewer frustrations, a smoother journey and a reduction in missed or canceled operations.
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REFERENCES
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- NICE guidance on the use of coronary artery stents, Technology Appraisal 71. October 2003. Available at: http://www.nice.org.uk/download.aspx?o=TA071guidance. Accessed January 18, 2007.
- British Heart Foundation. Coronary heart disease statistics. London: British Heart Foundation, 2003.
- National Institute for Clinical Excellence. Technical guidance for manufacturers and sponsors on making submission to a technology appraisal, 2001. Available at: http://www.nice.org.uk/pdf/technicalguidanceformanufacturersandsponsors.pdf. Accessed January 18, 2007.
- Joint Health Surveys Unit. Health survey for England 1998, vol 1. Findings. London: HMSO, 1999.
- Shearer A, Scuffham P, Mollon P. The cost of coronary artery disease in the UK. Br J Cardiol 2004;11:218–23. Available at: http://www.bjcardio.com/download/944. Accessed January 18, 2007.
- Raftery J. NICE: faster access to modern medicine? Analysis of guidance on health technologies. BMJ 2001;323:1300–3.1999;89:1091–5.[Free Full Text]
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ABSTRACT
INTRODUCTION
