Pathway to Success – Implementing a Clinical Pathway to Improve SICU CABG Outcomes

Purpose:
Develop and implement an evidence-based post cardiac surgery clinical pathway to improve coordination of care, utilization of resources and patient outcomes. Successful outcomes are defined as: CABG ICU LOS <48 hours CABG Ventilator Time < 6 hours with an internal stretch goal of <4 hours

Relevance/Significance:
The Society of Thoracic Surgeons (STS) is a national reporting database with critical care benchmarkson the following indicators: ICU length of stay (LOS) <48 hours, ventilator Time <6hours. ICU CABG Length of stay in 2011 was 75 hours. Median Ventilator time was 4.8 Hours. This prompted a need to develop a guideline for all disciplines involved in the care which would lead to improvements in patient care, utilization of resources and outcomes.

Strategy and Implementation:
Using the Shewhart Cycle of Plan-Do-Check-Assess, a clinical pathway was developed for CABG pts: Literature review done for evidence-based practices. Multi-disciplinary team of subject matter experts formed including physicians, nurses, PT, pharmacists and RT. Clear daily goals set from immediate post-operative time until discharge. Developed a Cardiac Surgery Clinical Pathways Designated a dedicated step-down area (CCU) for post open heart patients. Educated the Critical Care Staff on pathways. Educated the Critical Care Nurses on care of the post open heart patient in the ICU and Step-down unit. Created a clinical dashboard to trend patient data and outcomes. Monitored compliance with utilization of Clinical Pathway via daily chart audits by leadership team. Assessed patient tolerance and adherence to the pathway daily with the Critical Care team during Interdisciplinary Rounds. Discussed unit progress and outcomes monthly at the SMH Cardiac Surgery Taskforce meeting.

Evaluation:
ICU Median CABG LOS fell from over 70 hours in 2011 to 30 hours in 2014 with readmission rates also reduced. ICU median Ventilator times were reduced from 5.8 hours to 4.2 hours with reintubations rates reduced. And Mortality was reduced to ZERO in 2014. The pathway helped to reduce variability in care while closing the loop of communication among HCP.

Implications for Practice:
Utilization of a clinical pathway was an easy tool for HCP providers to use daily in the management of post CABG patients. The pathway ensured that patients progressed along a predetermined track within an acceptable timeframe and served as an educational resource for both HCP and patients.