NY hospitals offer benchmark for CABG

How does your hospital compare?

Although the number of coronary artery bypass graft (CABG) surgeries has increased by 12.6% in the past three years, the risk-adjusted mortality rate for patients in New York hospitals has dropped more than 40% in the last five years, reports a state health department in its annual cardiac surgery report.

The report, which has been published since 1989, not only evaluated 1994 mortality rates for 31 hospitals but also lists mortality rates for all surgeons who performed more than 200 CABGs during 1992 to 1994.

What factors contribute to these good outcomes? Cost Management for Cardiac Care asked the top hospitals’ physicians and nurses to identify them. Here are their answers:

1. High volume.

Of the nation’s more than 1,000 hospitals that performed CABG surgery on Medicare patients from 1990 to 1994, only 170 had a volume of at least 250 per year, pointed out Mehdi Marvasti, MD, director of cardiovascular surgery at St. Joseph’s Hospital in Syracuse, NY. The 431-bed facility, which has one of the country’s largest cardiac programs, performed nearly 1,700 operations during that period.

"When a procedure is performed over and over, surgeons develop more experience, so quality improves and complications decrease," says Marvasti, who outperformed all other surgeons in the state. Only one out of the 530 patients he operated on from 1992 to 1994 died as a result of complications from the surgery.

2. Skill and experience of entire team.

"Certainly there’s strength in numbers, but surgeons couldn’t achieve these high outcomes all by themselves," Marvasti stresses. "In order to be a top-performing hospital, you must have outstanding anesthesiologists, cardiologists, nurses, respiratory therapists, and physician assistants."

The current team has been working together for several years, he notes.

Alan Guerci, MD, agrees. "The skill and experience of the surgeons do have the greatest impact," says the medical director at St. Francis Hospital in Roslyn, NY. "So you not only have to attract people who trained at top programs, but who excelled within those programs."

Unlike a teaching hospital, St. Francis has a volunteer medical staff who maintain private practices in the community. "Particularly in a non-teaching environment like ours, where you do not have junior-level residents to assist, you cannot cut corners on the rest of the team and have good results," he warns. "In addition to outstanding cardiologists, anesthesiologists, and respiratory therapists, you must have a core of highly skilled nurses who can function like junior-level residents."

Guerci rarely accepts a nurse right out of school. "They need about five to 10 years of experience in order to function at the capacity required," he says.

3. Intense staff training.

That’s why St. Joseph’s puts such a high premium on hiring experienced nurses and then training them extensively, says Leslie Holmberg, RN, formerly the clinical nurse specialist for clinical care, now the heart disease prevention coordinator.

"Most nurses with general experience don’t have the specifics needed for a cardiac facility, such as how to interpret an EKG rhythm," she says. "So it is incumbent to provide the level of education necessary for quality patient care to occur."

For example, St. Joseph’s educational program for critical care nurses includes the following:

• partial day of classes on basic hemodynamics, peritoneal dialysis, and ventilator support;

• cardiovascular day, in which areas such as invasive and non-invasive diagnostic studies, ischemic heart disease, and treatments such as PTCA, stenting, atherectomy, and CABG are studied;

• a six-day EKG and arrhythmia course;

• a three-day class, plus mentoring, on cardiac and critical care medication;

• a four-day class on the respiratory, endocrine, renal, and neurological systems.

"The goal is that the RN will appreciate the interdependence of these body systems and intervene appropriately to improve patient care," Holmberg says. This teaching period also includes psycho-social considerations for cardiac patients.

At St. Joseph’s, nurses don’t undergo this rigorous curriculum during the initial orientation. "We don’t do it too soon because, first, we want them to get through the basics that every orientation contains and become familiar with their job. Second, we want to make sure they are happy working in this area."

The training program is executed in stages. "They alternate working for a while and increasing the level of knowledge," she says. "For example, we wouldn’t expect them to work with a balloon pump immediately."

Although Holmberg admits that this education of staff is an "expensive consideration," cost estimates are not available. "We have attempted to cost it out, but we are constantly changing the program to fit the demands so the data wouldn’t be accurate," she explains. "It is just the cost of doing business; the commitment to education and training results in quality outcomes."

Senior staff also mentor newcomers on the unit itself. "That’s essential to our outcomes because it enables new nurses to access years of practical experience," she says.

4. Commitment to patient needs.

"We offer high tech, of course, but for this level of outcomes, you must offer high touch as well," Holmberg says. "That means a commitment to going beyond typical hospital boundaries in order to best serve the patient."

For example, the blistering cold climate of New York is often a deterrent to discharging patients in a timely manner.

"Family members can’t drive through a blizzard [to pick up the patient], so we’ve arranged nearby home care accommodations [at an apartment building with home care on site] as a backup discharge plan," Holmberg says.

The stay, which usually lasts about two days, is covered by most health plans.

Another important part of meeting patients’ needs is a comprehensive patient education program that begins before admission.

"In the past, we taught postdischarge information in the hospital, but we found they don’t remember it. Now we have two classes a week that coincide with their preadmission testing," Holmberg explains.

A multidisciplinary cardiac team also designed a critical care pathway for patients, which is first presented at the class.

"We use a user-friendly format with cartoons to explain what they can expect when," Holmberg says. (See sample of form, pp. 7-8.)

Nurses also help patients and family members identify risk factors for cardiac disease. "We don’t just tell them what to do but show them how to do it," Holmberg says. "For example, we not only include information about diet, but we give them specific recipes."

Part of maintaining long-term outcomes is not having patients return, she notes. "We tell them, ‘Consider this is a once-in-a-lifetime opportunity!’"