Arthur St.Andre, MD FCCM
Robert Molyneaux, PA-C
Joyce Donnellan, RN

A male subject experienced chest pain during exercise one recent fall afternoon, requiring an emergent visit to the Washington Hospital Center’s (WHC) emergency department. During hospitalization a cardiologist stented his right coronary artery; however, he required further revascularization by cardiac surgery. During cardiac surgery the left internal mammary artery was grafted to his LAD artery, and a saphenous vein was grafted from the ascending aorta to his circumflex artery. Seven days later he returned home.

The clinical armamentarium to care for patients with complex coronary artery disease developed rapidly over the last decade. Simultaneously, the clinical and administrative processes to incorporate this source evolved successfully. Together these helped capitalize on the skills of clinicians resulting in programs such as the Washington Hospital Center’s, where more than 2,000 cardiac surgery procedures are performed each year. One step in our subject’s care occurred during the first 24 to 48 hours after surgery in an intensive care unit. A description of this period exemplifies some of the cornerstones of a successful large program.

The clinical team in WHC’s Cardiovascular Recovery Room (CVRR) is composed of nurses, mid-level practitioners (physician assistants and acute care nurse practitioners) and critical care physicians. Each provides 24-hour in-hospital coverage of the CVRR, which accepts 8-12 new patients daily. A myriad of additional supporting services and personnel contribute to the program. Success rests on the skills of individuals and the tools and resources necessary to provide care. It particularly relies on the dedication of the team to utilize and cultivate the guidelines, protocols, order sets and pathways developed to care for patients effectively and efficiently along the continuum of hospitalization. The central principle in this approach is the tacit agreement to care for patients uniformly modifying management according to the nuances of an individual patient rather than the particular desires of individual practitioners. This principle allows continuity, consistency, effectiveness and efficiency.

As patients arrive from the operating room and the baton passes to the CVRR team, a report is received with information stating that the operative, anesthetic and cardiopulmonary bypass techniques were uniform regardless of surgeon, anesthesiologist or perfusionist. This allows the use of a single postoperative order set to be developed and maintained by the critical care team in concert with the surgical team through a process of consensus. The order set drives the content of the clinical pathways. The pathway incorporates additional procedural details, time-based outcomes and communication milestones. These coincide with a patient’s expected pattern of recovery from surgery and the subsequent phases of hospitalization.

As a patient recovers from cardiac surgery, fluctuations in blood pressure and cardiac index, awakening from anesthesia and recovery of respiratory function occur. During this period, there may be excessive mediastinal bleeding and (rarely) tamponade. Practitioners use written guidelines to address these physiologic processes to provide care. Guidelines include basic principles as well as the steps of evaluation, monitoring and therapy to take in response to the dynamic recovery process. They address analgesia, sedation, weaning from the ventilator, use of blood products, evaluation and management of the cardiac system and hyperglycemia.

Of paramount importance in utilizing this approach are the skills and watchful eyes of each practitioner. An expert team effectively applies guidelines but quickly and flexibly deviates from them when patient physiology does not “cooperate” with expectations. This occurs more often when patients experience significant myocardial depression or excessive bleeding. Even when patients “fall” off a pathway, team members anticipate management since they are guided by critical care physicians with similar practice patterns. The day after surgery, 85% of patients transfer from the CVRR to a non-ICU environment by use of programmatic guidelines and expert clinician judgment.

The system supporting the cardiac surgery program is vital to its success. A most critical factor is the orientation and training of nurses and mid-level practitioners. Utilizing the central principles as a guide, orientation takes several months. Similarly, as new surgeons and critical care physicians join the staff they also participate in an orientation process. Once orientation is completed, clinician skills are reinforced and become solidified by exposure to numerous patients in large cardiac surgery programs such as the one at WHC. Skills of evaluation and management are emphasized during daily multiprofessional rounds by the critical care team where care is critiqued and alternative scenarios are discussed. If untoward events occur, discussions with the participating practitioners take place within 48 hours to analyze and talk about how to avoid future mishaps and astutely manage those that do occur. These discussions contribute to further growth of individual expertise and development of guidelines, pathways and order sets.

Departmental and cross-departmental operational committees support a process of study and consensus development. As a result, the documents supporting the pathway process undergo periodic revision in response to internal and external evidence-based practice, changes in patient acuity and modifications in operative and preoperative management. As an example, a guideline for the evaluation and management of heparin-induced thrombocytopenia (HITT) evolved in recent years and undergoes frequent revision. HITT may impact patients throughout hospitalization. Consequently, practitioners along the entire postoperative continuum with assistance from hematology have participated in the development and nurturing of this guideline. The development and maintenance of each guideline requires a point person--a champion who assumes responsibility to catalyze and foster the process.

This approach to care is not unique to WHC. An essential fundamental is effective implementation and frequent reassessment of guidelines, order sets and pathways by clinicians with significant experience in their development and execution. The prime factor in successful patient care is the participation of skilled practicing clinicians and their dedication to being guided but not rigidly channeled by a standardized approach to care of this large patient population.