1. Safety and Quality in the Cardiothoracic Operating Room
Engy Hanna, MD
Director, Cardiac Anesthesia
Abington Jefferson Health
April 7, 2017

2. Objectives
Review patient safety and quality initiatives within the Cardiac Surgery Program
Discuss safety challenges that are unique to minimally invasive cardiovascular surgery

3. Cardiac Surgery: Safety and Quality
High reliability organization
Efficient, safe, consistent care
Achieve high quality care for each patient
Create a resilient cardiac team
Minimize error
Continual improvement

4. Cardiac Surgery: Safety and Quality
Team time out at start of each case
Each member contributes
Formal hand-off between anesthesia and perfusion before going on cardio-pulmonary bypass
Formal sign-out to cardiac ICU team
Anesthesiologist & RNFA  intensivist, bedside nurse, CT surgery NP

6. Cardiac Surgery: Safety and Quality
Cardiac ICU nurses maintain a secure database to identify issues on arrival to the ICU
Metabolic acidosis, uncontrolled glucose, insufficient sedation
Real time feedback to the anesthesiologists and OR team
Root cause analysis  process & system improvements

7. Cardiac Surgery: Safety and Quality
Complex or unusual cases are discussed in advance with the entire team
Surgery, anesthesia, perfusion, RNFAs, OR nursing, CSU
Every member of the team is given the opportunity to contribute to the patient’s care
Open communication and collaboration

8. Cardiac Surgery: Safety and Quality
Protocols & standardization
Bloodless Surgery
Antibiotic prophylaxis
Perioperative ICD/PPM management
Deep hypothermic arrest for aortic surgery
Emergency protocols
Intraoperative echo assessment for LVADs
Percutaneous RVAD insertion

9. CT Surgery Performance Improvement
Multidisciplinary group
Goal is to provide infrastructure for team members to improve our system
We consider the patient’s journey
Preoperative consultation  surgery  ICU  Floor  rehab and home
We work to improve steps along the way
Make the process smoother & safer for patients
Remove unnecessary obstacles for staff

10. CT Surgery Performance Improvement
Examples:
ICU nurse identified an issue with excessive noise / conversation during hand off from OR team to ICU team
Implemented a “sterile space” for sign-out from anesthesia to ICU
TAVR Coordinator identified UTIs as an issue in the TAVR patient population
She worked with ID to implement a process for obtaining a urine culture on patients with concerning UAs

11. Ensuring Safety and Quality in Minimally Invasive Cases
New & complex equipment / instruments for proceduralist
Technical factors can become a distraction during the case

12. Ensuring Safety and Quality in Minimally Invasive Cases
Standard CT OR team:
Surgeon, anesthesiologist, perfusionist, RNFAs, OR nursing
For minimally invasive cases:
Different setting (Hybrid OR or cath lab)
Additional team members (Interventional cardiologists, cath lab nurses & technicians, radiology staff)

13. Open Cardiac Procedure: Minimally Invasive Procedure:
NIBP, Pulse Oximetry, EKG, CO2 monitoring
Arterial line
Intubated / mechanically ventilated patient
Central line
CVP
PA catheter
PA pressures
SvO2
CO / CI
Cerebral Oximetry
TEE

14. Ensuring Safety and Quality in Minimally Invasive Cases
Unique challenges for the team
Anesthesia team should always be prepared for emergencies or conversion to an open procedure

15. Ensuring Safety and Quality in Minimally Invasive Cases
Abington TAVR team:
Preoperative briefings
Frequent (weekly) team meetings to discuss cases
Limited team
In addition to standard operating room time-out, we use a specific TAVR checklist
Regular team retreats to assess progress & discuss future directions

16. Future Directions for Patient Safety in the Cardiac OR
Improved design of operating rooms with focus on workflow / human factors
Simulation training to improve team communication and preparation
Routine debriefings after every case

17. Thank you