1. Walk 4 Your Heart: 5 Tower Ambulation Project Team Members Physician: Dr. Schwartz Nurse Practitioners: Laura Triola, Janine Morrissey, Laura Smyth 5 Tower Nurses: Karen Thomas, Gemma Jose, Georgia Oros 5 Tower Patient Care Tech: Dawn Martinsen, Gladys Lowe Cardiac Rehab Nurses: Andrea Barczak, Susan Quinn, Audrey Reda Therapists: Kristen Ragan, Nicolette Mitchell Administrators: Mike Jarotkiewicz, Pam Skocir Center for Clinical Effectiveness: Mary Altier Confidential Quality Improvement Material

2. Opportunity For Improvement The challenge for all service lines is to improve outcomes and decrease costs. Reducing length of stay (LOS) and thereby improving throughput impacts costs. A review of the literature shows that a use of critical pathway, including early ambulation, can safely reduce LOS. A review of the literature shows that a use of critical pathway, including early ambulation, can safely reduce LOS. Anderson, B., Higgins, L., Rozmus, C. Critical pathways: applications to selected patient outcomes following coronary artery bypass graft. Applied Nursing Research 1999;12(4): 198-74. Murphy, MA, Richard, T., Perkins, J. Hands, LJ. Fast track open aortic surgery: reduced post operative stay with goal directed pathway. European Journal of Vascular and Endovascular Surgery.2007; 34(3):247-8. Confidential Quality Improvement Material

3. Opportunity for Improvement Forces of Magnetism Forces of Magnetism –Force 7: Quality Improvement –Force 11 Nurses as Teachers –Force 13 Interdisciplinary Relationships

4. Project Aim Statement To reduce post-operative length of stay (LOS) in the cardiovascular surgical patients who are ambulating and are discharged to home on 5 Tower. To reduce post-operative length of stay (LOS) in the cardiovascular surgical patients who are ambulating and are discharged to home on 5 Tower. Goal of the project is to reduce LOS from 8.08 days to below or at national average of 6.17 days. Goal of the project is to reduce LOS from 8.08 days to below or at national average of 6.17 days. Confidential Quality Improvement Material

5. Solutions Implemented Need for reduced LOS indentified at CVQI meetings by Cardiovascular Service line Administrative Director. Need for reduced LOS indentified at CVQI meetings by Cardiovascular Service line Administrative Director. Multidisciplinary group brainstormed possible factors to LOS that could be modified. Multidisciplinary group brainstormed possible factors to LOS that could be modified. Priority given to solutions that would decrease length of stay and resource utilization. Priority given to solutions that would decrease length of stay and resource utilization. Expectation of walking four times daily and up in chair for all meals reinforced during pre and post-op education. Expectation of walking four times daily and up in chair for all meals reinforced during pre and post-op education. Confidential Quality Improvement Material

6. Solutions Implemented Patient is seen by cardiac rehab staff Monday through Saturday. Patient is seen by cardiac rehab staff Monday through Saturday. 5 Tower staff completes required walks with patient daily. 5 Tower staff completes required walks with patient daily. A sticker is applied to an in-room chart to track patient activity and completion of ambulation requirements. A sticker is applied to an in-room chart to track patient activity and completion of ambulation requirements. Request made by 5 Tower staff in team huddles to better communicate patient ambulation limitations. Request made by 5 Tower staff in team huddles to better communicate patient ambulation limitations. Confidential Quality Improvement Material

7. Solutions Implemented Visual cues posted in patient room to better communicate ambulation limitations. Visual cues posted in patient room to better communicate ambulation limitations. 5 Tower staff in-serviced on appropriate use of gait belt by PT/OT and Clinical Resource Nurse. 5 Tower staff in-serviced on appropriate use of gait belt by PT/OT and Clinical Resource Nurse. Patient educated on cardiovascular service care map during preoperative education. Patient educated on cardiovascular service care map during preoperative education. Families of patients are instructed in the “Walk 4 Your Heart” guidelines. Families of patients are instructed in the “Walk 4 Your Heart” guidelines. Confidential Quality Improvement Material

8. Definition: Total length of stay for cardiac surgery patients. Data collected: Society of Thoracic Surgery Database and Nurse Practitioners Analysis: Total overall LOS has decreased by 1.1 days since January 2008 with implementation of the Walk for your Heart initiative. Spike experienced in May-July with move to 5 Tower. Education and Early Ambulation Task Force created in September. Last two months, overall LOS increased due to outliers with longer stays in ICU; however, once on 5 Tower and engaged in Walk 4 Your Heart program, discharge follows shortly thereafter. Cardiac patient population move to 5 Tower Staff education and “Early Ambulation” task force created Goal: 6.17 LOS

9. Definition: Length of stay in ICU s/p cardiac surgery Data Collected: Society of Thoracic Surgery database and Nurse Practitioners Analysis: LOS in the ICU has decreased since January 2008. Since creation of “Early Ambulation Committee in September of 2008, a steady decrease is noted. However, last 2 months LOS increased due to increase number of patients with complications adding to LOS. Investigation into causes of outliers being Investigated and trended.

10. Next Steps Continue the “Walk for Your Heart” project. Continue the “Walk for Your Heart” project. Ambulation Project committee will continue to meet monthly. Ambulation Project committee will continue to meet monthly. Identify potential barriers to success of project. Identify potential barriers to success of project. Identify trends in outliers. Atrial fibrillation is the outlier identified as an area for improvement. Identify trends in outliers. Atrial fibrillation is the outlier identified as an area for improvement. Re-educate staff on project during team huddles. Re-educate staff on project during team huddles. Report outcomes to key stake holders and celebrate successes. Report outcomes to key stake holders and celebrate successes. Confidential Quality Improvement Material