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Cardiac Surgery at Mountain View Medical Center 2017

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Summary of the processes used to improve cardiac surgery at MVRMC and the resulting outcomes for the program during 2017.

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Cardiac Surgery at Mountain View Medical Center 2017

  1. 1. Mt. View CT Surgery 2017 and in the future
  2. 2. Timeframe N Observed Mortality Expected Mortality O/E ratio Jan 2016 – Sep 2016 17 5.9% 2.2% 2.9 Timeframe N Observed Complications Expected Complications O/E ratio Jan 2016 – Sep 2016 17 17% 13% 1.1 Timeframe N Observed Blood Use Expected Blood Use O/E ratio Jan 2016 – Sep 2016 17 88% 43% 2.0 Timeframe N Observed Operative Time Expected Operative Time Jan 2016 – Sep 2016 17 355 min 309 min MORTALITY MAJOR COMPLICATIONS BLOOD USE OPERATIVE TIME
  3. 3. 0 10 20 30 40 50 60 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% More 0 5 10 15 20 25 Mortality Mortality and Morbidity Outcomes for Heart Surgery at Mt. View Dec ‘16 – Dec ‘17 (n=202) 17% 16.5 16 15.5 15 14.5 14 13.5 13 12.5 12 11.5 11 10% 8 6 4 2 0 Observed Expected O/E 0.75 O/E 0.83 Histogram of M&M Risk for CT Patients at Mt. View frequency Morbidity and Mortality Risk
  4. 4. Time Performance Low High Rapid Improvements 1st case …Nth case Robotic program introduced Trial and error Status quo Team Learning of Less Invasive Surgery Novice Proficient Expert
  5. 5. Expectations Time Low High 1st case …Nth case Status quo Organizational Learning of Less Invasiveness Novice Proficient Expert
  6. 6. Expectations Low High Status quo “The minimally invasive…much less traumatic. By the time you go home, you're pretty much ready to go back to work.“ LA Times, story by T Maugh Sept 2011May 1997 May 1999 “…backed away from minimally invasive after poor outcomes, concerns about difficulty, and high cost of the equipment.” Wall Street Journal, story by Ralph King “Our experience with the DaVinci robot… continues to be positive and satisfying, encompassing more than 200 patients with 1 death and 2 permanent strokes.” Editorial, Mayo Clinic Proceedings
  7. 7. Expectations Time Performance Low High Low High Rapid Improvements 1st case …Nth case Robotic program introduced Trial and error Status quo Organizational Learning of Robotic CABG Novice Proficient Expert STEP 1: Uncovering the Expectations – Reality Gap Expectations- reality gap
  8. 8. Concerns about the Safety of Less Invasive 1. Limited field of view slows response to adverse events 2. Case selection is both challenging and critical to success 3. Existing training does not address # 1 and #2 http://www.roboticctsurgery.com/2016/02/07/the-scandal-of-robotic-heart-surgery-training-and-what-to-do-about-it/
  9. 9. Learning Curve Challenges • Communication • Learning from failures • Teamwork • Prepare for safety threats Edmondson, Amy et al. Speeding Up Team Learning. Harvard Business Review 2001: 125-132.
  10. 10. Less costly More costly More Costly Categories Inhaled nitric oxide/flolan Intraop mentoring for TEE Anesthesia assistants for CT cases ECMO (two CT surgeons/perfusionists) Less Costly Categories Employee training: HRO Time-outs/OR briefings Debriefings in OR, ICU and IMC Participate in the STS database Safety Investments
  11. 11. Improvements • IT issues • Margo/Robin: Angiograms • Margo: Echo images sent via text • Matt: vital signs in robotic console • Equipment/supplies • Tim/Ray: IABP (cables, helium, working with cath lab), EKG troubleshooting • Carla/Melinda: esophageal pacing, fibrilator box, vital signs screen, cerebrox, cinch Medtronic MV, aortic cannula without stopcock, two iron interns • Jennifer: ABG vs. lab Hct, hemolyzed samples • Bob: Factor VII dosing • Tim: pleurovac/cell saving • Robin/Chelsie: abx dosing for wound infection • Communication • Mark: implicit vs. explicit (closed loop), safety of open RA/RV while on CPB • Chad: cerebral oximetry • Deannette: pacing wire/CO2 in the field • Robin: postop issues (SBP, reintubating) • Anesthesia: one-lung and pulm HTN • Dee: sterility, sponge counts, motherly advice • Matt: expertise with Everest patch, looking for bleeding sites • Tim/Roberto: reminders about unique patient issues (subclavian occlusion, femoral disease, IVC filter) • Becky: difficult airway • Safety • Matt/Carla: groin a-line • Tim: emergency bypass pack • Margo: new habits (time outs x 2 and at 6 hr) • Rhiana, Ann: TEE support • Robin/Chelsea: risk assessments • David: routine on-table CXR • Pericardial effusion prior to TEE removal, extubation checklist • Jim/Pat/Katt: flolan • David: de facto ICU director
  12. 12. Expectations Time Performance Low High Low High Rapid Improvements 1st case …Nth case Expectations- reality gap Robotic program introduced Trial and error Status quo Organizational Learning of Robotic CABG Novice Proficient Expert STEP 2: DILEMMA OF INFORMATION ASYMMETRY
  13. 13. Stakeholders outside the robotic OR: Administrators Referring physicians ICU nurses/managers Ancillary staff QA/Peer review Surgeon colleagues/competitors
  14. 14. Perfect Information CABG Imperfect Information Robotic CABG George A. Akerlof. The Market for "Lemons": Quality Uncertainty and the Market Mechanism. The Quarterly Journal of Economics, 1970; 84(3):488-500.
  15. 15. Improvements: ICU RN in the Operating Room • Rationale • Improve ICU nurse performance in the early postop phase • Provide assistance to anesthesia in high workload period • Metrics of success • Evaluate hemodynamics and ischemia effectively • Troubleshoot drips and lines • Give protamine, fluid and blood products and describe response • Empathy • Announce their arrival • Give them a break at 30 minutes
  16. 16. Near Misses • Severe protamine reaction • Off CPB without awareness • Low AUC for cerebral oximetry • Off CPB with ongoing surgical bleeding • Occlude coronary with no heparin • Large ptx noted after extubation • Retained heartstring
  17. 17. Dealing with Conflict • Administering protamine • Responding to intraop critique • Scheduling cases/room assignment • Changes in the arrangement of the room • Overreact to equipment problems • Staffing of valve cases • OR extubations • SBAR – “poor respiratory status” • Concerns about doing cases robots/off-pump
  18. 18. Expectations Time Performance Low High Low High Rapid Improvements 1st case …Nth case Expectations- reality gap Robotic program introduced Trial and error Status quo Organizational Learning of Robotic CABG Novice Proficient Expert STEP 3: ADAPTING TO A NEW WAY
  19. 19. 1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME
  20. 20. 1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME
  21. 21. Things to Watch Out For • Old habits • Noise in the OR (ventilation, too many people) • Work overload (anesthesia, perfusion) • Accountability (echo training, high risk cases) • Situational awareness • Cognitive tunneling/High stress decisions • Administration • Follow-up: TEG, CVVH machine • Involvement in clinical decisions
  22. 22. Robotics Increases the Risk of Blame • Adverse event: Loss vs. foregone gain • Poor morale – judgment calls go the wrong way Criteria for Blame Before Adverse Event After Adverse Event Blameworthy Planning Safety Risk unforeseeable Persistence = grit Negligent planning Persistence = disregard of safety Could’ve Type of program Type of surgeon Program is innovative Highly skilled Program is unsafe Skills are idiosyncratic Should’ve Cause of event Accountability Pioneering effort Team learning curve Reckless behavior Surgeon unable to learn Didn’t https://robpostonblog.wordpress.com/2017/12/26/the-real-reason-most-cardiac-surgeons-dont-use-robotics-its-not-about-patients/
  23. 23. Unique value of less invasiveness OPCAB results

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