This document discusses two opportunities to improve clinical, operational, and financial performance in cardiovascular surgery: 1) Standardizing treatment of coronary artery bypass graft (CABG) patients to reduce length of stay by implementing preventive atrial fibrillation medication protocols and ensuring effective heart rate stabilization and anticoagulant therapy. 2) Improving diagnosis of patients presenting with suspected acute myocardial infarction to improve outcomes and reduce length of stay by improving timeliness and accuracy of diagnostic testing through use of clinical pathways. Key performance measures for each opportunity are also outlined.

1. Improving Clinical, Operational,
and Financial Performance in
Cardiovascular Surgery
Cardiovascular surgery is one of the highest
revenue-producing specialties in U.S. health
care. When combined with cardiology, it is
estimated to contribute approximately one-
fifth of revenues to not-for-profit hospital
coffers. The successful planning and imple-
mentation of data-driven process improve-
ment initiatives in cardiovascular surgery thus
are critical for most acute care hospitals.
Although many improvement opportunities
exist, we focus here on two key opportunities—
the first with coronary artery bypass graft
(CABG) patients and the second with suspect-
ed heart attack patients.
Opportunity: Standardize and improve
treatment of CABG patients to reduce
their LOS
Problem: Approximately one-third of CABG
patients experience atrial fibrillation, a
disturbance in the rhythm of the heartbeat,
which delays their discharge, thereby
extending their length of stay (LOS).
Increased LOS decreases an organization’s
throughput and increases its costs, resulting in
decreased financial performance. Further-
more, patients with atrial fibrillation are at
increased risk for further complications of
care, including increased risk for stroke.
Strategy 1: Implement preventive atrial
fibrillation medication protocols.
Multiple studies have been completed in the
past decade demonstrating the efficacy of
several pharmacologic agents, including
amiodarone, in reducing the risk of atrial
fibrillation when administered prophylactically.
Typically these agents have decreased
postoperative atrial fibrillation rates by 10 to
20 percent.1 Hospital physician leaders could
consider developing and implementing a
protocol for the prophylactic administration of
amiodarone for CABG patients. Standardiza-
tion of this preventive approach could reduce
variation in care outcomes and LOS.
Performance measures:
• LOS by DRG
• Costs by DRG
• Total CABG patients
• Total elective CABG patients receiving and
not receiving prophylactic amiodarone
• Percentage of elective CABG patients with
prophylactic amiodarone who developed
atrial fibrillation (compared with percentage
of elective CABG patients with prophylactic
amiodarone who did not develop atrial
fibrillation)
HFMA and McKesson have collaborated on a four-part series of
educational reports focusing on opportunities for process improvement
in hospitals. This is the second report in that series.
The first report, “Key Strategies for Sustained Performance
Improvement,” presented three broad strategies that can be used to
improve overall performance. It appeared in the November 2004 hfm,
and can be found on the HFMA web site at http://www.hfma.org/
performance.
Watch the HFMA web site for the third and fourth reports, which will
present specific opportunities for performance improvement in
orthopedic surgery (report to be released in May) and laparoscopic
cholecystectomy (report to be released in August).

2. Strategy 2: Ensure effective heart-rate
stabilization and antithrombolytic
medication therapy.
Patients who are experiencing atrial
fibrillation are at increased risk for stroke, as
mentioned earlier. They require rate-control
intravenous anticoagulant medications to
stabilize their heart rates. A typical regimen
begins with heparin administration, followed
in later days by administration of warfarin.
Clinicians manage this complex medical
scenario to minimize risk of stroke. If
medications are provided in the right sequence
and duration, outcomes can be improved and
LOS reduced.
Performance measures:
• CABG LOS
• CABG variable direct costs
• Percentage of total CABG patients with atrial
fibrillation
• LOS for CABG patients with atrial
fibrillation
• Time between CABG procedure and first
evidence of atrial fibrillation, using rate-
control medication administration as the
proxy
• Percentage of atrial fibrillation patients suf-
fering a stroke postoperatively
Opportunity: Improve the diagnosis of
patients presenting with suspected acute
myocardial infarction to improve their
clinical outcomes and reduce their LOS
Problem: Rapid diagnosis of acute
myocardial infarction (AMI) is critical to
optimal patient outcomes.
Heart attacks are a high-volume health prob-
lem worldwide, and nearly 5 million
Americans suffer a heart attack each year.
Individuals presenting to EDs with acute chest
pain and suspected AMI represent one of the
most pressing diagnosis and care challenges
faced by acute care facilities. Every minute
that passes without medical treatment after a
heart attack reduces patients’ survival rates.
The costs associated with diagnostic workups
are significant, yet at least one-third of pre-
senting patients have not actually experienced
an AMI. Unfortunately, 5 to 8 percent of
patients discharged from the ED are found to
have suffered an AMI.2 Failure to diagnose and
treat AMI patients in the ED results in large
malpractice settlements each year.
Strategy: Improve timeliness and accuracy of
diagnostic workup.
If a heart attack is suspected, the ED physician
will usually order tests to confirm or rule out a
heart attack. Tests may include an electrocar-
diogram, echocardiogram, cardiac enzyme lab-
oratory studies, stress test, or coronary
catheterization. Timing of diagnostic tests and
their accurate interpretation by ED staff are
critical. Standardization of the ordering of
tests through use of clinical pathways can
reduce costs per stay (for example, decrease
wastage of nuclear cardiology and cardiac cath
laboratory materials) and LOS, while improv-
ing patient satisfaction.
Performance measures:
• Time from presentation in the ED and start
of cath laboratory procedure
• Mortality
• LOS
• Timing, utilization, and outcomes of
coronary catheterization
1. Institute for Clinical Systems Improvement, “Atrial fibrillation,”
Bloomington, Minn: Institute for Clinical Systems Improvement, 2003.
2. McCarthy, B.D., Beshansky, J.R., D’Agostino, R.B., et al. “Missed Diagnosis
of Acute Myocardial Infarction in the Emergency Department,” Annals of
Emergency Medicine, 1993. 22:579-582.mington, Minn: Institute for
Clinical Systems Improvement, 2003.
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