Difficult Decisions in Cardiothoracic Critical Care Surgery: An Evidence-Based Approach

Critical care medicine is responsible for many of the most important advances in outcomes after cardiothoracic surgery in the past two decades.  The expertise developed in this subspecialty accounts for the resiliency that characterizes gold standard results evident in institutions recognized for excellence.  This volume is intended to share ideas and algorithms that will improve outcomes in cardiothoracic critical care units. 

This book is part of the Difficult Decisions in Surgery series that covers surgical specialties.  The volumes are multi-authored, containing brief chapters, each of which are devoted to one or two specific questions or decisions within that specialty that are difficult or controversial.  The volumes are intended as a current and timely reference source for practicing surgeons, surgeons in training, and educators that describe the recommended ideal approach, rather than customary care, in selected clinical situations.  

• Language: English
• Publisher: Springer
• Release date: Feb 13, 2019
• ISBN: 9783030041465

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© Springer Nature Switzerland AG 2019

V. A. Lonchyna (ed.)Difficult Decisions in Cardiothoracic Critical Care SurgeryDifficult Decisions in Surgery: An Evidence-Based Approachhttps://doi.org/10.1007/978-3-030-04146-5_1

1. Introduction

Vassyl A. Lonchyna¹  

(1)

University of Chicago, Chicago, IL, USA

Vassyl A. Lonchyna

The original version of this chapter was revised. The correction to this chapter can be found athttps://​doi.​org/​10.​1007/​978-3-030-04146-5_​46

The mechanics of blood flow through the aortic valve and aortic root have only recently been described. However, the concept of how this flow shapes the movement of the anatomic structures in this part of the circulatory system was first described centuries ago by da Vinci:

The three-cusped valves of the heart were seen by Leonardo as a perfect example of mathematical necessity in the workings of nature. As blood was forced through the valve, eddies in the sinuses curved back into the cusps of the valve. When the flow ceased, these eddies opened the cusps against one another to form a perfect seal, preventing reflux. (Fig. 1.1) [1]

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Fig. 1.1

DaVinci Aortic valve. (RCIN 919082). Leonardo da Vinci. 1512–13. Royal Collection Trust / © Her Majesty Queen Elizabeth II 2018. [1]

This farsighted observation and musing by a thoughtful and inquisitive painter, sculptor, scientist, architect, engineer, anatomist, inventor and physiologist took almost 500 years to be proven correct [2]. Not only is he a true Renaissance man but he could be considered the father of Evidence Based Medicine. His above described conclusion came after multiple observations (such as the movement of spikes driven through pig’s hearts at their slaughter), multiple human cadaver dissections and laboratory experiments duplicating blood flow through the aortic valve:

…he described and drew a way to make a glass model of the heart. When filled with water, it would allow him to observe the way blood would swirl as it passed into the aorta. He used a bull’s heart as a model, filling it with wax using the sculptor’s technique he had used in creating a model of the brain. When the wax hardened, he made a mold to build a glass model of the heart chamber, valve and aorta. By sprinkling in grass seeds, he made the flow of water more visible. [3]

Evidence Based Medicine

Acute observations, an inquisitive mind, honesty, and knowledge are all traits that have served scientists and experimenters well in promulgating discovery. Medical therapeutics has likewise evolved over the centuries due to the works of notable physicians and scientists. Change, or improvement, is proceeding at breakneck speed in current times. Although one might say that we as clinicians have always practiced medicine based on research and data, this has crystallized more in the late 1990s and is the mantra of the current generation of physicians.

Evidence based medicine (EBM) consists of identifying a clinical problem or question, doing a focused search in the literature for relevant studies, choosing the most pertinent studies, and critically evaluating them for guidance as to the right answer to the initial clinical question. The guru of EBM, Dr. David L Sackett of Oxford University, described this succinctly in an editorial in 1986 that resonates even today:

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.

Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.

By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. [4]

EBM is a continuum. It relies on investigators challenging the status quo and creating trials and experiments that will test sometimes time-honored precepts of medicine or new concepts. Through structured studies, the gold standard of which is the randomized controlled trial (RCT), one can produce data that can confirm or dispute current thinking, a hypothesis or the benefits of a therapeutic regimen.

Is it possible to reverse our medical thinking? Prasad and Cifu in their 2015 book Ending Medical Reversal show with multiple examples how traditional, widely practiced therapeutic regimens have been reversed based on good quality studies, be they an RCT or a meta-analysis of multiple studies. In fact, the authors go out on a limb to say that a good deal of what doctors do is wrong. Our treatments are often widely instituted before there are good studies to show the benefits or harms to the patient. The reversal occurs when robust clinical studies prove ineffectiveness of certain therapeutic regimens [5].

A History Lesson

The Death of George Washington

George Washington died in the late evening hours of December 14, 1799 (Fig. 1.2). His terminal illness was quick but he suffered terribly. The day after riding for five hours at his farm in Mt. Vernon in inclement wet snowy weather, the President developed a sore throat, chills, fever, and difficulty swallowing and breathing. Summoned to his bedside, his long time personal physician, Dr. James Craik, bled him (as was the norm in those days for respiratory illnesses) twice (about 600 ml each time). He summoned consultants Dr. Brown and Dr. Dick. After their arrival, another 950 ml of blood was bled. In addition, Washington was given purgatives and enemas, which contributed to his dehydration. He remained conscious but had labored breathing. The younger Dr. Dick suggested a new procedure he had just learned, tracheostomy, to relieve his breathing. He was overruled by his older colleagues. The tremendous therapeutic loss of blood along with dehydration caused his death from hypovolemic shock that was hastened by the suffocation caused by his inflamed epiglottis [7].

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Fig. 1.2

Washington on his deathbed. Junius Brutus Stearns. 1851. (Courtesy Wikimedia Commons) [6]

Bloodletting as Therapy

The physicians of the ancient world, most notably Hippocrates, considered humans to have four basic humors: blood, phlegm, black bile and yellow bile. Disease was considered to cause an imbalance of these humors, so a readjustment was conceived of: bloodletting [8]. Bloodletting was the therapy for many maladies, especially pneumonia and other infections. It was also used prophylactically in the spring and autumn to reinvigorate the human body.

At the time of Washington’s death, there were physicians who saw the danger and ineffectiveness of bloodletting. One of the most staunch supporters of this therapy, however, was the noted signer of the Declaration of Independence, Dr. Benjamin Rush. During the yellow fever epidemics of 1793 and 1797 he pushed his depletion therapy of vigorous purgatives and aggressive bloodletting. He was challenged in Philadelphia on his results and poor record keeping by a publisher, William Corbett, which resulted in public feuding and such editorializing as, The times are ominous indeed when quack to quack cries purge and bleed (Porcupine’s Gazette, Sept 19,1797) [9].

Meanwhile, in Edinburgh, two physicians likewise took opposite sides in the usefulness of bloodletting. Dr. William Alison was stubborn in keeping with his clinical experience and empirical observation in defending this age old practice. The younger Dr. Hughes Bennett was more progressive in that he relied upon newer methods in pathology and physiology to prove or disprove effectiveness of therapy. Central to his argument was that he observed an improved outcome in patients with pneumonia as the incidence of bloodletting diminished [8]. Here, in the middle of the nineteenth century, was the beginning of the use of statistics and an epidemiological approach to the study of the effectiveness of therapy as well as a more scientific study of disease [10].

Unfortunately, it would take almost another century to fully debunk the use of bloodletting. Even the esteemed physician Sir William Osler, in his first edition of Principles and Practice of Medicine (1892), described several indications for bloodletting, including timely venesection in cases of pneumonia [11]. This recommendation continued well after his death, as noted in the 14th edition (1942) of his classic textbook [10]. Finally, bloodletting, after a run of several millennia as a widely accepted and practiced therapy, was abandoned when its ill effects (hypotensive shock) and its ineffectiveness and harmfulness as a therapy was finally recognized and accepted. Perhaps George Washington could have been saved from his ultimate acute illness of epiglottitis if he were not bled and purged into hypovolemic shock (four times for total of more than 2.1 l). Here, then, is an example of medical reversal upending a sacred medical practice. In the last hundred years, the red tide has turned and we are infusing blood as rapidly and frequently as physicians of yesteryear bled them of massive amounts for any and every condition that offendeth man.

With Washington’s breathing difficulty, what should have been done to rescue him from his symptoms of epiglotitis? Tracheostomy in 1799 was not yet a common procedure in the armamentarium of the physician. The history of tracheostomy goes back to the beginning of mankind. It was, however, during the Renaissance that this procedure was utilized in resuscitation, in drowning and choking victims, and in animal experiments. Despite knowledge of this procedure, its implementation was haphazard until well into the middle of the nineteenth century with the discovery of anesthesia and the usefulness of endotracheal intubation for airway control.

Dr. Dick dared to suggest this intervention at the bedside of George Washington, but was overruled or intimidated into not trying it by the other more senior physicians at the bedside. I proposed to perforate the trachea as a means of prolonging life, and for affording time for the removal of obstruction to respiration in the larynx… It was received at first, at least by one of the physicians, with a seeming acquiescence…and finally a firm opposition to the measure (letter written by Dr. Dick on January 10, 1800 and published in 1917 in The Medical Record [12]).

Here was a technique that surely would have been of benefit yet, at the time, had not undergone enough scrutiny and study to be commonly accepted. One may question, however, the need for exhaustive trials to prove the worth of tracheostomy in a patient with respiratory embarrassment. To intervene could be lifesaving, to do nothing leads to suffocation. This is a lesson from history of a very difficult decision in the setting of critical illness; one could even argue of a surgical nature (to cut or not to cut…). The therapy afforded at that time, bloodletting, has, with appropriate studies, undergone medical reversal. The surgical procedure of tracheostomy, which could have been lifesaving, was not yet evaluated, studied and accepted widely enough to have become the standard of care.

The Book

This is a volume that is dependent upon evidence-based data to support the difficult decisions made in the course of treating critically ill patients in the ICU. The authors were tasked with developing their chapter themes by first structuring the questions to be asked according to the PICO (Patients of interest, the Intervention that was applied, Comparator patients with similar conditions but treated differently, and Outcomes of interest) model (Fig. 1.3) [13]. Examples of questions asked to focus the search strategy are listed in Fig. 1.4 [13].

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Fig. 1.3

PICO model. (Data from [13] with permission from the University of Illinois)

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Fig. 1.4

The PICO model for clinical questions. (Data from [13] with permission from the University of Illinois)

Once the search strategy was formulated, a literature search in PubMed, Cochrane Collection, Google Scholar and other databases was performed. By focusing the search queries using PICO terms, the authors could optimize their efforts in finding the most relevant studies needed to support their chapter themes. Selected papers were evaluated as to the quality of the evidence presented. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system for grading the evidence is used throughout this book. The authors were to develop recommendations for what is the best practice based on the published evidence. The strength of the recommendations likewise follows the GRADE system.

Grade

Guidelines that serve to provide clinicians with the most up to date recommendations about the diagnosis and treatment of various diseases and guiding them through alternative therapies have been created by various working groups and professional societies for several decades. The evaluation of the quality of evidence and the strength of the recommendations have been inconsistent because of the various different methodologies used. For the last 20 years the GRADE Working Group, based at McMaster University in Hamilton ON, but with an international collaborative group, has developed a system that combines the best of all the systems for grading guidelines.

An advantage of the GRADE system over others is that there is clear separation between the grading of the quality of evidence and the strength of the recommendations. Other strengths are that outcomes of alternative management strategies are evaluated; there are precise methods and instructions on the upgrading and downgrading of the quality of evidence ratings; the process of moving from evidence to recommendations is clear and structured; and the interpretation of the recommendations as strong or weak are clear and unambiguous to the user of the guidelines [14].

The universality of interpretation and use of guidelines that follow this GRADE system of evaluation is acknowledged by the policy of the publisher of The British Medical Journal Group to require that authors submitting clinical guidelines articles use this GRADE system for grading evidence [15]. To date, the GRADE system is used by more than 106 organizations world-wide, amongst them the World Health Organization (WHO), American Association of Chest Physicians (AACP), Society of Critical Care Medicine (SCCM), American Thoracic Society (ATS), Up to Date and The Cochrane Collection [15].

Two major components of the GRADE system of grading are the evaluation of the quality of evidence and the strength of the recommendation.

Quality of Evidence

The GRADE system classifies the Quality of Evidence into: high, moderate, low and very low quality [14]:

High quality – Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality – Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality – Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality – Any estimate of effect is very uncertain."

Randomized controlled trials (RCT) are the pinnacle of evidence based studies and are rated high in quality. Observational studies lack the stringent data and organization of a RCT that they are rated low in quality. Expert reports, case reports and other uncontrolled clinical studies and observations are valued as very low in quality of evidence [14]. Ratings must remain fluid because they sail in a sea where weather and sea conditions change and can cause changes in the outcome of the voyage. Our confidence in the study may be decreased by flaws noted in the study, such as reporting bias, inconsistency of results, imprecision of estimates (manifested by wide confidence intervals), and study design limitations. In that case, our classification of the quality of evidence may be downgraded [16]. The quality of evidence may be upgraded if there is a very large magnitude of effect, (the evidence becomes stronger), if there is a dose-response gradient or if all plausible biases would reduce an apparent treatment effect [16].

Why Separate the Evidence from the Recommendation?

A high quality of evidence does not necessarily translate into a strong strength of recommendation and vice versa. To give separate evaluations allows the clinicians to better understand the treatment recommended for a particular disease or condition. While the evidence from a robust RCT study shows clear benefits, there may be side effects that may lead to a weak recommendations. The therapy must match the patient both in compatibility and desires. The choice of the patient must be taken into consideration when weighing the pros/cons of the therapy. Most importantly, the overall benefit of the therapy for the individual patient should outweigh the possible adverse effects.

Strength of Recommendation

Simply put, the strength of recommendation is a reflection of our confidence that the purported desirable effects of the therapy are greater than the undesirable effects [17].

The recommendation can be strong, weak, or conditional. It is dependent not only on the quality of evidence but on the balance between desirable/undesirable side effects, preferences of the patient (patient autonomy) and even best use of resources (global health).

Desirable effects may be an improved survival, reduced morbidity, improvement of quality of life, or any measure that is an indication of the success of the intervention. Undesirable effects are adverse side effects that may detract from the goal of therapy.

With a strong recommendation the author or patient or clinician are confident of the superiority of the desired over the undesired effects. With a weak recommendation, the confidence level is brought down to that of probably outweighs. This simplifies possible decisions made by the patient. A strong recommendation is one that has overwhelming positive strengths and will most likely be acceptable to the patient and treating physician. A weak recommendation introduces enough doubt that the patient or clinician will weigh carefully the effects and may need additional discussions and possibly structured decision aids to help in tailoring the intervention to the patient [17].

The strength of recommendation also can be applied to diagnostic tests and treatment strategies. Here one deals with not only the accuracy of the test (true/false positives, true/false negatives) but more importantly, how does the diagnostic test result impact the outcomes important to the patient. A true positive result in a diagnostic test may lead to the use of a therapy of benefit to patients while knowing a test is a true negative may spare the patients an unnecessary test/therapy. In the case of a false positive test, it may lead a patient to have unnecessary therapy and may even put him at risk unnecessarily. A false negative test may prevent a patient from receiving therapy that is necessary or even lifesaving [18]. Knowing the accuracy of tests help to guide the patient in the selection of tests needed. Despite the accuracy of tests, it is only if patients sustain an improved outcome do they have value [18].

Should costs of therapy be a factor in the GRADE evaluation? This is a challenge to most clinicians involved with guideline development. Costs could be considered as another outcome, relevant when comparing various ways of managing the patient. Many clinicians may feel that costs should not influence daily decisions for therapeutic intervention in patients. But healthcare costs do affect society and a particular treatment plan may increase or decrease these costs [19].

Policy makers charged with distribution of global health care resources need to incorporate costs into the availability and distribution of health care resources, especially if such resources are limited. The parable of the tragedy of the commons underscores the need to take a communal responsibility for providing effective healthcare and bearing responsibility for its costs [20].

Summary

This book is unlike any other in the field of surgical critical care because it incorporates the criteria of evidence based medicine in the text. We are well into the twenty-first century and live in an era where we have to question our behavior on a daily basis – where is the data that what I am offering my patient has merit and what is my confidence level in this data?

Medical information has exploded and complete mastery is impossible. We must rely on working groups to research the most focused and highest quality literature and provide information in the form of guidelines to steer us in the right direction in the care of our patients. Gone are the days when we were guided only by our personal experience. Gone are the days when our mentors can back up their teachings by saying That’s the way I’ve done it for years and it’s always worked out well. We have to be observant, as our clinical experience is very important. We have to know how to read the literature, how to question dogma, and know that our endpoint is to achieve the best outcome for our patients.

The GRADE system of evaluation is a transparent and accurate method of evaluating medical studies. A thumbnail sketch is provided above but the reader is encouraged to delve deeper into this system of grading by going to the web site of the GRADE Working Group, where the most up to date information is available [15].

References

1.

Clayton M. Leonardo da Vinci. The anatomy of man. Boston: Little, Brown and Company; 1992. p. 130.

2.

Robicsek F. Leonardo da Vinci and the sinuses of Valsalva. Ann Thorac Surg. 1991;52:328–35.Crossref

3.

Isaacson W. Leonardo da Vinci. New York: Simon & Schuster; 2017. p. 419.

4.

Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71.Crossref

5.

Prasad VK, Cifu AS. Ending medical reversal. Improving outcomes, saving lives. Baltimore: Johns Hopkins University Press; 2015.

6.

https://​upload.​wikimedia.​org/​wikipedia/​commons/​b/​ba/​Life_​of_​George_​Washington%2C_​Deathbed.​jpg. Accessed 27 Aug 2018.

7.

Wallenborn WM. George Washington’s terminal illness: a modern medical analysis of the last illness and death of George Washington. 1999. The Washington Papers. http://​gwpapers.​virginia.​edu/​history/​articles/​illness/​. Accessed 18 Jan 2016.

8.

Greenstone G. The history of bloodletting. BC Med J. 2010;52:12–4.

9.

Davies NE, Davies GH, William Corbett SE. Benjamin Rush and the death of General Washington. JAMA. 1983;249:912–5.Crossref

10.

Thomas DP. The demise of bloodletting. J R Coll Physicians Edinb. 2014;44:72–7.Crossref

11.

Osler W. Principles and practice of medicine. 1st ed. London/New York: Appleton & Co.; 1892. p. 530.

12.

Nydegger JA. The last illness of George Washington. Med Rec. 1917;92:1128.

13.

PICO Model. The University of Illinois at Chicago’s Library of the Health Sciences at Peoria. http://​researchguides.​uic.​edu/​c.​php?​g=​252338&​p=​3954402. Accessed 15 Mar 2017.

14.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6.Crossref

15.

The organizations from 19 countries around the world that have endorsed or are using GRADE. The GRADE working group http://​gradeworkinggrou​p.​org. Accessed 23 Aug 2018.

16.

Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ. What is quality of evidence and why is it important to clinicians? BMJ. 2008;336:995–8.Crossref

17.

Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schunemann HJ. GRADE: going from evidence to recommendations. BMJ. 2008;336:1049–51.Crossref

18.

Schunemann AHJ, Oxman AD, Brozek J, Glasziou P, Jaeschke, Vist GE, Williams JW, Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH. GRADE: grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 2008;336:1106–10.Crossref

19.

Guyatt GH, Oxman AD, Kunz R, Jaeschke R, Helmand M, Liberati A, Vist GE, Schunemann HJ. GRADE: Incorporating considerations of resources use into grading recommendations. BMJ. 2008;336:1170–3.Crossref

20.

Roman BR. On marginal health care – probability inflation and the tragedy of the commons. N Engl J Med. 2015;372:572–5.Crossref

Part IQuality, Care and Ethics

© Springer Nature Switzerland AG 2019

V. A. Lonchyna (ed.)Difficult Decisions in Cardiothoracic Critical Care SurgeryDifficult Decisions in Surgery: An Evidence-Based Approachhttps://doi.org/10.1007/978-3-030-04146-5_2

2. Quality and Value in the Cardiothoracic Intensive Care Unit

Kevin Lobdell¹  , Joe Mishkin¹, Rakesh C. Arora², ³ and Rohan Mukund Sanjanwala²

(1)

Atrium Health, Charlotte, NC, USA

(2)

Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada

(3)

Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada

Kevin Lobdell

Email: [e-mail]

Keywords

QualityValueRiskTeamworkCommunicationGoal-directed therapy

Introduction

High-value health care provides both high performance and high reliability [1, 2]. The domains of quality (Q), safety (S), value (V), as well as the applied resources (R), are fundamental to high-value cardiothoracic critical care (CCC)-where V α (Q + S)/R. Cardiac surgery and associated CCC efforts are common, costly, and contribute greatly to a hospital’s income and profit margin [3, 4]. Cardiac surgical risk correlates with cost, additive costs of major complications associated with cardiac surgery are substantial, and a strong correlation between poor quality and increased cost has been demonstrated [5–10].

Various models for death and complications have been developed and lend insight into risk-adjusted performance, (but the statistician George E. P. Box would remind the reader that all models are wrong, some are useful [11]). Risk scoring systems can be static-calculated only prior to operative intervention, dynamic-evolve with patient’s clinical course, general, organ specific, associated with a specific phase of care [12] (e.g. before anesthesia or in the intensive care unit), and may be specialty specific-such as the Society of Thoracic Surgeons Adult Cardiac Surgery Risk Calculator and EuroSCORE II [13, 14]. Risk model characteristics include, calibration-observed and expected rate of agreement, discrimination-ability to separate high & low risk or those that have event/disease from those that do not, accuracy, precision, etc. [15–17]

Search Strategy

The PICO question asked for this review was, In the post cardio-thoracic surgery patients admitted to the intensive care unit, what is the impact of high-value critical care compared to standard care on outcomes such as ICU length of stay, postoperative complications, quality of life and survival? Using the PICO framework (Table 2.1) an electronic search was performed using combination of MeSH terms and their synonyms that include Open & Closed Intensive Care, Intensive Care Staff Model, Activity Based Staffing, Acuity Based Staffing SBAR, Goal Sheets, Checklist, Multidisciplinary Rounds, Tele-ICU, Teamwork, and Goal Directed Therapy. The databases searched were PubMed, Cochrane Evidenced Based Medicine, Embase, Science Citation Index/Social Sciences Citation Index, and Google Scholar. Studies, including publication type such as systematic reviews, literature review, randomized control trials (RCT), prospective cohort studies (PCT), case reviews and editorial correspondence from 2000 till 2017 were included. The studies were graded according to the GRADE system.

Table 2.1

PICO terms for quality, value and risk assessment in the CCC

Results

Cardiothoracic Critical Care (CCC) Structure

Organizational staffing of critical care units with closed management by dedicated critical care trained providers, as opposed to the open model of non-critical care trained providers, has been shown to correlate with lower mortality, morbidity, and shorter LOS [18]. Intensity of staffing and nighttime intensivist staffing requires further investigation [19–21]. Activity based staffing has been studied for decades and the concept of optimizing staffing for complexity is essential in high-value CCC [22, 23]. Refer Table 2.2 for quality of evidence.

Table 2.2

Structures of the CCC

PCT Prospective cohort study, RCT Randomized controlled trials, LOE Level of Evidence, NA Not Applicable, ICU intensive care unit, LOS Length of stay, RR relative risk, RaR Rate ratio

aStudy population included medical and/or surgical intensive care unit patients

Cardiothoracic Critical Care (CCC) Process

Reliable group interactions in high-risk environments, such as CCC, are fostered through disciplined communication and should include efforts such as Situation-Background-Assessment-Recommendation (SBAR) and read backs [25]. Goal sheet utilization positively correlates with improved communication of goals and shorter ICU LOS [26] (Table 2.3). Similarly, checklists and hand-off tools correlate with improved efficiency-LOS & readmissions-and efficacy-reduced mortality and morbidity [27, 28] (Table 2.3). Multidisciplinary teams are standard in contemporary cardiac efforts [29]. High performing CCC teams are proactive, interactive, precise, expert, and provide continuity [24, 30]. Teaming is increasingly utilized in other complex industries and vital to the delivery of high-value CCC [35]. Regularly scheduled multidisciplinary rounds capitalize on the expertise of the healthcare team and may mitigate mortality risk for critically ill patients [31, 32, 36]. Our patient-centered transformational redesign (PCTR) in CCC, utilizing tele-rounding and tele-ICU technology, mirrors that of others who have lowered mortality, morbidity, and reduced LOS [32, 36]. Comprehensive, integrated innovation such as PCTR, where talent is leveraged with technology, creates value by matching demand and resources, eliminating unnecessary variation, bottlenecks and waste, and affords the CCC team the opportunity to learn faster through an increased volume of patient encounters and learning through pattern recognition [33, 37]. CCC teams must share goals, mental models, learn together, and focus on learning how as opposed to learning what [38]. Disciplined programs to improve the quality, safety, and value of cardiac surgical care are well documented and should aim to avoid complications, arrest the cascade of complications, and improve failure-to-rescue rates [34, 39, 40]. Considerable variation in cost to rescue has been described without obvious outcome benefits from high-cost institutions [41].

Table 2.3

Various process and methods in the CCC

PCT Prospective Cohort trial, NA not applicable, NR Not Reported, ICU intensive care unit, LOS Length of stay, LOE Level of Evidence, MDT multidisciplinary team, PCTR Patient-centered transformational redesign

a(FTR) Mortality related to stroke, renal failure, reoperation and prolonged ventilation

Goal-Directed Therapy (GDT)

GDT-popularized by Shoemaker-sets physiologic goals and employs various therapeutic strategies with the aim of mitigating the risk of untoward outcomes [42–44]. Quantified goals include blood pressure, cardiac index, systemic venous oxygen saturation, & urine output. Additionally, oxygen consumption, oxygen debt, lactate levels, and other biomarkers may augment diagnostic modalities and therapeutic tactics. Intraoperative GDT has been studied and risk of acidosis, AKI, and respiratory insufficiency may be mitigated through these efforts [45–47].

GDT in CCC patients consistently demonstrates reduced complication rates and length of stay [48–51]. For example, Osawa et al. reported on 126 patients randomized to cardiac output driven algorithm and the primary outcome was a composite endpoint of 30-day mortality and major complications [52]. The study demonstrated that the cardiac output driven algorithm was associated with a significant reduction in the composite endpoint along with reduced ICU and hospital length-of-stay (LOS), reduced infection rate, and reduced occurrence of the low cardiac output syndrome. Although the isolated 30-day mortality rate remained unchanged, the data suggest that GDT may significantly reduce complications and LOS for cardiac surgery [52]. Additionally, Kapoor et al. correlate GDT efforts with reduced LOS, duration of inotrope use, a more rapid decline in lactate levels after surgery, and lower levels of biomarkers-BNP and NGAL-that are associated with complications [53, 54].

Optimal goals, their means and rate of achievement (e.g. oxygen debt repayment schedule), their interactions, and potential to mitigate specific complications, such as AKI [55, 56], requires further investigation. Cost-effectiveness and value of GDT have been studied in surgical patients, but not in cardiac surgery [49, 57]. Refer to Table 2.4 for GDT in the CCC.

Table 2.4

Goal directed therapy (GDT) in the CCC

GDT Goal dirated therapy, PCT Prospective Cohort Trial, RCT Randomized Controlled trial, GDT Goal direct therapy, AKI Acute Kidney Injury, ICU Intensive care unit, LOS Length of stay, PCWP Pulmonary capillary wedge pressure, SVR systemic vascular resistance, CI Cardiac Index, QualyP an additive score design to estimate perfusion adequacy

Recommendations

Use of closed staffing model such as greater use of intensivist may improve survival and reduce ICU and in-hospital LOS. Such approach is not associated with increased resource utilization. This recommendation is not consistent for prolonged ICU stay patients, nor for night-time intensivist staffing.

Greater use of critical care trained staff may improve survival and reduce LOS (Level of evidence: Low, Limited Data; Strength of Recommendation: high (Ib), Benefits > risk)

An experienced, multidisciplinary team evaluating patients in critical care may reduce efforts, conflicting aims, and patients’ confusion resulting in improved patient safety by reducing preventable harm. The multidisciplinary collaboration can be enhanced by improved communication and information transfer tools such as goal forms, hand-offs, tele-ICU and checklists is associated with increase survival and reduced LOS (ICU and in-hospital).

Multidisciplinary team and standardized use of communication tools improves patient safety, reduces LOS and improves survival (Level of evidence: Low, Limited data; Strength of Recommendation: moderate (IIb), benefits > risk)

Goal Directed Therapy targeting physiological parameters such as Cardiac Index (CI), oxygen delivery (DO2), maximum oxygen consumption (VO2), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance (SVR), systemic blood pressure, and urine output, with a goal to optimize perfusion may result in reduced incidences of acute renal failure; shorten ICU and hospital LOS and improved survival.

GDT targeting perfusion parameters such as CI, DO2, VO2, PCWP, SVR, systemic blood pressure, and urine output results in reduced AKI, LOS and improved survival (Level of evidence: moderate; Strength of Recommendation: strong (Ib), benefits > risk)

Personal View

It is said that the future is here, it’s is just not evenly distributed [58]. This statement alludes to the considerable variation in care quality, safety, and cost. The future of quality, risk assessment and mitigation, safety, and value in CCC will be built on a foundation of real-time data management, analytic capability, computer decision support, and the widespread access and utilization by clinicians. The natural history of this technological innovation-diminished costs and increased accuracy and reliability-will also accelerate universal adoption. For example, biomarkers, wearable biosensors and the ‘Internet of Things’ [59] will facilitate the development of personalized, proactive strategies and early warning systems to assure quality and mitigate risk. Simultaneously, continuous, rapid learning by clinical teams will occur and compliance with protocols and pathways will be ascertained. Finally, workflow must be evaluated and comprehensively re-engineered to mitigate the risk of complications and clinician burnout [60–62].

Summary

The staggering costs and inefficiencies of cardiothoracic surgery and CCC coupled with an exponential improvement in data management, analytics, and decision support create an epic opportunity to revolutionize care. Systematic and meticulous risk assessment and mitigation of modifiable risks must be incorporated into all aspects of cardiac surgical care. Continued innovation in technology and teamwork communication will accelerate the transformation of high-value, networked, and decentralized CCC. Proteomic and genomic investigation and innovation will add additional insight.

Appendices

Appendix 1

Examples of the surgeon, anesthesia and intensivist handover checklist from the St. Boniface Hospital, Winnipeg, Canada

../images/441225_1_En_2_Chapter/441225_1_En_2_Figa_HTML.png../images/441225_1_En_2_Chapter/441225_1_En_2_Figb_HTML.png../images/441225_1_En_2_Chapter/441225_1_En_2_Figc_HTML.png

Appendix 2

Examples of goal sheets from the Carolinas Medical Center, Charlotte, NC

../images/441225_1_En_2_Chapter/441225_1_En_2_Figd_HTML.png../images/441225_1_En_2_Chapter/441225_1_En_2_Fige_HTML.png

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© Springer Nature Switzerland AG 2019

V. A. Lonchyna (ed.)Difficult Decisions in Cardiothoracic Critical Care SurgeryDifficult Decisions in Surgery: An Evidence-Based Approachhttps://doi.org/10.1007/978-3-030-04146-5_3

3. OR to ICU Patient Handoff: A Matter of Communication

Subhasis Chatterjee¹  

(1)

Michael E. DeBakey Department of Surgery, Division of General & Cardiothoracic Surgery, Baylor College Medicine, Houston, TX, USA

Subhasis Chatterjee

Email: [e-mail]

Keywords

Critical carePatient safetyHandoff checklists

Editor’s Note

This chapter is an introductory white paper into the need for handoff checklists in the CT surgical intensive care unit. It was presented at the 2018 Annual Meeting of The Society of Thoracic Surgeons (STS). The STS Workforce on Critical Care took up the task of performing a systematic review of this topic and is in the process of preparing a Practice Guideline on Handoffs from the OR to Cardiothoracic Surgical ICU that will be published in The Annals of Thoracic Surgery in 2019. The reader is encouraged to download this document (https://​doi.​org/​10.​1016/​j.​athoracsur.​2018.​11.​010) for a full evidence based medicine review, critique and recommendations of this important ICU communications tool.

Introduction

Since the landmark Institute of Medicine’s report To Err is Human was published in 1999, the estimate of 44,000–98,000 preventable hospital deaths annually in the United States has justifiably focused attention on patient safety [1]. In 2007, The Joint Commission’s (TJC) Annual Report on Quality and Safety Mandate listed the implementation of a standardized approach to handoff communications, including an opportunity to ask and respond to questions, as a requirement for hospitals [2]. Other medical specialties have shown similar encouraging benefits of handoffs in surgery [3] and procedural checklists for central line placement promoting patient safety [4]. Handoff communications involves the transfer of information, responsibility and authority to ensure patient care continuity and safety. In this chapter we will review some of the important questions regarding handoff checklists:

1.

Why should we have handoff checklists?

2.

Is there data that shows that handoffs make a difference?

3.

How do I implement checklists in my intensive care unit?

Why Have Handoff Checklists?

Handoffs are more important now due to the recognition that breakdown in communication during transitions of care may result in adverse events. With resident duty hour restrictions, there is an increasing recognition of the discontinuity of care as postoperative care is divided amongst more caregivers. One investigation found that 85% of sentinel events were a result of communication breakdowns while 77% of communication errors occurred during the late shift in surgical intensive care units [5]. Additional challenges in a cardiothoracic surgical ICU include a decrease in mandated cardiac surgery rotations by the American Board of Surgery. As a result, surgical residents are increasingly replaced by advanced care practitioners (e.g. Physician Assistants, Nurse Practitioners) as primary first-line caregivers in the intensive care unit (ICU). Such a development represents a significant change in the landscape of the surgical ICU landscape over the last 10–15 years.

Increased documentation requirements for billing impacts intensivists by requiring significant increases of an intensivist’s time for this purpose. Intensivists must ensure that rounds and handoffs are efficient without sacrificing important information. Nursing shortages may result in less experienced nurses working at night, a vulnerable time in an ICU. In academic medical centers cross coverage demands routinely require a single resident to cover 20–40 ICU patients a shift. Moreover, it has been demonstrated that preventable adverse events have doubled under cross-coverage. Since a typical patient may experience 15 handoffs in a week, this requires that a proper handoff is performed to prevent untoward complications [6].

The Society of Thoracic Surgeons has recognized the critical role of communication: Operating room to intensive care unit handoffs are a particularly vulnerable area for communication breakdown, with a clear risk for direct patient harm [7]. It is vital to communicate surgical and anesthetic concerns from the operating room to the multidisciplinary intensive care unit teams. When evaluated it has been shown that postoperative information is lost after 52% of handoffs with only 30% of essential surgical information transferred [8]. Root cause analysis frequently implicates inadequate ICU handoffs in near miss scenarios. At its worst, handoffs have been described as remarkably haphazard [9]. Rushing the handoff can lead to small but critical errors that may lead to patient harm. Patient safety recognizes that individual clinicians interact with each other (team) and with their environment (system). On the other hand, handoffs are also an opportunity to be able to improve care. During a handoff, the person accepting the responsibility has a fresh perspective while having the opportunity of detecting fixation errors [10]. The team immediately taking care of a patient in the OR or ICU may be highly focused on one particular approach of patient care. A fresh set of eye may provide an alternative approach to the patient.

Communication failures are a prime cause of sentinel events. Indeed, it has been recognized that a focus on improved communication is a key aspect of reducing medical error. An analysis of 444 closed surgical malpractice claims found that 60 (13.5%) cases demonstrated communication breakdowns [11]. This was distributed across all surgical phases with 38% identified in the preoperative phase, 30% intraoperative, and 32% postoperatively. Furthermore, status asymmetry between specialists and experience levels was identified as an important component of the communication breakdown. Further analysis showed that 43% of communication breakdowns occured during handoffs [11]. This responsibility often falls on the shoulder of the attending intensivist who must create a culture where less experienced members of the care team do not feel intimidated to voice a concern. The critical care teams must view these as teachable moments and an opportunity for education. Successful reduction in the breakdowns of communication can improve patient safety and reduce errors.

The ability to look at other industries and learn lessons that are applicable is important. Prof. Marc de Leval of the Great Ormond Street Hospital sought to analyze Formula 1 pit stop crews to better understand the handoffs in congenital cardiac operating rooms to the ICU [12]. The journey from the operating room to the intensive care unit was identified as a high-risk environment. It was discovered that current handoffs were unstructured with distractions, parallel conversations, and that key personnel were not always present and available simultaneously. A structured organization of the handoff process was found to lead to a reduction in errors [12]. Hierarchy and the perception of feeling incompetent is often a reason why information transfer may not occur. Promoting the concept that sharing information is not a sign of weakness but a sign of competent strength is important to establish a culture of safety.

Is There Data That Handoffs Make a Difference?

What kind of complications can be reduced? In a large review, the big difference observed was a reduction in preventable complications (prolonged hypotension, line complications, anaphylaxis/allergic reactions, iatrogenic pneumothorax) as opposed to serious complications (cardiac arrest, death, myocardial infarction, sustained metabolic acidosis, neurologic injury/stroke, acute renal failure) [13]. A systematic review of important characteristics of handoff checklists identified specific items: a standardized process (checklists and handoffs), completing urgent clinical tasks before the handoffs, allowing only patient-specific discussions during the handoff, requiring all relevant team members to be present, and providing training in team skills and communication [14]. Each of these suggests that communication between the ICU and the surgical team is important. An extension of that is the concept of trigger events which are serious events, staff concerns, or changes in patient location that prompt communication with a surgical attending directly. This may have prevented 26–44% of the communication breakdowns in one analysis [11].

What can we learn from other industries? In airline safety culture, the Tenerife airport disaster of 1977 is a case in point. Two Boeing 747s’ collided on the runway in the Canary Islands killing almost 600 people. Investigation into that crash revealed that garbled transmission from the air traffic controllers to the cockpit along with culture of adherence to strict hierarchy prevented questioning the captain, even in the face of imminent catastrophe, with disastrous consequences [15]. As a result, this led to the development and implementation of a standardized handoff communication practice. [16]. NASA psychologist John Lauber developed the concept of crew resource management, which were a set of training procedures to use when human error could result in serious adverse consequences [17]. After studying airline cockpits for several years, Lauber realized that while it was necessary to retain a command hierarchy, the concept was intended to foster a less authoritarian cockpit culture. Co-pilots were encouraged to question captains if they observed them making mistakes. Gordon, Mendenhall, and O’Connor’s book Beyond the Checklist is instructive and emphasizes the need for buy-in at the highest levels [18]. Moreover, the concepts of standardized information transfer, up-to-date information, limited interruptions, and structured face-to-face handoffs are integral for safety. As clinicians we need to engage thusly as an active part of the environment where we practice.

How to Implement Checklists

In 2013, the American Heart Association issued a Class I recommendation that formal handoff protocols be implemented during the transfer of cardiac surgical patients [19]. The process of handoffs should begin in the operating room with a phone call to the intensive care unit staff to provide notification of when a patient is expected to arrive from the OR to the ICU [20]. This allows for preparation of personnel and equipment for a smooth transition. Breaks and personnel allocation can be planned with this in mind and simultaneous expected arrivals can be anticipated. Close coordination between nursing, critical care, respiratory therapy, radiology technicians can be facilitated for the arrival of the patient in the ICU. The handoff structure requires that the room is quiet and there are no interruptions. A protocol determines who speaks and in what order i.e. surgery then anesthesia. Checklists provide a structured format of the expected contents for a verbal handoff (usually consisting of a separate surgeon and anesthesiologist checklist). An integral element of structured handoffs is avoiding a noisy environment with