Innovative Methods to Transform Cardiac Care Have Never Been Better

The American Association of Thoracic Surgery (AATS) annual meeting was held in Toronto between in early May 2019. Quality was central to the agenda and emphasized by AATS President David Adams MD from Mount Sinai Health System as well as Eugene Blackstone MD from the Cleveland Clinic. We’re fortunate that for 30 years our specialty — cardiac surgery — has had the Society of Thoracic Surgeons Adult Cardiac Database (STS-ACD) which is recognized as the “gold standard” for clinical databases. The cardiac surgery database has supported our specialty’s leadership in quality improvement. In fact, the STS-ACD represents greater than 99 percent of the USA’s cardiac surgery programs and has supported the National Quality Forum’s approval of more than 30 metrics — the most of any specialty — and public reporting of risk-adjusted outcomes. It will also soon have personalized reviews for surgeons to evaluate their efforts, learn, and improve. The strategic use of advanced, innovative technologies such as cloud computing, automated data abstraction and analysis, as well as artificial intelligence, will accelerate the systematic improvement of cardiac care.

Also, most noteworthy were the multiple interactive sessions highlighting leading efforts on vital issues through all phases of care. This emphasis on quality, safety, and value was highlighted in the Enhanced Recovery After Surgery (ERAS) sessions. The foundation for ERAS is a combination of multidisciplinary teamwork, compliance with evidence-based guidelines, learning quickly and continuous improvement.

Ironically, simultaneous with the 99th Annual meeting was the publication of ERAS®-Cardiac guidelines. In addition, Judson Williams, MD from WakeMed in Raleigh, NC presented on their experience implementing the U.S.'s first ERAS-Cardiac program, which is now also available online. Their efforts demonstrated improvement in hospital and intensive care unit length of stay as well as patient and teammate engagement. Similarly, Nathalie Roy, MD and her team at Boston Children’s Hospital shared their early experience with ERAS in congenital cardiac surgery as well as their opportunities to improve.

Rakesh Arora, MD, from St. Boniface Hospital in Winnipeg, Saskatchewan, presented an expert overview of prehabilitation in adult cardiac surgery. Other presentations associated with the preoperative phase emphasized the importance of frailty, glycemic control, and nutrition to risk mitigation strategies.

The intraoperative phase of care had tremendous presentations stressing the importance of goal-directed anesthesia and perfusion to reduce the risk of acute kidney injury (AKI) from Michael Grant, MD, Glenn Whitman, MD, and their colleagues at Johns Hopkins. Rigid sternal fixation was expertly debated by Louis Perrault, MD from the Montreal Heart Institute and Michael Tong MD from the Cleveland Clinic. Active chest tube clearance was also debated. Spencer Melby, MD from Washington University shared his research on retained blood, inflammation, and their correlation with the prevalent problem of postoperative atrial fibrillation. I shared my views on the need for a more comprehensive understanding of chest drains (procedure, type of drain and combinations, location of tubes, etc.) and prioritized research like that being done by Drs. Melby and Perrault.

Intensive care-related presentations reinforced the importance of analgesia, delirium, AKI, and the timing of extubation after cardiac surgery. Dan Engelman, MD — President of ERAS®-Cardiac — shared Baystate Medical Center’s experience with Nephrocheck® (biomarkers associated with AKI) and their associated improvement of AKI risk prediction and mitigation. Alex Gregory, MD, from the University of Calgary, shared his expert anesthesiologist’s experience and perspective on ultra fast-track techniques. I also shared the perspective of a cardiac surgeon and intensivist-based on 15 years of experience and research — with early extubation and quality improvement — at Atrium Health in Charlotte, NC. I drew attention to the importance of a personalized, precise approach to risk assessment that includes the patient, the protocol, providers, and their team in the intensive care unit, as well as the context of an institution’s outcomes and prioritized opportunities to improve. We are elevating and accelerating this personalized, precise approach through our “Perfect Care” efforts in the Carolinas.

Finally, Kamal Khabbaz, MD, from Harvard’s Beth Israel Deaconess Hospital, educated us on the principles and measurement of value in health care.

In summary, the comprehensive, multidisciplinary efforts to learn quickly and continuously improve were brilliantly displayed by leaders in cardiac surgery, anesthesia, and critical care at the Enhanced Recovery sessions at the 99th Annual AATS. The opportunity to employ innovative methods to transform cardiac care have never been better. Onward and upward!

References

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6. Stamou SC, Camp SL, Reames MK, Skipper E, Stiegel RM, Nussbaum M, Geller R, Robicsek F, Lobdell KW. Continuous quality improvement program and major morbidity after cardiac surgery. Am J Cardiol. 2008 Sep 15;102(6):772-7. doi: 10.1016/j.amjcard.2008.04.061. Epub 2008 Jun 28. PubMed PMID: 18774005.

7. Stamou SC, Camp SL, Stiegel RM, Reames MK, Skipper E, Watts LT, Nussbaum M, Robicsek F, Lobdell KW. Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc Surg. 2008 Aug;136(2):494-499.e8. doi: 10.1016/j.jtcvs.2007.08.081. PubMed PMID: 18692663.

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