Accelerated Recovery Protocol

CARU: Cardiac Accelerated
Recovery Unit
Shannon Pengel, MSN, RN, NE-BC
Clinical Nursing Director
Heart and Vascular Institute
• Driving Force in 2010
-
High Surgical Volume
Lack of ICU Bed Availability
Increasing Length of Stay
Extended Wait Times for Surgical Dates
• Concept
-
“Fast Track” Patients
Improve ICU Bed Availability
Improve Length of Stay
Improve Patient Satisfaction
• Patient Selection
- Retrospective Review of Former Patients
- Procedure
•
•
•
•
Robotic Cases
Mitral Valves
CABG’s
Septal Myectomies
- Medical Presentation
• Normal Ejection Fraction
• Absence of Renal Failure, Severe Pulmonary
Disease, or other co-morbidities
• Research
- Cleveland Clinic¹
• Comparative Study of 291 patients
• Lower rates of atrial arrhythmias and
re-operations
• Decreased ICU and hospital length of stay
- European Journal of Cardio-thoracic Surgery²
• Comparative study of 264 patients
• Safety of fast-track extubation in coronary bypass
patients
• Mean ventilation and intubation time significantly
shorter in fast track group
• Similar morbidity and mortality
¹Cleveland Clinic (Insler et al., 2003)
²European Journal of Carido-thoracic Surgery (Reis et al., 2002)
Short Stay Beds 1-15
PACU Beds 16-21
CARU Beds 22-29
• Opens Monday morning with “A” round
cases
• Closes Saturday afternoon after last
patient transfer out
• ACNP as primary coverage
• Physicians:
- Cardio-Thoracic Anesthesia Intensivist
- Cardio-Thoracic Surgery Fellow
• RN Staffing - 1:1 initially, then 1:2
• Not on multiple high dose vasoactive or
inotropic infusions
• No Complete Heart Block/Asystole
- Pacer dependent
• No coagulopathic/bleeding patients
• No ventricular arrhythmias (VT/VF, ST
elevation)
• AVR
• AV repair
- Mini sternotomy
• MVR
• MV repair
- Thoracic
- Robotic
AVR/MVR
• TVR
• CABG
• Ascending Aorta
Replacement
• Myectomy
• OPCAB
• ASD/PFO
• Percutaneous AVR
• Pericardiectomy
•
•
•
•
From unit opening to March 31, 2011
~ 7 month
299 patients
Unit closed 19 days (no appropriate
patients)
• Average between 1 and 6 patients
• Hypoxemia:
- requires face mask
- CPAP/BiPAP
• Hypotension
- Pressors
• Bradycardia/CHB
pacer dependent
• Low CO/CI
requires inotrope
• Confusion,
agitation, change in
LOC
• Bleeding
- Coagulopathy
- Chest tubes
continued
• Only 7% were
readmitted to CVICU
PROTOCOLS AND METRICS
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•
•
•
•
Some patients extubated in OR
Propofol off on arrival to CARU
WTE if VSS and not bleeding
CPAP as soon as awake and breathing
Goal: less than 4 hours
• Only 1 patient of 299
reintubated!!
Initial Results – CARU Extubation Times
5
4.5
4.4
Avg Hrs to Extubation
4
3.6
3.6
3.5
3.5
3.1
3
2.5
2.5
2
2
1.5
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
J33 Average
Hours to Extubation
CARU 2011 and 2012
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
J33 Average
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•
•
•
•
•
•
Pain scores: goal is < 3
Multimodal therapies
Fentanyl PCA and clinician doses
Toradol
Lidoderm patches
IV Acetaminophen
Alternative therapies
- Reiki, guided imagery
CARU, 2011 – 2012
Average Pain Scores
4.0
3.5
3.0
Axis Title
2.5
2.0
Avg 24 hr Pain score
Avg 48 hr Pain Score
1.5
1.0
0.5
0.0
• Dangle at side of bed 4 – 5 hours after
extubation
• Up in chair for approximately one hour
before 6 am
• Chest tubes removed in am after up in
chair if < 50 cc for 2 hours
• Activity exclusion guidelines:
- Vasopressor or inotrope > 2 mcg
- Diminished LOC, lethargic, or unable
to stand/pivot to chair
- Hemodynamically unstable rhythm
- Respiratory insufficiency requiring
high flow oxygen.
- Chest tube drainage > 100 ml/hr
• Decreased LOS
• Decreased ICU Re-admissions
- Better pain control
- Early mobilization
• Decrease in lab/ABG draws
• Improved Satisfaction
CARU 2011 – 2012
Post Operative Length of Stay
12.0
LOS
10.0
8.0
6.0
4.0
2011 LOS HVI Post op
2011 LOS Overall Hospital
Patient Volume vs Readmissions to CVICU
50
45
40
35
30
25
20
15
10
5
0
Total Patients
Readmissions
• RN orientation/education
• Appropriate mix of staff
• Surgeon comfort with new staff and
environment
• Lack of consistent patient volume
• Inexperience of staff to major complications
• Ongoing cost effectiveness
2014 Approach
Next Steps at Cleveland Clinic
• Embed the CARU concept in all ICU’s
• Order sets driven by Intensivist on
admission
• CARU care is not dependent on
location
• Continue CARU concept to step-down
• Incorporate Cardiac Rehab, Clinical
Navigator, and Pain Champions
EMR Integration
• Insert Embedded Order Sets
EMR Integration
• Insert EPIC patient list
- Management tracking/daily
assignments
- Data abstraction
- Patient ID for
• Throughput
• Clinical navigator
• Cardiac rehab
HVI CARU Patient List
Involvement of Step-down
• Accelerated Recovery to reduce Hospital LOS
- Continues across entire admission
- Dedicated Care Plan on SDU
• Aggressive mobility
• Early consult to cardiac rehab
• Proactive pain control
• Non-pharmacologic interventions
• Reiki
• Massage
Conclusion
• Based on our experience:
- Early extubation and mobility accelerate
recovery
- Excellent pain control is critical
- Alternative therapies are helpful at reducing pain
and anxiety while improving satisfaction
- Cost effective staffing models must be a
consideration
- Nurse competency and training is critical in
acceptance of this model
- Collaborative approaches across the continuum
of care

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