EP Initiatives

Measuring the Clinical and Operational Effectiveness of Post-Anesthesia Care in the Cardiovascular Short-Stay Unit

Michael A. Neal, DNP, CRNA1

Jill R. Engel, DNP, ACNP, FNP, NEA-BC, FAANP2, J.F. Titch, DNP, CRNA3, Virginia C. Muckler, DNP, CRNA, CHSE4, Bradi B. Granger, PhD, RN, FAHA, FAAN5

1Duke Heart Center Anesthesia Team, Duke University Hospital, Clinical Associate Faculty and EP Lab SRNA Site Coordinator, Duke University School of Nursing; 2Associate VP of Heart Operations, Nursing, and Patient Care Services, Duke University Health System; 3Associate Clinical Professor, Duke University Nurse Anesthesia Program; 4Assistant Professor and Clinical Education Coordinator, Duke University Nurse Anesthesia Program; 5Professor, Duke University School of Nursing, Director of Heart Center Nursing Research Program, Duke University Health System

Durham, North Carolina

Michael A. Neal, DNP, CRNA1

Jill R. Engel, DNP, ACNP, FNP, NEA-BC, FAANP2, J.F. Titch, DNP, CRNA3, Virginia C. Muckler, DNP, CRNA, CHSE4, Bradi B. Granger, PhD, RN, FAHA, FAAN5

1Duke Heart Center Anesthesia Team, Duke University Hospital, Clinical Associate Faculty and EP Lab SRNA Site Coordinator, Duke University School of Nursing; 2Associate VP of Heart Operations, Nursing, and Patient Care Services, Duke University Health System; 3Associate Clinical Professor, Duke University Nurse Anesthesia Program; 4Assistant Professor and Clinical Education Coordinator, Duke University Nurse Anesthesia Program; 5Professor, Duke University School of Nursing, Director of Heart Center Nursing Research Program, Duke University Health System

Durham, North Carolina

BACKGROUND

The electrophysiology (EP) patient population presents a unique challenge for both anesthesia and post-procedure recovery staff. For anesthesia providers, delivering care to EP patients includes the same basic anesthesia requirements (e.g., amnesia, analgesia, and homeostasis) that most surgical patients require. EP anesthesia providers must meet basic anesthesia care requirements as well as manage a unique set of complication risks that occur during arrhythmia induction (e.g., hypotension) or complications that occur during cardiac ablation or device implantation (e.g., cardiac tamponade and/or effusion).1 The risk of these complications can extend into the post-procedure recovery stage, making care of EP patients particularly challenging for recovery staff. Hospitals typically use post-anesthesia care units (PACU), often located in the peri-operative section of a hospital (which may be remote to the EP lab), to recover patients who received general anesthesia during their EP procedure. However, there are organizational concerns associated with recovering EP patients in a remote and non-specialized setting, including decreased efficiency due to longer transport times and/or a lack of available PACU beds. 

Available Knowledge

A comprehensive systematic literature review was conducted on the topic of recovery care, safety, and efficiency/timeliness of post-procedure care of EP lab patients. The following databases were searched as part of the literature review process: CINAHL, PubMed, Medline, and the Cochrane Library databases. Each database was searched for critical information on evidenced-based studies, peer-reviewed articles, and/or research data to support the clinical project. The databases mentioned contained full-text journals, systematic reviews, evidence-based methods, and studies on post-recovery care of EP patients. Key concepts for this project were paraphrased, and word searches were performed on the topics of EP patient post-recovery care (including post-EP procedure complications) and EP lab efficiency. Keyword searches provided 100+ matches of peer-reviewed articles that addressed EP lab procedure complications. However, only seven articles were found that comprised of descriptive designs and systematic review studies specifically addressing post-EP procedure recovery care. These seven articles supported the aspects of the proposed clinical project, such as safety, effectiveness, and/or timeliness of recovery care of post-procedure EP patients. There were no publications found in the literature review that specifically addressed the topic of post-recovery care efficiency or timeliness of care issues in the EP lab setting. 

The literature review highlighted that even with advances in surgical procedures, anesthesia monitoring, and combined surgical-anesthesia technologies, there is still a chance of life-threatening complications, such as the formation of cardiac tamponade and/or effusion both during and after EP procedures.2 A systematic review identified complication rates (i.e., cardiac tamponade) as high as 5.9% in EP ablation cases.1 However, complications associated with pacemaker and/or defibrillator implant procedures may occur in as many as one-third of the cases studied.3 EP case complications may extend into the post-procedure recovery phase as well. A systematic review of data from 1000 consecutive ablation procedures revealed a life-threatening complication rate of 3.9%, with cardiac tamponade formation as having the highest complication rate both during and after ablation procedures.4 Even though the occurrence rate is low, the formation of a post-procedure cardiac effusion or tamponade is a serious and life-threatening patient complication. It is essential to quickly identify a suspected post-procedure cardiac tamponade or effusion in order for lifesaving procedures such as pericardiocentesis to be performed, to prevent serious complications and/or death.1 

Evidence suggests that having specialized cardiac nursing care during the recovery of post-cardiac procedure patients can improve patient care and safety.5 Adequate amounts of time are required to recover EP patients from the effects of general anesthesia. Because EP cases are complex and have a unique set of potential post-procedure complications, nurses who recover EP patients should be educated to quickly recognize life-threatening cardiac complications and be able to respond correctly to prevent negative outcomes.4 Although standard patient needs may be met in a traditional PACU setting, if problems arise that are specific to the EP patient population, nurses may have a greater challenge treating EP patients if they have not received specific training.4 

The literature review also revealed a limited amount of published data regarding the effectiveness of utilizing a cardiovascular short-stay unit (CVSSU) to help increase EP lab post-procedure safety and efficiency/timeliness of recovery care. However, logic suggests that having a shorter distance to transport post-procedure EP patients to a recovery area would help to decrease turnover times between EP cases. Organizationally, EP lab efficiency can be affected when an EP lab is not located near a PACU section. EP lab case turnover times are impacted if anesthesia providers must transport post-procedure EP patients to another area of the hospital, especially to a different floor. After an EP anesthesia provider gives report and turns care of the patient to the PACU nurse, the anesthesia provider must then return to the EP lab and prepare for another case before bringing the next patient into the EP lab. Occasional delays in room turnover times are inevitable, but if the turnover times are consistently prolonged, practice hours to complete surgical cases could be lost, and this could negatively impact the timeliness of patient care and hospital finances.

SPECIFIC AIMS AND OBJECTIVES

The primary objective of this project was to evaluate the effectiveness of cardiac-specific nursing care delivered to post-procedure EP patients. The CVSSU PACU initiative focused on the supposition that having specialized cardiac care nurses located in a CVSSU setting would help improve the recovery care (patient centeredness) of post-procedure EP patients. To measure this objective, patient care surveys were administered before and after the CVSSU PACU initiative to CVSSU nursing staff as well as EP nurses, nurse anesthetists, nurse practitioners, and EP physicians.

A secondary objective of this project focused on patient safety. The objective was to determine if patient safety could be improved while patients were recovering from EP procedures by having a faster response time to perform a transthoracic echocardiography (TTE) diagnostic test in the CVSSU PACU versus the main PACU. To measure this objective, echocardiography machine (echo) transport time trials were conducted that measured how long it would take to transport an echo machine to each PACU area.

The second objective of this project also focused on EP lab efficiency and timeliness of recovery care. The objective was to determine whether EP lab case turnover times would improve by utilizing a CVSSU PACU versus the main PACU. To measure this objective, EP lab turnover times were analyzed 12 months before and after the start of the CVSSU PACU improvement initiative.

METHODS

Interventions

This project utilized healthcare quality improvement guidelines entitled STEEEP Principles, created by the Institute of Medicine (IOM), when designing project inventions. In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, in which the IOM introduced the STEEEP framework as a way to help improve the quality of medical care, research, and QI improvement efforts.6 The STEEEP framework provides recommendations and goals for healthcare providers to improve patient care in six categories: safe (S), timely (T), effective (E), efficient (E), equitable (E), and patient (P) centered.7 Given that today’s healthcare environment is complex and constantly changing, it is important for QI projects to not lose focus on the improvement of critical areas in healthcare, such as those identified by the STEEEP framework.8 This project focused on multiple domains of the STEEEP framework that were combined into two separate areas of intervention measurement: effectiveness of patient care (patient centeredness) and safety/efficiency (timeliness) of patient care. 

The first intervention of this project focused on the IOM domain of patient care effectiveness. The intervention measured the effectiveness of nursing care (patient centeredness), specifically the effectiveness of recovery care, by utilizing a CVSSU PACU. It was based on the question of whether EP and CVSSU staff would perceive that having a CVSSU PACU would help improve the recovery care of post-procedure EP patients. A pre-survey and post-survey were conducted before and after the implementation of a CVSSU PACU initiative. The surveys assessed the perception of EP and CVSSU nursing staff and EP physicians to determine whether they anticipated EP patient care would improve by implementing a CVSSU PACU. 

The second intervention of this project focused on the IOM domain of patient safety. It measured whether safety could be improved by having a faster response time to perform a TTE diagnostic test in the CVSSU PACU versus the main PACU. The procedure involved having cardiac ultrasound (echo) sonographers transport a mobile TTE echo machine from the echocardiogram workstation to both the main PACU and CVSSU PACU areas. Each of the two echo sonographers completed two trips to the CVSSU PACU and main PACU areas, and the times for each trip were measured and recorded. The same echo machine was used by the sonographers, and the same route and set of elevators were used during machine transport. It was noted when measuring echo machine transport times to the main PACU (which requires the use of an elevator) that there were differences in elevator availability from trip to trip. Even though this was noted as a data collection variable, it is applicable to real life, as elevator wait times are typically not consistent, especially during busy daytime hours.

The second intervention of this project also focused on the IOM domain of efficiency (timeliness) of patient care. It was based on the question of whether EP lab case turnover times would be decreased by utilizing a CVSSU PACU to recover post-procedure EP patients. EP lab case times were analyzed to compare any differences in EP lab turnover rates, associated with both PACU settings, during a 12-month period before and after the start of the CVSSU PACU improvement initiative.

Setting

This project was conducted at the Heart Center at Duke University Hospital (DUH), which is a 957-bed academic medical center located in Durham, North Carolina. The sample included an intervention group of post-procedure EP patients and staff from both the EP lab and CVSSU. The EP lab and CVSSU staff consisted of physicians, nurses, nurse practitioners, and certified RN anesthetists ranging in different ages, ethnicity, and levels of clinical experience. A total of 49 out of 52 EP and CVSSU staff participated in the CVSSU PACU pre-initiative patient care survey. Fifty-three out of 59 EP and CVSSU staff participated in the CVSSU PACU post-initiative patient care survey. The project sample also included a TTE ultrasound machine transport time survey conducted at the medical center. The study protocol was approved and designated as an exempt quality improvement study by the Institutional Ethical Review board of the medical center as well as the sponsored academic institution.

Measures and Analysis

Effectiveness of Recovery Care

Prior to the launching of the CVSSU PACU improvement initiative, a pre-initiative EP/CVSSU patient care survey was created using Qualtrics software (Qualtrics, LLC). Once the CVSSU PACU pre-survey was created, the program then generated a URL that could be sent online via email to prospective survey participants. The link to the survey was then forwarded to the Heart Center administrators, who distributed the survey to CVSSU and EP staff electronically via email. Once a CVSSU or EP staff member received the online link, they could activate it and be directed to the online survey. The survey was designed to be completely anonymous, with answers to the survey questions recorded on the Qualtrics server. The EP and CVSSU staff had approximately one month to complete the survey before the CVSSU PACU initiative was launched. The only demographic information recoded was the date, time, and city in the U.S. where the survey was completed when the link was activated by the participant.

A CVSSU/PACU post-initiative survey was distributed to the CVSSU and EP staff in a similar fashion utilizing Qualtrics. The post-initiative survey questions were similar in content to the pre-survey, but were modified to indicate that the CVSSU PACU initiative had already occurred. The survey asked EP and CVSSU staff to rate their perception as to whether the CVSSU PACU had helped to increase the level of care of post-procedure EP patients. The CVSSU PACU initiative pre-survey was distributed and results collected from August 15, 2016 and September 15, 2016. The CVSSU PACU initiative post-survey was distributed and results collected from September 28, 2017 to November 28, 2017.

Post-Procedure Safety

Two different sonographers were recruited to help gather the TTE echo machine transport survey data. Each of the sonographers made two separate trips to each of the PACU areas, for a total of four trips each. A stopwatch was used to measure how long it took for the sonographers to transport an echo machine to the designated PACU and power on the device. The start time was recorded when a sonographer received a simulated “STAT” request, and began the process of mobilizing an ultrasound machine to perform a TTE scan in either of the designated PACU areas. 

For purposes of this project, a card was placed in front of a sonographer that listed a STAT PACU bedside TTE request to rule out cardiac effusion/tamponade, versus placing an actual computer order. The simulation was also conducted during a period in the day when there were few echo service requests in an attempt to minimize interruptions that could negatively impact patient care. The results from the timed TTE transport trials were analyzed and compared for possible statistical differences. The statistical analysis of the TEE transport times determined whether recovering post-EP procedure patients in the CVSSU PACU led to faster response times in performing post-procedure TTE scans. The ability to improve post-EP procedure TTE scan response times to rule out cardiac tamponade or effusions should lead to an improved level of safety and care of EP patients during the recovery process. The TTE echo machine transport time survey occurred on November 17, 2017.

Efficiency and Timeliness of Care

To evaluate the effects of the CVSSU PACU initiative on EP lab case turnover times, data was collected 12 months before and after the start of the CVSSU PACU improvement initiative. Time data was collected from archived computerized documented records made daily by EP lab staff utilizing Xper Information Management (Philips). EP lab time records were analyzed to specifically track when a post-procedure EP patient left an EP lab procedure room and when the next pre-procedure EP patient was brought into the same procedure room. The amount of time between cases was logged as the turnover time for that particular EP lab. An analysis was then made regarding the differences in EP lab turnover times of both PACU settings during a 12-month period. The EP lab case turnover time data was analyzed for statistical differences in order to determine if the CVSSU PACU initiative had an effect on EP lab case turnover times. The analysis also took into consideration the pre-procedure location of the patient being transported to the EP lab. An independent T-test was conducted of the data for equality of means, including Levene’s test for equality of variances.

This project did not directly access private patient health records. A statistician assisted in the gathering of EP lab case turnover times utilizing Xper. Using the Xper charting database, the statistician was able to query EP lab case start and stop times to determine EP lab turnover times. The statistician was also able to gather data during the requested time periods and transfer it into Excel. The data was then analyzed using SPSS Statistics. Since project data did not have any secure patient information or identifiers, there was no need to encrypt project data results during the statistical analysis process. The data collection period of pre-initiative EP lab case turnover times occurred between September 2015 and September 2016. The data collection period of post-initiative EP case turnover times was between December 2016 and December 2017.

RESULTS

Effectiveness of Recovery Care

Results from both the pre and post CVSSU PACU initiative surveys revealed favorable responses from EP and CVSSU staff about having PACU recovery services in the CVSSU. Descriptive statistics (n, %) were conducted for pre (n=49) and post (n=53) CVSSU PACU initiative surveys. (Figure 3) 

Prior to the start of the CVSSU PACU initiative, the majority of staff (73%) indicated via the pre-survey that they anticipated the CVSSU PACU initiative would help improve patient care by allowing cardiac-specific post-procedure recovery issues to be addressed sooner in the CVSSU PACU than in the traditional PACU setting. After the CVSSU PACU initiative was in operation for over a year, 64% of staff believed care was improved by the CVSSU PACU initiative. The pre- and post-surveys also revealed that EP and CVSSU staff believed that recovery care was improved when EP patients received specialized nursing care from cardiac-trained CVSSU PACU nurses. Over half of staff indicated on the pre- (59%) and post-survey (54%) that the post-procedure recovery care for EP patients was improved when it was provided by a nurse with cardiac-specific nursing training versus standard PACU nursing personnel. A total of 61% on the pre-survey and 43% on the post-survey also felt that EP patient recovery care was improved by having an EP attending anesthesiologist and/or EP CRNA available in the CVSSU PACU area to meet patient recovery care needs. 

EP and CVSSU staff also indicated on both the pre- and post-surveys that having a CVSSU PACU improved response times to life-threatening conditions such as airway complications. In total, 38% of staff indicated on the pre-survey that they believed having a shorter distance to transport post-procedure patients to the CVSSU would decrease the chance of airway complications, with a percentage increase to 49% on the post-survey. In addition, approximately 65% of staff indicated on the pre-survey (43% on the post-survey) that there was a faster response time for an echo sonographer to complete a bedside TTE in the CVSSU PACU versus the main PACU. Over half of the EP and CVSSU staff (78% on the pre-survey and 61% on the post-survey) felt that if a post-procedure cardiac effusion or tamponade was discovered, there would be a shorter distance to transport EP patients from the CVSSU PACU to the EP to receive life-sustaining treatment versus the main PACU. Over half of the staff also believed (73% on the pre-survey and 64% on the post-survey) that having a CVSSU PACU led to improved EP lab bed flow. A Mann-Whitney U test revealed no statistical difference between the overall pre (median=5) and post (median=5) survey scores (z=-.45, P=.653).

Post-Procedure Safety

The results of the survey also demonstrated a reduction in time to transport an echo machine to the CVSSU PACU versus the main PACU. The mean time to transport an echo machine to the main PACU (3.46 minutes) was more than twice the amount of time required to transport to the CVSSU PACU (1.51 minutes). Since the startup time of the echo machine used in the survey was 1.2 minutes, this time was also applied to each PACU transport time measurement. A Mann-Whitney U test revealed that the time to perform a TTE on a post-procedure EP patient in the CVSSU PACU area (median = 3 minutes, 15 seconds) was significantly lower than in the main PACU area (median = 5 minutes, 11 seconds), z = -2.31; P=.021.

Efficiency and Timeliness of Care

Independent sample t-tests were conducted to compare EP lab case turnover times. Case turnover times were improved after the start of the CVSSU PACU initiative, although the results were not statistically significant (all P>.05; Table 1). 

DISCUSSION

The CVSSU PACU initiative has had a positive impact on the effectiveness of recovery care of post-procedure EP patients. This project demonstrated the success of the CVSSU PACU initiative to help the DUH Heart Center optimize patient centeredness and safety. Positive feedback was obtained via the pre- and post-initiative surveys, with EP and CVSSU staff reporting that both recovery care and safety of EP patients was improved by having a CVSSU PACU versus recovering EP patients in the main PACU. Those results, coupled with the results of the echo machine transport time survey, indicate that a CVSSU PACU can help improve patient care and safety.

This project also revealed that EP lab efficiency/timeliness of care can be improved with the use of a CVSSU PACU. The results of this project demonstrated that EP lab turnover times improved (albeit not statistically significant) after the start of the CVSSU PACU initiative. By better utilizing EP lab procedure space, the CVSSU PACU initiative had a positive effect on daily EP lab operations, helping to maximize the use of available hospital resources and staff to increase EP lab efficiency. This project is an example of how a quality improvement project such as the CVSSU PACU initiative can help foster positive change-management to help healthcare institutions improve the care, safety, and timeliness of care of patients.

Limitations of this project included variables that were not discovered until EP lab turnover time data was being collected. There were multiple occasions during the data collection timeframe when only two or three electrophysiologists were present in the EP lab on a particular day when there were five procedure rooms available, which created lab vacancies in-between EP procedures. In these situations, anesthesia providers had to wait until an electrophysiologist completed an EP procedure prior to loading an electrophysiologists’ next (new) case into an available lab. Another factor that created delays between cases were EP lab equipment and/or integrated technology (IT) related issues. There were instances (varying from no delays to multiple delays in a given EP procedure day) when computer or equipment malfunctions (i.e., the fluoroscopy system) required repair, and the lab would be vacant until the repairs were completed. Even if there were no equipment malfunctions, sometimes there were still room turnover delays related to the complex IT platforms utilized in the EP lab setting (i.e., having to switch out different types of computerized mapping systems utilized during EP ablation cases).

Also, when measuring the average turnover times both before and after the CVSSU PACU initiative, it was difficult to filter out downtime periods in a particular lab when data was obtained from the Xper system. This was due to the Xper system recording the time a patient was brought into an EP lab at the beginning of a case and when leaving the room at the end of a case. Turnover times were then determined when a patient left the lab and the next patient was brought into the lab at the start of a new case. Xper did not account for case turnover delays, such as low number of EP staff and/or equipment issues, and instead averaged the delays as part of the official EP lab case times for a particular day. 

Another limitation of this project was that it lacked comparison of actual tamponade and/or effusion complication rates before and after the implementation of the CVSSU PACU initiative. Fortunately, there was a very low occurrence of these complications prior to the initiative. There were also no known occurrences of cardiac tamponade and/or effusion in the CVSSU PACU that required surgical intervention during the data collection of this project. To address the lack of patient recovery care data for comparison, this project surveyed the opinions of EP and CVSSU staff about whether having a CVSSU PACU would increase the diagnosis and treatment success should these complications occur in the future. Both the EP lab and CVSSU staff indicated on the surveys that they believed having a CVSSU PACU would help improve diagnosis and treatment success should cardiac tamponade or effusion arise in the future while patients were recovering from EP procedures.

CONCLUSION

This project demonstrated that EP and CVSSU staff believed having a CVSSU PACU improved the care and safety of EP patients recovering from EP lab procedures. It also revealed a faster response time to diagnose and treat via a bedside TTE in the CVSSU PACU versus the main PACU. Finally, this project also showed that EP lab efficiency/timeliness of care could be improved with the use of a CVSSU PACU by decreasing EP lab turnover times. Even though the results revealed minor improvements in some categories, there was enough data to indicate that EP lab efficiency could be improved by utilizing a CVSSU PACU located in closer proximity to the EP lab to recover post-procedure EP patients. Our hope is to share this information with EP providers to improve the care of future EP patients and EP lab operational efficiency at medical care institutions. ν

Acknowledgments

Michael A. Neal, DNP, CRNA would like to thank Duke University School of Nursing’s project chairperson, Bradi Granger, PhD, RN, FAHA, FAAN, as well as the following project committee members: Jill Engel, DNP, ACNP, FNP, NEA-BC, FAANP, Virginia Muckler, DNP, CRNA, CHSE, and James Titch, DNP, CRNA. He would also like to acknowledge the members of the Duke Heart Center management for providing support while completing this project, as well as echo sonographers Hillary Hrabak and Josh Lander for helping to collect TTE echo machine transport time data. Additionally, he would like to recognize the providers and staff of the Duke Heart Center, CVSSU, and EP lab for their ongoing dedication to improving patient care and safety, and helping to meet the future needs of Duke Heart Center patients.

Disclosures: The authors have no conflicts of interest to report regarding the content herein.  

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