JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING

JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
Class
I
I
I
I
I
I
I
I
GHS
Urgent
Both
both
Both
Both
Both
Both
Both
Both
Both
#
PILOT
REG
1
3
6
11
BPE
Operational definition
I
EARLY EXTUBATION
(LOW/MED RISK)
Anesthetic management directed toward early
postoperative extubation and accelerated recovery of lowto medium-risk patients undergoing uncomplicated CABG
is recommended.
For all CAB patients with a predicted STS mortality of
<=2%, a LVEF of >= 40%, a Class I or II airway using the
Mallampati scoring system, and an ASA status <4...the
attending anesthesiologist will document a dialogue with the
CRNA team and the attending surgeon regarding
appropriateness for for early extubation and rapid recovery.
A
All CAB patients with a predicted STS mortality of >=5%,
LVEF of <=25%, Left Main stenosis of >=50%, previous
sternotomy, or who has been deemed by the attending
cardiac surgeon to be "high risk" will have TEE
intraoperatively by an experienced anesthesia or cardiology
practitioner, prior to incision.
A
In all post-operative CAB patients, heart rates >120 or <50,
diastolic BP <50 or >100, CVP <6, PAD <8, Hct <=24
and/or urine output of <15 ml/hr when monitored by Foley
or <180 ml/12 hrs when not….will be evaluated by a
clinician and a note entered in the record documenting the
assessment and management plan. These same parameters
will be targeted by the anesthesia team in the OR.
A
I
X
I
13
I
14
I
16
17
INDICATOR
I
X
I
X
TJC/NPSG
I
A fellowship-trained cardiac anesthesiologist(or
experienced board-certified practioner) credentialed in
the use of perioperative transesophageal
INTRAOP TEE (HIGH RISK)
echocardiography is recommended to provide or
supervise anethetic care of patients who are considered
to be at high risk.
INTRAOP MONITORING
Management targeted at optimizing the determinants of
coronary arterial perfusion (e.g. heart rate, diastolic or
mean arterial pressure, and right ventricular or LV enddiastolic pressure) is recommended to reduce the risk of
perioperative myocardial ischemia and infarction
Use of continuous intravenous insulin to achieve and
maintain an early postoperative blood glucose
INTRAOP BLOOD GLUCOSE concentration less than or equal to 180mg/dL while
MGT
avoiding hypoglycemia is indicated to reduce the
incidence of adverse events, including deep sternal
wound infection, after CABG.
INTRAOP ABX REDOSING
Continuous intravenous insulin will be started in the OR
when hourly surveilance blood glucose levels rise above 180
mg/dl. Adjustments based on the GHS protocol for CTS will
be made hourly to achieve a target intraoperative blood
glucose concentration of between 140-180.
IV cefazolin (Ancef) will be repeated every 4 hours until
Ancef q 4 hours
last incision is closed.
Both
20
I
WHO
Numerator: #
patients with BS
>180/dl & with
documented
intervention
Denominator: #
patients with BS
>180/dl
Numerator: #
patients with DOS >4
hrs (ancef) & recd
timely abx redose.
Denominator: #
patients with DOS > 4
hrs (Ancef)
Anes record
POST-INCISION TEG
A
NO RBCS IF HCT>24
A multimodal approach with transfusion algorithms, point
No RBCs will be given if the HCT is >=24 without expressed
of care testing, and a focused blood conservation strategy
permission of an attending physician.
should be used to limit the number of transfusions.
A
LIMA FOR LAD BYPASS
Anes record
Anes record
Anes Record
A time out should be conducted in the OR/procedure room
before the procedure/incision. It should involve the entire
operative team, use active communication, be briefly
documented, such as in a checklist (organization should
determine the type and amount of documentation) and
should include:
All coronary grafts to the LAD that do not use the LIMA will
be justified in the attending surgeon's operative note.
Progress notes, H&P, Echo Report,
Consults,cath report, Anes record
EF (screen 12/17), Left Main
Disease (screen 12/17), STS
mortality (screen 28), previous
CV interventions (screen 11),
intraop TEE (screen 19)
A
A multimodal approach with transfusion algorithms, point
TEG will be measured on all CAB patients, while in the OR,
of care testing, and a focused blood conservation strategy
before and after incision.
should be used to limit the number of transfusions.
If possible, the left internal mammary artery (LIMA)
should be used to bypass the left anterior descending
(LAD) artery when bypass of the LAD artery is indicated.
Progress notes, H&P, Anesthesia
Record, Echo Report, Consult
Intubation/extubation date/times
(screen 16); Extubation in OR
(screen 21), Extubated in OR
(screen 22), risk of mortality
(screen 28), EF (screen 12/17),
Anesthesia record
A
Patient Safety/SCIP Time Out
STS FIELDS
A
PRE-INCISION TEG
TIMEOUT
DOCUMENTATION SOURCE
Anesthesia record, OR nursing
record
A multimodal approach with transfusion algorithms, point
TEG will be measured on all CAB patients, while in the OR,
of care testing, and a focused blood conservation strategy
before and after incision.
should be used to limit the number of transfusions.
Correct patient identity.
Correct side and site (cardiac surgery exempt from site
marking).
Agreement on the procedure to be done.
I
CALC
Time
I
4
Draft as of December 2013
Blood products (screen 19)
A, CTS
Numerator: #
patieints with
documented TO
Denominator: # CABG
patients
OR Nursing record, consent
Operative Note, Yellow sheet,
stenosis (mulitple sources)
IMA artery as graft (screen 10)
JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
III h
Both
21
I
ARTERIAL GRAFT FOR
STENOSIS >70%
I
Urgent
only
39
I
PULMON ART CATH P/T
INCISION
I
Both
I
44
ON-PUMP LYSINE
ANALOGUES
GHS
Both
50
I
GHS
Both
51
I
CELL SAVER
GHS
Both
56
I
WASH SHED BLOOD
JSUMC
I
I
I
I
I
1
61
Both
Both
Both
Both
Both
both
X
SCIP-INF10
2
P
5
7
12
15
18
I
P
X
X
SCIP-Inf-4
SCIP-Inf3b
P
P
P
P
An arterial graft should not be used to bypass the right
coronary artery with less than a critical stenosis
Placement of a pulmonary artery catheter is indicated,
preferably before the induction of anesthesia or surgical
incision, in patients in cardiogenic shock undergoing
CABG.
Lysine analogues are useful intraoperatively and
postoperatively in patients undergoing on-pump CABG to
reduce perioperative blood loss and transfusion
requirements.
DAILY PAIN ASSESSMENT
POSTOP MONITORING
A pulmonary artery catheter will be placed before surgical
incision, in all patients in cardiogenic shock (STS definition)
undergoing CABG.
A
Anes record
Cell saver use
Cell saver will be used in all CAB operations.
A
No shed blood reinfusion without washing
All shed blood will be washed before reinfusion.
A
Peri-Op Temperature Management (Off pump)
Numerator: Surgery patients for whom either active
warming was used intraoperatively for the purpose of
maintaining normothermia or who had at least one body
temperature equal to or greater than 96.8 degrees
Fahrenheit (F)/36 degrees Celsius (C) recorded within the
30 minutes immediately prior to or the fifteen minutes
immediately after Anesthesia End Time.
Denominator: All patients, regardless of age, undergoing
surgical procedures under general or neuraxial anesthesia of
greater than or equal to 60 minutes duration (off pump
CABG only)
A
Prophylactic antibiotics will be discontinued within 48
after surgery, unless contraindicated (infection)
MD RN
PA/APN
In all post-operative CAB patients, heart rates >120 or <50,
diastolic BP <50 or >100, CVP <6, PAD <8, Hct <=24
and/or urine output of <15 ml/hr when monitored by Foley
or <180 ml/12 hrs when not….will be evaluated by a
clinician and a note entered in the record documenting the
assessment and management plan. These same parameters
will be targeted by the anesthesia team in the OR.
A
Numerator: Surgery patients with controlled 6 A.M. blood
glucose (less than or equal to 180 milligrams per deciliter
[mg/dL]) on Postoperative Day (POD) 1 and POD 2.
Denominator: Cardiac surgery patients with no evidence of
prior infection.
MD PA/NP
POSTOP TEG (FUTURE)
A multimodal approach with transfusion algorithms, point
of care testing, and a focused blood conservation strategy TEG will be measured on all CAB patients after operation.
should be used to limit the number of transfusions.
DAILY PROGRESS NOTE
See #12 and:
All CAB patients will have a progress note placed in their
Efforts are recommended to improve interdisciplinary
medical record each day of their hospitalization that
communication and patient safety in perioperative period documents a dialogue among an attending surgeon, the
advanced practitioners covering the patient, the responsible
nursing staff and appropriate consultants.
lowest temp (screen 18)
Soarian nursing, progress notes,
consults, H&P
PACU record, Soarian nursing
PACU record, Soarian nursing, lab
reports, orders, progress notes
See Column I
Numerator: Number of surgical patients whose prophylactic
antibiotics were discontinued within 24 hours after
Anesthesia End Time (48 hours for Coronary Artery Bypass
Graft [CABG] or Other Cardiac Surgery).
Denominator: All selected surgical patients with no evidence
of prior infection. (see other exclusions)
OR Nursing record, anes record
Anes record, PACU record
See Column I
The daily progress note for all responsive CAB patients will
Multidisciplinary efforts are indicated to ensure an optimal document the patient's self-report of pain and the adequacy
level of analgesia and patient comfort throughout the
of its relief. For all unresponsive patients, the note's author
perioperative period.
will evaluate the patient for pain and document their plan
for management.
Management targeted at optimizing the determinants of
coronary arterial perfusion (e.g. heart rate, diastolic or
mean arterial pressure, and right ventricular or LV enddiastolic pressure) is recommended to reduce the risk of
perioperative myocardial ischemia and infarction
Cannulation sites (screen 18)
Lysine analogues will be used intraoperatively in patients
undergoing on-pump CABG.
A
Use of continuous intravenous insulin to achieve and
maintain an early postoperative blood glucose
concentration less than or equal to 180mg/dL while
POSTOP BLOOD GLUCOSE
avoiding hypoglycemia is indicated to reduce the
MGT
incidence of adverse events, including deep sternal
wound infection, after CABG. SCIP-Inf-4 (Cardiac patients
with controlled 6 AM postop blood glucose)
POSTOP ABX
DISCONTINUATION
Operative Note, Yellow sheet,
stenosis (mulitple sources)
All RBCs transfused to CAB patients will be leukocytereduced unless a clinician documents that a delay to obtain
this is dangerous.
LEUKOCYTE REDUCED RBCS Leukocyte reduced RBC
TEMP MGT
An arterial graft (IMA, radial or gastroepiploic) will only be
used to bypass the right coronary artery if the RCA is
compromised by a stenosis of >= 70%.
MD PA/APN
Orders, MAR
See Column I
A
Progress note
Abx d/c (screen 10)
JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
IIIh
Both
19
P
NO COX-2 INHIBITORS
I
Both
25
P
POSTOP ASA
I
I
Both
Both
26
27
I
Both
28
III h
Both
30
I
I
Both
Both
32
33
X
AMI-2
X
X
AMI-10
MAR, orders
Unless a clinician documents a contraindication (ie
bleeding), aspirin (at least 81mg orally or 600mg rectally,
daily) will be: (A) initiated (or continued) at first contact
If aspirin (100 mg to 325mg daily) was not initiated
with patients who are to undergo CAB, (B) given within 1
preoperatively, it should be initiated within 6 hours
hour prior to CAB if not taken within 24 hours and (C)
postoperatively and then continued indefinitely to reduce
resumed within 24 hours following CAB. Aspirin (at least
the occurrence of saphenous vein graft closure and
81mg orally, daily) will be prescribed at discharge,
adverse cardiovascular events.
unless a clinician documents a contraindication, and,
at the post op clinic visit the patient will be advised
to continue aspirin indefinitely.
Numerator: CABG
patients who are
prescribed aspirin at MD PA/NP
hospital discharge or
have documented
contraindication.
Denominator: CABG
patients.
MAR, orders, med rec
Numerator: #
All CAB patients will have statin therapy initiated as
patients with PO
soon as oral intake is possible post-op, prescribed
MD PA/NP
statin order.
statins at discharge and advised at the post-op clinic visit to
Denominator: # CABG
continue, unless contraindications are documented.
patients
MAR, orders
All patients undergoing CABG should receive statin
therapy, unless contraindicated.
P
STATIN RX AT D/C
All patients undergoing CABG should receive statin
therapy, unless contraindicated.
All CAB patients will have statin therapy initiated as soon as
oral intake is possible post-op, prescribed statins at
discharge and advised at the post-op clinic visit to
continue, unless contraindications are documented.
P
D/C HRT
Postmenopausal hormone therapy should not be
administered to women undergoing CABG
Following CAB, estrogen and progesterone compounds will
not be given to any woman who is postmenopausal.
Beta blockers should be reinstituted as soon as possible
after CABG in all patients without contraindications to
reduce the incidence or clinical sequelae of AF.(also
included as Section 5.7, Class I, #2)
Beta blockers will be reinstituted after CABG in all patients
without contraindications (ie allergy, need for hemodynamic
support or dysrhythmias) as soon as oral intake is tolerated.
Numerator: #
MD PA/NP
If oral intake is not possible but no other contraindicatins
patients with PO BB
exist, IV beta blockers will be used. (Also included as
order. Denominator:
Section 5.7, Class I, #2)
# CABG patients
MAR, orders
P
AMI-5
ASA RX ON D/C
MAR, orders
POSTOP STATIN
P
X
X
P
COX-2 inhibitors (defined in STS drug table) will not be
administered to patients hospitalized following CAB, unless
no other alternative.
Unless a clinician documents a contraindication (ie
bleeding), aspirin (at least 81mg orally or 600mg rectally,
daily) will be: (A) initiated (or continued) at first contact
If aspirin (100 mg to 325mg daily) was not initiated
with patients who are to undergo CAB, (B) given within 1
preoperatively, it should be initiated within 6 hours
hour prior to CAB if not taken within 24 hours and (C)
postoperatively and then continued indefinitely to reduce
resumed within 24 hours following CAB. Aspirin (at
the occurrence of saphenous vein graft closure and
least 81mg orally, daily) will be prescribed at discharge,
adverse cardiovascular events.
unless a clinician documents a contraindication, and, at the
post op clinic visit the patient will be advised to continue
aspirin indefinitely.
Cyclooxygenase -2 inhibitors are not recommended for
pain relief in the postoperative period after CABG.
P
POST OP BB
BB RX AT D/C
Beta blockers should be prescribed to all CABG patients
without contraindications at the time of hospital
discharge.
Beta blockers will be prescribed to all CABG patients without
a clinician's documentation of a contraindication at the time
of hospital discharge.
Numerator:CABG
patients who are
prescribed a statin
medication at
hospital discharge or
have documented
contraindication.
Denominator: CABG
MAR, orders, med rec
D/C meds (screen 25)
D/C meds (screen 25)
MAR, orders, med rec
Numerator: CABG
patients who are
prescribed a betablocker at hospital
discharge or have
documented
contraindication.
Denominator: AMI
patients.
MD PA/NP
MAR, orders, med rec, d/c
medication list
D/C meds (screen 25)
JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
I
I
Both
Both
34
34
X
X
I
Both
35
X
I
Both
36
X
I
Both
37
P
Pr
AMI-3
POSTOP ACE/ARB
D/C PREOP ACE/ARB
P
ACE/ARB RX AT D/C
P
SMOKING CESSATION
P
I
Both
38
P
I
Both
40
P
CARDIAC REHAB
Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin-receptor blockers given before CABG should
be reinstituted postoperatively once the patient is stable,
unless contraindicated.
Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin-receptor blockers given before CABG should
be reinstituted postoperatively once the patient is stable,
unless contraindicated.
CAB patients on ACE and/or ARB preoperatively will have
them stopped for 48 hours before operation to decrease
post-op vasodilation, and will have them restarted
following operation one day after initiation of
optimal (HR <= 70) postoperative Beta Blockers, as
long as the SPB is greater than 100 and the patient's
renal function is determined stable by a clinician. If
the ACE and/or ARB is withheld per clinician
MD PA/NP
judgement, then the patient should be reevaluated
each subsequent day and drug started when SBP and
renal function allows. The med should continue
Numerator: #
indefinitely.These should be perscribed at discharge and
patients with PO
confirmed at post op visit. CAB patients NOT on ACE
ACE/ARB order
and/or ARB preoperatively and with LVEF > 40%,
and without hypertension, or DM,will NOT have ACE Denominator: # CABG
and/or ARB started post-op.
patients without
MAR, orders, med rec, transfer
contraindications
records
Preop meds (screen 9)
CAB patients on ACE and/or ARB preoperatively will
have them stopped for 48 hours before operation to
decrease post-op vasodilation, and will have them
restarted following operation one day after initiation of
optimal (HR <= 70) postoperative Beta Blockers, as long as
the SPB is greater than 100 and the patient's renal function
MD PA/NP
is determined stable by a clinician. If the ACE and/or ARB is
Numerator: #
withheld per clinician judgement, then the patient should be
patients with PO
reevaluated each subsequent day and drug started when
ACE/ARB order
SBP and renal function allows. The med should continue
Denominator: # CABG
indefinitely.These should be perscribed at discharge and
patients without
MAR, orders, med rec, transfer
confirmed at post op visit.
contraindications
records
Preop meds (screen 9)
CAB patients NOT on ACE and/or ARB preoperatively and
with LVEF <= 40%, or hypertension, or DM should have
them started following operation one day after initiation of
optimal (HR <= 70) postoperative Beta Blockers as long as
ACE inhibitors or angiotensin-receptor blockers should be
the SPB is greater than 100 and the patient's renal function
initiated postoperatively and continued indefinitely in
is determined stable by a clinician. If the ACE and/or ARB is
Numerator: #
CABG patients who were not receiving them
withheld per clinician judgement, then the patient should be
MD PA/NP
patients who are
preoperatively, who are stable, and who have an LVEF
reevaluated each subsequent day and drug started when
prescribed an ACEI or
less than or equal to 40%, hypertension, diabetes
SBP and renal function allows. The med should continue
mellitus, or chronic kidney disease, unless
ARB at hospital
indefinitely. These should be perscribed at discharge
contraindicated.
discharge or with
and confirmed at post op visit.CAB patients NOT on ACE
documented
and/or ARB preoperatively and with LVEF > 40%, and
contraindication.
without hypertension, or DM,will NOT have ACE and/or ARB
Denominator: AMI
started post-op.
patients with LVSD.
MAR, orders
All smokers should receive in-hospital educational
counseling and be offered smoking cessation therapy
during CABG hospitalization.
Cardiac rehabilitation is recommended for all eligible
patients after CABG.
Numerator: #
All patients who indicate current tobacco use before CAB will
patients with
receive in-hospital educational counseling and be offered
smoking cessation therapy during CAB hospitalization. They documented smoking
will be advised not to smoke at discharge and in clinic visit. cessation educatoin.
Denominator: #
CABG patients with
smoking hx (1 year)
After CAB, all patients whose insurance will cover it, will be
referred to a cardiac rehabilitation program. Those whose
coverage does not apply, will be advised to engage in similar
self-directed activities.
PA/NP
MAR, ORDERS, MED REC, D/C
FORM, SOARIAN RN, CARE MGR P.
NOTE
D/C meds (screen 25)
ORDERS
discharge (screen 25)
Continuous monitoring of the electrocardiogram for
POSTOP EKG MONITORING arrhythmias should be performed for at least 48 hours in Built into system- no need for "Hardwiring"
all patients after CABG.
RISK ADJUSTED DATA
Public reporting of cardiac surgery outcomes should use
risk-adjusted results based on clinical data.
Built into system- no need for "Hardwiring"
STS
JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
I
I
GHS
GHS
Both
Both
Both
Both
JSUMC
I
I
I
I
41
43
54
58
62
Both
Both
Elective
Only
Urgent
only
p
8
P
X
X
X
X
9
X
10
X
22
23
X
X
P
SCIP-VTE-2
SCIP-INF-9
SCIP-Inf2b
SCIP-Inf1b
P
P
Pr
DATA REGISTRY
DEEP SSI
All cardiac surgery programs should participate in a state,
regional, or national clinical data registry and should
built into system- no need for "Hardwiring"
receive periodic reports of their risk-adjusted outcomes.
A deep sternal wound infection should be treated with
aggressive surgical debridement in the absence of
complicating circumstances. Primary or secondary closure
with muscle or omental flap is recommended. Vacuum
therapy in conjunction with early and aggressive
debridement is an effective adjunctive therapy.
FOLLOW UP APPT
Follow up visit timing
VTE PROPHYLAXIS
All CAB patients will have some means of DVT
prophylaxis ordered. Acceptable options include
Subcutaneous heparin, Anti-embolism stockings and Ace
wraps to both legs. Ambulation alone is NOT sufficient.
Any of the following:
• Low-dose unfractionated heparin (LDUH)
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor
• LDUH or LMWH or Factor Xa Inhibitor combined with
IPC or GCS
Any of the following:
• Graduated Compression stockings (GCS)
• Intermittent pneumatic compression devices (IPC)
D/C POSTOP FOLEY
APPROP ABX SELECTION
Timely postop d/c Foley
Approved abx: Cefazolin, Cefuroxime,Table 3.1
or Vancomycin1 Table 3.8
If β-lactam allergy: Vancomycin2 Table 3.8 or
Clindamycin2 Table 3.9
STS
All deep sternal wound infections in CAB patients will be
treated with aggressive surgical debridement and primary or
secondary closure with muscle or omental flap or vacuum
therapy unless an attending surgeon documents
complicating circumstances.
At discharge all patients will be given a follow-up visit with a
clinician (PCP, Cardiologist, CT surgeon or AP) for no later
than 14 days after the date of D/C (eg d/c date = day 0)
OP note, Progress notes, yellow
sheet
Numerator: #
patients with
documented appt
MD PA/Np
within 14 days.
Denominator: # CABG
patients
D/C form, progress note
Numerator: Surgery patients who received Venous
Thromboembolism (VTE) prophylaxis 24 hours prior to
Anesthesia Start Time to 24 hours after Anesthesia End
Time.
Denominator: All selected surgery patients.
MD PA/NP,
RN
orders, MAR, soarian nursing
See Column I
Numerator: Number of surgical patients whose urinary
catheter is removed on POD 1 or POD 2 with day of surgery
being day zero.
Denominator: All selected surgical patients with a catheter in
place postoperatively.
Numerator: Number of surgical patients who received
prophylactic antibiotics recommended for their specific
surgical procedure. (CABG Table 5.01)
Inhospital comps (screen 23),
readmits (screen 25), reops
(screen 26)
MD, RN
See Column I
MD PA/NP
See Column I
Numerator: #
patients appropriate
wt based abx.
Denominator: #
patents with abx
prescribed
preop meds (screen 8/9)
orders, progress note, soarian
nursing
Orders, Weight (multiple sources),
Allergies (multiple sources)
Weight (screen 4/6/15), Abx
(screen 10)
PR
APPRP ABX DOSE
SELECTION
All abx will be prescribed using pharmacy weight-based
dosing protocol
Ancef 1 g (< 80kg); 2 g (>100kg);, Vanco 1 g (<100 kg);
1.5 g (>100kg)
Pr
TIMELY PREOP ABX
Preopabx will be administered within recommended
guidelines. Ancef <60 minutes, Vanco < 120 minutes.
Numerator: Number of surgical patients with prophylactic
antibiotics initiated within one hour prior to surgical incision
(two hours if receiving vancomycin or fluoroquinolone).
Denominator: All selected surgical patients with no evidence
of prior infection.
Anes record
Abx timing (screen 10)
D/C PREOP PLAVIX,
BRILINTA, EFFIENT
In patients undergoing CABG operation will be deferred for
Clopidogrel and ticagrelor should be discontinued for at
at least five 24 hour periods from the last dose of
least 5 days before surgery (B) and prasugrel for at least
clopidogrel or ticagrelor to incision (for prasugrel, at least
7 days (C ) to limit blood transfusions. (Also included as
seven 24 hour periods.) (Also included as Section 5.8,
Section 5.8, Class1, #3)
Class1, #3). Exclusion: Unless platelet assay is therapeutic.
Cath report,med rec, ED record,
transfer records, MAR
Antiplatelets (screen 10)
In patients referred for CABG, short acting intravenous
glycoprotein llb/llla inhibitors (eptifibatide or tirofiban)
should be discontinued for at least 2 to 4 hours before
surgery and abciximab for at least 12 hours beforehand
to limit blood loss and transfusions. (Also included as
Section 5.8, Class I, #5)
Med rec, MAR, orders, transfer
records, ED record
Preop meds (screen 9)
Pr
Pr
D/C PREOP INTEGRILIN,
AGGRASTAT, REOPRO
In patients referred for CABG, short acting intravenous
glycoprotein llb/llla inhibitors (eptifibatide or tirofiban) will
be discontinued for at least 6 hours before incision and
abciximab for at least 24 hours unless the attending surgeon
documents that delay is dangerous. (Also included as
Section 5.8, Class I, #5)
MD PA/NP
A
See Column I
JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
I
I
I
I
GHS
GHS
GHS
GHS
GHS
GHS
Both
Both
Both
Urgent
only
Both
Both
Both
Both
Elective
Only
Both
24
31
X
X
PR
SCIP-CARD2
42
Pr
45
Pr
46
Pr
47
Pr
48
49
Pr
X
52
Both
55
GHS
Elective
Only
57
SCIP-INF-6
PR
Pr
53
GHS
Pr
Pr
X
PREOP ASA
PREOP BB
CTSURG: CONSULT FOR
SIGNIFICANT CAD
DELAY SURGERY
INDICATION
CTSURG: CARD CONSULT
FOR AMI WITH RV
INVOLVEMENT
Unless a clinician documents a contraindication (ie
bleeding), aspirin (at least 81mg orally or 600mg
rectally, daily) will be: (A) initiated (or continued) at
If aspirin (100 mg to 325mg daily) was not initiated
first contact with patients who are to undergo CAB,
preoperatively, it should be initiated within 24 hours
(B) given within 1 hour prior to CAB if not taken
postoperatively and then continued indefinitely to reduce
within 24 hours and (C) resumed within 24 hours
the occurrence of saphenous vein graft closure and
following CAB. Aspirin (at least 81mg orally, daily) will be
adverse cardiovascular events.
prescribed at discharge, unless a clinician documents a
contraindication, and, at the post op clinic visit the patient
will be advised to continue aspirin indefinitely.
Beta blockers should be administered for at least 24
hours before CABG to all patients without
contraindications to reduce the incidence of clinical
sequelae of postoperative AF (also included as Section
5.7, Class I, #1)
A multidisciplinary team approach (consisting of a
cardiologist, cardiac surgeon, vascular surgeon, and
neurologist) is recommended for patients with clinically
significant carotid artery disease for whom CABG is
planned.
It is recommended that surgery be delayed after the
administration of streptokinase, urokinase, and tissuetype plasminogen activators until hemostatic capacity is
restored, if possible. The timing of recommended delay
should be guided by the pharmacodynamic half-life of the
involved agent
CAB will be delayed after the administration of
streptokinase, urokinase, and tissue-type plasminogen
activators until the attending surgeon determines and
documents that hemostatic capacity is adequately restored,
or that further delay is more dangerous than proceeding.
Indication
Attending surgeon documents a Class I or II indication for
CAB pre-op from ACCF/AHA 2011 Guideline document.
RV
In any CAB patient with the pre-op diagnosis of AMI with
significant RV involvement as determined by echo, the
primary cardiac surgeon will document a dialogue with
another cardiac surgeon and a cardiologist and note the
rationale for proceeding with the procedure.
MUPIROCIN FOR S.AUREUS Mupirocin for Staph Aureus nasal carriers
APPROP HAIR REMOVAL
PREOP HGA1C
CHLORHEX WASH
Pr
D/C PREOP NSAIDS
Pr
OSA SCREENING
Numerator: Surgery patients on beta-blocker therapy prior
to arrival who received a beta-blocker during the
perioperative period.
Denominator: All surgery patients on beta-blocker therapy
prior to arrival.
All CAB patients over age 65 or, with a history of CVA, TIA,
carotid bruit , carotid endarterectomy, peripheral vascular
disease, visibly calcified great vessels, LM >=50%, current
smoking and/or combined diabetes and hypertension will
undergo carotid duplex scanning unless the attending
cardiac surgeon documents that delay is dangerous. If the
carotid study documents hemodynamically significant
disease in both carotids, the attending cardiac surgeon must
document a dialogue with a cardiologist and either or both a
vascular surgeon or a neurologist regarding planned
treatment.
Hair removal
Intranasal mupirocin will be administered to all CAB patients
prior to operation unless a nasal culture for s. aureus is
negative. Urgent patients will be treated as soon as
identified and elective patients for at least 5-days
preoperatively.
Numerator: Surgery patients with surgical site hair removal
with clippers or depilatory or with no surgical site hair
removal.
Denominator: All selected surgery patients.
Pre-op HgA1c and defer op for >10
HgA1c will be documented pre-op on all CAB patients.
Chlorhexedine shower/ pre-op wipe
All elective CAB patients will be instructed to shower with
Chlorhexedine daily for 3 days before operation; all urgent
CAB patients will shower, be bathed or wiped with
chlorhexadine daily from initial CTS evaluation until
operation.
Hold pre-op NSAIDS
In all CAB patients, NSAIDS will be stopped at the point of
initial contact.
Screening for , evaluation and treatment of OSA
OSA screening tool will be documented on all pre-op CAB
patients and if positive, referral for evaluation will be done
at the post-op clinic visit.
Numerator: #
patients w/ASA
prescribed p/t 24 hrs
of CABG.
Denominator: #
CABG patients
without documented
ASA contraindications
See Column I
Med rec, ED record, transfer
records, MAR, orders
Preop meds (screen 9)
MD NP/PA,
A
MAR, orders, med rec, ED record,
transfer record
Preop meds (screen 9)
H&P, Progress notes
Age/hx/disease ONLY
MAR, orders, ED record, transfer
records
Preop meds (screen8/9)
Consult, H&P, OP note
Consult, progress note, echo report,
H&P
AMI hx, echo results ONLY
MAR, orders
OR RN
See Column I
OR Nursing record
Lab report
risk factors (screen 4)
Orders, soarian nursing?
Numerator: #
patients without
MD PA/NP
NSAIDS orders preop.
Denomitor: # CABG
MAR, orders, consult, H&P, med rec Preop meds (screen 8/9)
patients
OSA screening form (electives),
H&P, consult
risk factors (screen 4)
JSUMC CABG MODEL 4 BEST PRACTICE ELEMENTS (BPE) FOR MONITORING
GHS
Elective
Only
JSUMC
III h
Both
59
Pr
60
Pr
29
X
TSH
PREOP RA ABG (COPD)
Euthyroid
TSH will be documented pre-op in all CAB patients. If >=
10, operation will not proceed until an endocrinologist clears
the patient.
Preop Room Air Blood Gas
Preop RA ABG will be obtain in patients with COPD on home
oxygen/steroids and patients with pulmonary fibrosis
Discontinuation of statin or other dyslipidemic therapy is
Pr/P DO NOT D/C STATIN PREOP not recommended before or after CABG in patients
without adverse reactions to therapy.
Lab report
H&P, labs
Numerator: #
patients with statin MD PA/NP
order pre/postop.
Denominator: #
patients with statin
on admission med rec
MAR, orders, med rec
risk factors (screen 4)
Preop meds (screen 9)