Ebinger Joseph E, Porten Brandon R, Strauss Craig E, Garberich Ross F, Han Christopher, Wahl Sharon K, Sun Benjamin C, Abdelhadi Raed H, Henry Timothy D
From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.).
Circ Cardiovasc Qual Outcomes. 2016 Sep;9(5):593-9. doi: 10.1161/CIRCOUTCOMES.116.003122. Epub 2016 Aug 23.
Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery, which results in increased morbidity, mortality, length of stay, and hospital costs. We developed and followed a process map to implement a protocol to decrease POAF: (1) identify stakeholders and form a working committee, (2) formal literature and guideline review, (3) retrospective analysis of current institutional data, (4) data modeling to determine expected effects of change, (4) protocol development and implementation into the electronic medical record, and (5) ongoing review of data and protocol adjustment. Retrospective analysis demonstrated that POAF occurred in 29.8% of all cardiovascular surgery cases. Median length of stay was 2 days longer (P<0.001), and median total variable costs $2495 higher (P<0.001) in POAF patients. Modeling predicted that up to 60 cases of POAF and >$200 000 annually could be saved. A clinically based electronic medical record tool was implemented into the electronic medical record to aid preoperative clinic providers in identifying patients eligible for prophylactic amiodarone. Initial results during the 9-month period after implementation demonstrated a reduction in POAF in patients using the protocol, compared with those who qualified but did not receive amiodarone and those not evaluated (11.1% versus 38.7% and 38.8%; P=0.022); however, only 17.3% of patients used the protocol. A standardized methodological approach to quality improvement and electronic medical record integration has potential to significantly decrease the incidence of POAF, length of stay, and total variable cost in patients undergoing elective coronary artery bypass graft and valve surgeries. This framework for quality improvement interventions may be adapted to similar clinical problems beyond POAF.
术后心房颤动（POAF）是心脏手术常见的并发症，会导致发病率、死亡率、住院时间和住院费用增加。我们制定并遵循了一个流程地图来实施一项减少POAF的方案：（1）确定利益相关者并组建工作委员会；（2）正式的文献和指南审查；（3）对当前机构数据进行回顾性分析；（4）数据建模以确定变革的预期效果；（4）制定方案并将其纳入电子病历；（5）持续审查数据并调整方案。回顾性分析表明，POAF发生在所有心血管手术病例的29.8%中。POAF患者的中位住院时间长2天（P<0.001），中位总可变成本高2495美元（P<0.001）。建模预测，每年最多可避免60例POAF病例，节省超过20万美元。一个基于临床的电子病历工具被纳入电子病历，以帮助术前门诊提供者识别有资格接受预防性胺碘酮治疗的患者。实施后的9个月期间的初步结果表明，与符合条件但未接受胺碘酮治疗的患者以及未接受评估的患者相比，使用该方案的患者POAF发生率降低（11.1%对38.7%和38.8%；P=0.022）；然而，只有17.3%的患者使用了该方案。一种标准化的质量改进和电子病历整合方法有潜力显著降低接受择期冠状动脉搭桥术和瓣膜手术患者的POAF发生率、住院时间和总可变成本。这种质量改进干预框架可能适用于POAF以外的类似临床问题。
