Design and impact of an intraoperative pathway: a new operating room model for team-based practice.

BACKGROUND: The concept of a team-based model for delivery of care has been critical at our institution for improving efficiency and safety. Despite these measures, difficulties continue to occur during lengthy operating room procedures. Using a novel team-based practice model, a multidisciplinary team was organized to improve efficiency in microsurgical breast reconstruction. We describe development of an intraoperative pathway for deep inferior epigastric perforator (DIEP) flap breast reconstruction and its impact on various outcomes. STUDY DESIGN: We evaluated 150 patients who underwent DIEP flap breast reconstruction at Beth Israel Deaconess Medical Center from 2005 to 2008. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures before the intraoperative pathway and 25 unilateral and 25 bilateral procedures after. Outcomes measured included operative time, complications, operating room and hospital costs, proper administration of prophylactic antibiotics and heparin, and staff satisfaction surveys. RESULTS: Mean operative times decreased after pathway implementation in both unilateral (8.2 hours to 6.9 hours; p < 0.001) and bilateral groups (12.8 hours to 10.6 hours; p < 0.001) and complication rates were unchanged. Mean operating room costs decreased in the unilateral group by 10.2% (p = 0.018). Prophylactic heparin administration showed substantial improvements, although antibiotic administration and redosing of antibiotics trended upward. Staff surveys showed improved interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization. CONCLUSIONS: Implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. Refinement of the pathway with team resolution of variances might continue to improve outcomes. Complex, multi-team procedures can derive benefits from standardization and intraoperative pathway development.

Implementing tight glucose control after coronary artery bypass surgery.

BACKGROUND: The clinical benefit of tight glucose control has been demonstrated in diabetic patients. In adopting an approach of tight glucose control for all cardiac surgery patients at Beth Israel Deaconess Medical Center, we encountered several challenges, including defining good glucose control, meaningfully measuring control, and assessing the impact of variables that may affect control. METHODS: An interdisciplinary team used an insulin protocol to achieve tight glucose control of cardiac surgery patients in the operating room and intensive care unit as part of an effort to reduce sternal wound infections. Good control was defined as glucose less than 130 mg/dL for more than 50% of measured time. RESULTS: Eight hundred eighteen patients underwent coronary artery bypass grafting between November 2002 and August 2004. Seven hundred thirty-seven (90%) received insulin. Fifty-seven percent did not have a preoperative diagnosis of diabetes. The trigger for insulin initiation was decreased sequentially from 150 mg/dL to 110 mg/dL, but the measure of good control remained the same: glucose less than 130 mg/dL. The factor most highly predictive of glucose being well controlled was the protocol with the 110 mg/dL trigger for insulin (p < 0.001). Patient factors such as age, ejection fraction, preoperative angiotensin-converting enzyme inhibitor or beta-blocker use, or time on cardiopulmonary bypass were not significantly associated with glucose control. During the course of the protocols, the rate of mediastinitis decreased from 1.6% to 0%. CONCLUSIONS: Key elements to implementing tight glucose control include having a standard protocol and metrics to track protocol performance. This practice improved control and was associated with a marked reduction in mediastinitis.