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Ann Thorac Surg 1996;62:391-392
© 1996 The Society of Thoracic Surgeons
DR LUDWIG K. von SEGESSER (Zurich, Switzerland): I congratulate you on your excellent results. Have you lost any patient at home? If a patient dies during the hospital stay, how does your model handle this patient?
DR TURLEY: Hospital deaths were not included in the statistical analysis of hospital stay. For this reason, the three deaths were presented initially. There were no deaths outside the hospital. None of the 214 consecutive patients left the hospital for another facility. All survivors were discharged home.
DR MARSHALL L. JACOBS (Philadelphia, PA): Doctor Turley, I compliment you not only on your responsiveness to the forces that are brought to bear on all of us in terms of redesigning practice but also on the very careful and elegant analysis and the good results. You did mention a family satisfaction survey. If there were a physician satisfaction survey polling the opinions of yourself and your cardiology colleagues, would you conclude that this is a good thing?
DR TURLEY: Thank you, Dr Jacobs, for your kind comments. The interesting thing about this whole process is that it involves a number of critical moments, the first of which occur before the patient actually enters the hospital. Those are the introduction by the clinical nurse coordinator and what we call empowerment. In our initial experience, we used the term indoctrination. It implied that the family was given the information and then in the second step became thoroughly familiar with what its role would be. In fact, the family became an advocate for the child. The family took the child through the hospitalization as members of the health care team, became empowered by the knowledge of what its role was, and asked us the critical question, "Why are we in the hospital?" Because the cardiology, anesthesia, intensive care, and nursing staffs are intimately involved in the entire process, we have had no negative family assessments. All of us are moving toward the same end point. Physician and nursing evaluation of a successful course reflects the same team effort, successful care of the patient and delivery of that patient to the home care situation. This is the goal to which we all aspire.
DR LEE H. ELLISON (Hartford, CT): I missed the beginning, so if you covered this, please forgive me. Do you do anything different in terms of extubation? Do you have criteria for early extubation?
DR TURLEY: Our protocol for extubation is designed around the individual patient, lesion, operative approach, and expected pathway plan. We speak of our anesthesia technique as being both patient friendly and pathway friendly. The anesthesiologist and the rest of the team are on board in the pathway plan. If the planned operation turns out to be one in which early extubation is possible, for example, the Ross-Konno type of root replacement, the anesthesiologist has designed his or her plan to accommodate the potential for early extubation. In the patient having a Ross-Konno procedure, extubation was accomplished 4 hours postoperatively. Because there was no postoperative hemorrhage, the patient had a rapid recovery, as in all our pathway planning. A rigid structure should not preclude the patient's outperforming the system.
DR ELLISON: For what lesions do you plan to leave the patient intubated overnight? Do you ever extubate in the operating room?
DR TURLEY: Our extubation plan is based on our radical outcome method (ROM) level. We do occasionally extubate in the operating room at the discretion of the anesthesiologist because we have a distance to travel to the intensive care unit. In patients on ROM level 4 or higher, the plan is for extubation the day after operation. It is extremely rare for patients at level 4, such as those with a ventricular septal defect, to require overnight intubation. That is why they are a crossover group in our analysis and were not included as a separate group. In fact, a small number of patients with ventricular septal defects require intubation overnight or for a longer period, but the majority can be extubated in the early postoperative period. It has been difficult to separate the various subgroups, although there is clearly a group who can be easily extubated and unless intraoperative problems develop, an extubation regimen is possible. As our results indicate, early extubation is commonly possible in patients on ROM levels 5, 6, and 7 and in the comorbidity group beyond. It is the most important critical moment in rapid acceleration of the ROM design and again reflects the patient's ability to outperform our pathway design, which is an intrinsic part of our system that we readily accommodate. In this setting, ROM allows the patient to avoid the bias (critical pathway) and the rigidity of our clinical experience, and we can address the patient as an individual in his or her response to the clinical experience.
DR EDWARD L. BOVE (Ann Arbor, MI): Doctor Turley, what percentage of your patients were neonates? Do you have any data on their average length of stay?
DR TURLEY: Our neonatal population is small. As indicated in the paper, the median age of our patient population was 3 years. The range from the neonate to patients 19 years of age reflects the nature of the health care maintenance facility. Our experience in an acute-care setting demonstrates that pathway methodology is possible in neonatal subgroups, such as patients requiring an arterial switch, although critical moments 3 and 4, operation and extubation, are more variable and do have an impact on variation in pathway design. However, in the neonatal group, ROM can be effectively applied with a significant reduction in length of stay, both in the intensive care unit and in the hospital.
DR DONALD C. WATSON, JR (Memphis, TN): Doctor Turley, this is a very elegant description and a very sophisticated data analysis. The crux of this system depends on having a family to empower. How do you deal with families without a mother or father who can be empowered?
DR TURLEY: Thank you, Dr Watson, for your kind comments. One of the fascinating things in our experience has been that neither in our previous pathway designs nor in our current methods have we found a family or a subgroup of the family unit, for example, guardians of the state, patients whose parents are divorced or are in the process of getting a divorce, or single parents, who during the time of hospitalization has not found a champion for the child. Preoperative involvement in the introduction and empowerment moments addresses these issues and identifies champions, be they parents or commonly grandparents, older siblings, or guardians from the state who can fulfill this role. What we were most surprised at early and what we were most impressed with over time was the availability of and constant care delivered by such champions once they were identified. The importance of the preoperative process must be stressed; to attempt this during the traditional hospital approach on admission is doomed to failure. The family dynamics must be evaluated and the champion in place by the time that most emotionally charged period occurs, the day of admission.
Related Article
Ann. Thorac. Surg. 1996 62: 386-391.
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