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)
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