Design, Challenges, and Implications of Quality Improvement Projects Using the Electronic Medical Record

Abstract

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.

Value-Based ST-Segment–Elevation Myocardial Infarction Care Using Risk-Guided Triage and Early Discharge

“…While this current initiative focuses on post-PCI care for STEMI, numerous other risk calculators and models exist across the spectrum of cardiovascular disease. 13–15 Within acute myocardial infarction, expansion of risk models to the triage of patients presenting with non-ST Elevation Myocardial Infarction and Unstable Angina for early discharge may be able to realize similar reductions in LOS and total costs, without compromising quality of care or patient outcomes. Similarly, as percutaneous approaches to structural and valvular heart disease increase, risk-based care delivery strategies may help to achieve higher value care.…”

Amiodarone Protocol Provides Cost-Effective Reduction in Postoperative Atrial Fibrillation

“…In the current environment of quality improvement and focus on protocol driven care it is critical to evaluate these interventions using the value framework. (9) There are many pitfalls in designing and implementing and evaluating the success of quality improvement projects as described in a recent paper by Ebinger et al(26) However, these authors do not mention the significant investment of personnel hours to develop and successfully deploy a major service line wide initiative. While these estimates are difficult to identify and quantify, this prophylactic amiodarone protocol required over 100 hours of work from surgeons, nurses, and quality officers with an estimated cost of $3,530.…”

Health Services Research

“…Based on clinical trials and guidelines (17,18), we developed a decision support tool that prompts providers to prescribe prophylactic amiodarone to eligible patients prior to cardiac surgery. Although efficacy was previously shown in trials, this work demonstrated the effectiveness of this intervention, with a reduction in post-operative atrial fibrillation rates from 38% to 11% and an estimated cost savings of >$200,000 annually (19). …”