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Vital Signs at UMass Memorial

Nurse input helps resuscitate once-troubled cardiac surgery program

Monday March 9, 2009
“The hospital and all of the staff involved responded with the kind of leadership required to turn the program around.”

<i>— Paul Dreyer, Massachusetts Deptartment of Public Health</i>
“The hospital and all of the staff involved responded with the kind of leadership required to turn the program around.” — Paul Dreyer, Massachusetts Deptartment of Public Health
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In September 2005, the nonprofit hospital and clinical partner of UMass Medical School faced what easily could have become the death knell for its cardiac surgery program. The Massachusetts Department of Public Health had released a report on statewide adjusted mortality rates by hospital for coronary artery bypass graft surgeries performed in 2003, and UMass Memorial had the highest rate in the state.

But rather than bury the news and hope it would go away, the hospital used the report as a wake-up call to totally revamp its program. Hospital administrators voluntarily suspended all elective cardiac surgeries while they took a hard look at how things were done and made a host of changes. Nurses were front and center during the initiative and have played a vital role in the program's turnaround ever since, administrators say.

Much of the success for this turnaround hinged on nurses' feedback and participation, says Jay Cyr, RN, MS, MBA, the vice president of UMass Memorial's Heart and Vascular Center of Excellence.

"Nurses had a tremendous amount of input," he says. "They pushed back a lot of times."

Once the hospital discovered its troubling mortality rates — which were twice the state average for CABG surgery performed from 2004 to 2005 — the hospital moved quickly to get to the bottom of the problem. An emergency meeting of top hospital administrators was called and the decision made to voluntarily close the program to elective surgery. An outside panel of cardiac experts came in, interviewed physicians and staff, and submitted a written report outlining some of the problems with the cardiac surgery program. The program reopened after six weeks to low-risk elective patients with the state's approval after major changes were made to all aspects of care, from pre-operative to post-discharge.

Among several red flags the outside experts found was the hospital's prior elimination, for financial reasons, of a dedicated cardiac ICU and acute-care area for cardiac surgery patients. Around 2002, Cyr says, the hospital had stopped grouping together heart patients after surgery and instead sent them to a more general acute-care floor for care. "That diluted the nursing care that was being delivered on that floor," he explains.

Also, in the late 1990s, the hospital joined its general surgery ICU with the cardiac surgery ICU, again diluting the specialization of the nursing care available to heart patients. Where before there might have been 20 to 25 nurses who specialized in taking care of heart patients, there were now 50 to 60 nurses involved in their care but who also cared for other patients, he says.

Hospital administrators split up two large acute-care floors into four smaller floors that were more specialized. In January 2007, the hospital opened a combined heart and vascular ICU. And in January 2009, the hospital opened a new heart and vascular step-down unit. All of the nurses who had been taking care of cardiac patients had to go through a reorientation and recertification as cardiac surgery nurses, Cyr says.

"Now we were working as a team," says Laura Everett, RN, the unit manager for the 3-West Cardiac/Vascular unit at UMass Memorial. "The standards were clear; people were held accountable and had the ability to be because we all made sure everybody had the education they needed."

Several years later, the cardiac surgery program at UMass Memorial is recognized nationally and locally, and now the media reports are glowing instead of disparaging. In January 2008, it achieved the highest ranking — three stars — given by the Society of Thoracic Surgeons. The Centers for Medicare and Medicaid Services recently ranked the hospital No. 1 in Massachusetts and No. 2 in the U.S. for surviving a heart attack. The hospital also was listed in Thomson Healthcare's Top 100 for Cardiovascular Benchmarks for Success.

"We are pleased with the progress that UMass Memorial Medical Center has made with respect to its cardiac surgery program," Paul Dreyer, the director of Health Care Safety and Quality for the Massachusetts Department of Public Health, said in an e-mail. "The hospital and all of the staff involved responded with the kind of leadership required to turn the program around."

Cyr, a cardiac ICU surgery nurse by training, was a key member of a work group given the task of implementing changes the outside panel recommended. The work group divided itself into three task forces. "In all aspects of that, nursing was involved," he says.

Nancy Kruger, RN, DNSc, UMass Memorial's senior vice president and chief nursing officer, says the increased collaboration between physicians and nurses boosted morale. "I think in general nurses carry their heads high when their physician colleagues and others work with them as real colleagues and partners in care," she says. "I really think that has been a large part of this success."

Barbara Kirchheimer is a freelance writer. To comment, e-mail editorNE@gannetthg.com.