Optimizing Length of Stay for Cardiac Surgery Through Preoperative Workflow Redesign

Optimizing hospital length of stay (LOS) has many advantages, such as lower risk of hospital-acquired conditions, increased patient satisfaction and reduced hospital costs. These advantages loomed large when Cleveland Clinic’s Heart and Vascular Advisory Services team performed an initial assessment of the cardiovascular service line of Kaweah Health (KH), recognizing an opportunity to significantly shorten preoperative LOS for patients undergoing elective cardiac surgery through process improvements and workflow redesign.

The assessment took place in the early stages of an affiliation relationship that KH, which serves California’s Central Valley, entered into with Cleveland Clinic’s Heart, Vascular & Thoracic Institute in 2019 to promote quality outcomes and share best practices pertaining to patient experience and efficiency.

Backdrop to the project

For years, cardiac surgeons at KH had arranged for their elective surgery patients to be admitted to the hospital prior to the day of surgery as a “courtesy admission” during which the surgical team could finalize the preoperative evaluation and provide formal presurgical education to the patient and family. The aim was to afford surgeons better control of elective surgery start times since patients would already be in-house.

In practice, courtesy admission patients could spend anywhere from 12 hours to several days waiting to go to surgery as a result of incomplete preoperative tests or being delayed for more urgent cases. The resulting prolonged hospitalization time waiting for an elective procedure became a significant source of patient dissatisfaction.

This dissatisfaction was exacerbated in the spring of 2020 when the COVID-19 pandemic brought new restrictions limiting family members from visiting their loved ones in the hospital. This proved to be a huge stressor to patients prior to surgery. The need to shorten or eliminate preoperative LOS was more apparent than ever from patients’ standpoint. Unnecessary presurgical admissions also reduced access to limited hospital beds, as some were occupied by preoperative patients who didn’t yet need them.

Essentials of the process redesign

Challenges and opportunities related to this courtesy admission process were identified in Cleveland Clinic’s initial review of KH cardiovascular operations. Working with Cleveland Clinic consultants who performed the review, KH cardiac surgery leadership undertook an initiative to eliminate preoperative admissions for elective surgery patients in order to (1) promote patient satisfaction, (2) increase preoperative workup efficiency and (3) reduce the cost of elective surgery cases by avoiding expenditures for unnecessary preoperative hospital stays.

After thorough communication to the teams involved about expected benefits of the project for patients and the hospital, KH cardiac surgery leadership and a Cleveland Clinic consultant initiated discussions about how best to redesign the process and workflow for presurgical workup of elective surgery patients. All affected areas were covered, from surgical offices to the preoperative and cardiovascular care units to the preadmission testing area.

Through a series of interviews and formation of a stakeholder team, the Cleveland Clinic consultant worked with KH to:

• Create “current state” productivity timelines to visually display productive versus nonproductive portions of the presurgical admission process
• Recommend “ideal state” pathways to incorporate key steps into the surgical evaluation process
• Create an ideal state process map as a visual aid for workflow transparency once workflows were agreed upon and adopted

Under the leadership of Christine Aleman, Director of Cardiovascular Operations at KH, and with support from Leheb Araim, MD, Cardiac Surgery Director, education on the workflow redesign was provided to the cardiovascular surgery nurse practitioners and preoperative nursing teams. Patient evaluation, testing and presurgical education were then transitioned to be done on an outpatient basis by existing preoperative hospital personnel.

Figure. Steps involved in the development of Kaweah Health’s same-day admission process for elective cardiac surgery patients.

Initial impacts of the same-day admission pathway

The result was a redesigned process — the same-day admission pathway — with outpatient workflows that eliminated the need for admission prior to surgery. This allows KH personnel to provide necessary patient education on the procedure and expectations for postoperative recovery several days prior to surgery rather than the day before, giving patients and families time to formulate questions and fully prepare for the operation.

“All our elective cardiac surgery patients’ preoperative work is now completed through phones calls and outpatient communication,” says KH’s Aleman. “Paperwork is completed before their arrival at the hospital, and expectations for their surgery and recovery have already been discussed with them in detail. Patients are appreciative of our new process because it allows them to be at home where they are most comfortable until the day of surgery. Patients are now more at ease because they have already met most of the healthcare professionals they will see the day of surgery and have had a chance to process all the educational information with their families. This tends to reduce patients’ stress, which should ultimately result in better outcomes and faster recovery.”

Implementation of the same-day admission pathway has been too recent to allow comprehensive assessment of its impact on patient satisfaction, but it is expected to have positive effects. In addition, the new pathway has provided an efficient and effective process for surgical evaluation, with no negative impact on quality.

Moreover, preoperative testing on an outpatient basis has proved less expensive than inpatient testing due to savings realized through shorter inpatient stays, elimination of facility charges, and reduced use of labor, supplies and textiles. “Since implementing the same-day admission process, our hospital is saving thousands of dollars per patient by avoiding costs typically associated with an increased length of stay,” says Aleman.

“Working with Cleveland Clinic was a worthwhile strategic move that provided insights, evaluations and resources to bring the same-day admission process to life for our cardiac surgery patients,” she adds. “We have been able to take the concept and turn it into a process that works across multiple departments in our hospital.”

“Sharing best practices lies at the foundation of our affiliate arrangements,” notes Edward Soltesz, MD, MPH, cardiothoracic surgeon and Director of Cardiac Surgery Affiliate Services at Cleveland Clinic. “The same-day admission process has been shown to not only improve efficiency and patient satisfaction but also encourage a protocol-driven approach to the multidisciplinary evaluation that is the cornerstone of surgical quality. We are excited that KH has operationalized this important program, and we look forward to seeing its positive results.”

For information on affiliation and alliance opportunities with Cleveland Clinic’s Heart, Vascular & Thoracic Institute, email Amanda Lesesky at leseska@ccf.org.