High on Volume, Low on Error: Mount Sinais Secret
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| Mount Sinai Medical Center has the highest volume of PCI procedures in New York State and also the lowest rate of complications. |
Last year, the nearly 1,200-bed Mount Sinai facility was named a Top Hospital by U.S. News & World Report, even making the magazine’s elite “Honor Roll” list. In the category of heart and heart surgery, the hospital significantly improved its ranking from 41 in 2008 to 18. In 2007, the hospital’s cardiac care wasn’t even ranked.
“Back in the late 1990s, Mount Sinai was well known for general cardiology, but was never on the interventional map,” says Samin K. Sharma, MD, director of the cardiac cath lab. Today, the synthesis of safety, teamwork and protocol-driven practices coalesce to facilitate and improve patient care.
According to Sharma, the 130 members of the cath lab staff strive to meet guidelines and national benchmarks to drive care. The cath lab performs the largest number of PCI procedures in New York State and has a mortality rate that sits well below the state average.
In 2006, Sharma and colleagues performed 4,786 PCIs, with a low risk-adjusted mortality rate of 0.50 compared to the statewide average of 0.63. This year, Sharma expects the provider to perform approximately 5,800 PCIs with a mortality rate of 0.16.
“Although patient volume has skyrocketed over the past few years, the quality of care has not suffered,” Sharma says. He attributes the cath lab’s turnaround to “one simple thing: being protocol driven.”
The lab’s use of a 76-page cath lab-specific protocol-based manual provides procedural-based instructions to help achieve consistent results. The manual assists in training and teaching new hires, fellows and attendings. “During the first weeks of orientation, we review point by point how a procedure has to be done,” says Annapoorna Kini, MD, associate director of the cath lab.
Protocols include post-PCI patient treatment, managing contrast allergies prior to a procedure and how to properly run a post-PCI routing lab check, among others. “Being protocol driven, we can manage each case” and ensure that “we don’t try new techniques that may not work,” Kini says.
Team spirit
Sharma and his staff have daily, weekly and monthly meetings to ensure everyone is on the same page. Morning meetings last about 20 to 30 minutes and include discussions of the 40 to 50 patient cases that day. This “open forum” allows staff members to identify patient issues from the previous day and “change the practice accordingly” to resolve the problem and avoid risks, Sharma says. “We scrutinize our own complications and our own mistakes. The whole process is to achieve excellence.”Weekly floor meetings also analyze patient cases and associated complications. Staff are then educated on proper procedures, thereby, reducing future risk. Protocol-specific teachings help keep complications to a minimum, says Sharma. For example, nurses and staff already know what to do if a patient has an allergic reaction to dye. “Although this patient will see multiple staff during his or her visit, all staff members will use the same protocol because they are all trained in the same way. We strive to have the care be consistent,” he says.
To continue this trend, monthly staff meetings review difficult patient cases, complications and patient complaints to “identify any problems and work accordingly to rectify them,” says Sharma. “We have created a team spirit. Our main motto is that we all have to work together.”
Decreasing complications
Performing a procedure safely is one aspect, but providing top-notch care for patients is another, says Kini. After a procedure, nurses meet with the patient and the family to create a picture of what occurred during surgery and, most importantly, to outline future considerations for the patient. “This multidisciplinary approach is the best one for optimal patient care,” she says.Every third Tuesday of the month, the cath lab broadcasts a live webcast to highlight the complex patient cases. The coronary intervention series launched last July discusses and critiques patient cases with staff, as well as outside doctors, to provide an additional educational outlet and training tool.
“The success rate of the cath lab is not just about what is done by the doctors or physicians during the procedure, but also the pre- and post-op care, which are equally important, if not more,” says Sharma.
Adherence to national and institutional benchmarks has reduced the lab’s procedural complication rates by 50 percent. Statistics of major complications—mortality, heart attack, the need for bypass surgery and stroke—are collected and reported quarterly to measure the success of the protocols. From 2006 to 2008, the major complication rate was 0.3 percent, while the minor complication rate was 1.1 percent. If a staff member goes beyond benchmarks, he or she has a one-on-one meeting with a supervisor.
Outreach
Learning techniques from other institutions and cardiologists also has helped Mount Sinai employ methodologies that have the potential to reduce complications. Sharma says they often use a retrograde approach to better treat chronic total occlusions (CTOs). To learn this technique, Mount Sinai brought in experts from Japan, where the retrograde approach has been refined. The Japanese interventionalists worked with their U.S. counterparts, training and teaching the new technique.“Until you are in the field doing a procedure yourself, you don’t really know the best way to approach it,” Sharma says. With the use of specialized guidewires, the traditional antegrade opening of a CTO is possible in 75 percent of the lab’s patient cases.
Use of the retrograde technique at Mount Sinai, however, has had a success rate of 95 percent, a big turnaround from the previous 65 percent rate, says Sharma. “This has really improved safety and success for us,” he adds.
Setting examples of dedication makes other people around you “want to work in the same way,” says Sharma. “It’s hard work, but anyone can achieve success with full dedication.”