Quality and Value in the Cardiothoracic Intensive Care Unit

  • Kevin LobdellEmail author
  • Joe Mishkin
  • Rakesh C. Arora
  • Rohan Mukund Sanjanwala
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Quality and value is dependent on structure and processes. In the cardiothoracic critical care unit, structure relates to how the team is organized and processes relate to how the team does its work. Herein, the review of pertinent literature is described and the results succinctly described.


Quality Value Risk Teamwork Communication Goal-directed therapy 


  1. 1.
    Bhalla V, Caye J-M, Dyer A, Dymond L, Morieux Y, Orlander P. High-performance organizations – the secrets of their success. The Boston Consulting Group online publications. Published September 1, 2011. Accessed 8 May 2017.
  2. 2.
    Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459–90.CrossRefGoogle Scholar
  3. 3.
  4. 4.
    Resnick A, Corrigan D, Mullen J, Kaiser L, Copeland EM, Resnick AS. Surgeon contribution to hospital bottom line: not all are created equal. Ann Surg. 2005;242(4):530–9.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Titinger DP, Lisboa LAF, Matrangolo BLR, et al. Cardiac surgery costs according to the preoperative risk in the Brazilian public health system. Arq Bras Cardiol. 2015;105:130–8.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Osnabrugge RL, Speir AM, Head SJ, et al. Performance of EuroSCORE II in a large US database: implications for transcatheter aortic valve implantation. Eur J Cardiothorac Surg. 2014;46(3):400–8.CrossRefGoogle Scholar
  7. 7.
    Pintor PP, Bobbio M, Colangelo S, Veglia F, Marras R, Diena M. Can EuroSCORE predict direct costs of cardiac surgery? Eur J Cardio-Thorac Surg. 2003;23(4):595–8.CrossRefGoogle Scholar
  8. 8.
    Speir AM, Kasirajan V, Barnett SD, Fonner E. Additive costs of postoperative complications for isolated coronary artery bypass grafting patients in Virginia. Ann Thorac Surg. 2009;88(1):40–6.CrossRefGoogle Scholar
  9. 9.
    Ferraris VA, Ferraris SP, Singh A. Operative outcome and hospital cost. J Thorac Cardiovasc Surg. 1998;115(3):593–603.CrossRefGoogle Scholar
  10. 10.
    Osnabrugge RL, Speir AM, Head SJ, et al. Cost, quality, and value in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2014;148(6):2729–2735.e1. Scholar
  11. 11.
    Box GEP. Science and statistics. J Am Stat Assoc. 1976;71(356):791–9.CrossRefGoogle Scholar
  12. 12.
    Khosro H. CASUS-intensive care medicine score. Accessed 8 May 2017.
  13. 13.
    Online STS adult cardiac surgery risk calculator. Accessed 8 May 2017.
  14. 14.
  15. 15.
    Bertges DJ, Goodney PP, Zhao Y, et al. The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients. J Vasc Surg. 2010;52(3):674–683.e3.CrossRefGoogle Scholar
  16. 16.
    Protopapa KL, Simpson JC, Smith NCE, Moonesinghe SR. Development and validation of the Surgical Outcome Risk Tool (SORT). Br J Surg. 2014;101(13):1774–83.CrossRefGoogle Scholar
  17. 17.
    Vincent J-L, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;14(2):207.CrossRefGoogle Scholar
  18. 18.
    Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA. 2002;288(17):2151–62.CrossRefGoogle Scholar
  19. 19.
    Kerlin MP, Adhikari NK, Rose L, Wilcos ME. An official American Thoracic Society systematic review: the effect of nighttime intensivist staffing on mortality and length of stay among intensive care unit patients. Am J Respir Crit Care Med. 2017;195(3):383–93.PubMedGoogle Scholar
  20. 20.
    Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201–9.CrossRefGoogle Scholar
  21. 21.
    Gupta P, Rettiganti M, Jeffries HE, et al. Association of 24/7 in-house intensive care unit attending physician coverage with outcomes in children undergoing heart operations. Ann Thorac Surg. 2016;102(6):2052–61.CrossRefGoogle Scholar
  22. 22.
    Guccione A, Morena A, Pezzi A, Iapichino G. The assessment of nursing workload. Minerva Anestesiol. 2004;70(5):411–6.PubMedGoogle Scholar
  23. 23.
    Laura L. Hospital ICUs mine big data in push for better outcomes. WSJ. 2015. Accessed 8 May 2017.
  24. 24.
    Kumar K, Singal R, Manji RA, et al. The benefits of 24/7 in-house intensivist coverage for prolonged-stay cardiac surgery patients. J Thorac Cardiovasc Surg. 2014;148(1):290–297.e6.CrossRefGoogle Scholar
  25. 25.
    Sexton JB, Grote G, Naef W, Straeter O, Helmreich RL. The better the team, the safer the world. Golden rules of group interaction in high risk environments: evidence based suggestions for improving performance. 2004.
  26. 26.
    Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71–5.CrossRefGoogle Scholar
  27. 27.
    Casale AS, Paulus RA, Selna MJ, et al. “ProvenCareSM” a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg. 2007;246(4):613–23.CrossRefGoogle Scholar
  28. 28.
    Toccafondi G, Albolino S, Tartaglia R, et al. The collaborative communication model for patient handover at the interface between high-acuity and low-acuity care. BMJ Qual Saf. 2012;21(Suppl 1):i58–66.CrossRefGoogle Scholar
  29. 29.
    Holmes DR, Mohr F, Hamm CW, Mack MJ. Venn diagrams in cardiovascular disease: the Heart Team concept. Eur Heart J. 2013;35(2):66–8.CrossRefGoogle Scholar
  30. 30.
    Shake JG, Pronovost PJ, Whitman GJR. Cardiac surgical ICU care: eliminating “preventable” complications. J Card Surg. 2013;28(4):406–13.CrossRefGoogle Scholar
  31. 31.
    Lobdell KW, Stamou SC, Mishra AK, et al. Multidisciplinary rounds: the work, not more work. Ann Thorac Surg. 2010;89(3):1010.CrossRefGoogle Scholar
  32. 32.
    Lilly CM, Zubrow MT, Kempner KM, et al. Critical care telemedicine: evolution and state of the art. Crit Care Med. 2014;42(11):2429–36.CrossRefGoogle Scholar
  33. 33.
    Rechel B, Wright S, Barlow J, McKee M. Hospital capacity planning: from measuring stocks to modelling flows. Bull World Health Organ. 2010;88(8):632–6.CrossRefGoogle Scholar
  34. 34.
    Edwards FH, Ferraris VA, Kurlansky PA, et al. Failure to rescue rates after coronary artery bypass grafting: an analysis from the society of thoracic surgeons adult cardiac surgery database. Ann Thorac Surg. 2016;102(2):458–64.CrossRefGoogle Scholar
  35. 35.
    The importance of teaming. WORKING KNOWLEDGE business research for business leaders. Published 2012. Accessed 8 May 2017.
  36. 36.
    Critical care symposium to examine role of Tele-ICUs in improving quality, value. CC synposium. Published 2016. Accessed 8 May 2017.
  37. 37.
    Spath P. The quality-cost connection: improve patient flow by reducing bottlenecks. RELIAS. Published 2005. Accessed 8 May 2017.
  38. 38.
    Tucker AL, Nembhard IM, Edmondson AC. Implementing new practices: an empirical study of organizational learning in hospital intensive care units. Manag Sci. 2007;53(6):894–907.CrossRefGoogle Scholar
  39. 39.
    Share DA, Campbell DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff. 2011;30(4):636–45.CrossRefGoogle Scholar
  40. 40.
    Stamou SC, Camp SL, Stiegel RM, et al. Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc Surg. 2008;136(2):494–499.e8.CrossRefGoogle Scholar
  41. 41.
    Pradarelli JC, Healy MA, Osborne NH, Ghaferi AA, Dimick JB, Nathan H. Variation in medicare expenditures for treating perioperative complications: the cost of rescue. JAMA Surg. 2016;151(12):e163340.CrossRefGoogle Scholar
  42. 42.
    Bland RD, Shoemaker WC, Abraham E, Cobo JC. Hemodynamic and oxygen transport patterns in surviving and nonsurviving postoperative patients. Crit Care Med. 1985;13(2):85.CrossRefGoogle Scholar
  43. 43.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee T-S. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176–86.CrossRefGoogle Scholar
  44. 44.
    Shoemaker WC. Cardiorespiratory patters of surviving and non surviving postoperative patients. Surv Anesthesiol. 1973;17(1):80.CrossRefGoogle Scholar
  45. 45.
    De Somer F, Mulholland JW, Bryan MR, Aloisio T, Van Nooten GJ, Ranucci M. O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury: time for a goal-directed perfusion management? Crit Care. 2011;15(4):R192.CrossRefGoogle Scholar
  46. 46.
    Rubino AS, Torrisi S, Milazzo I, et al. Designing a new scoring system (QualyP Score) correlating the management of cardiopulmonary bypass to postoperative outcomes. Perfusion. 2014;30(6):448–56.CrossRefGoogle Scholar
  47. 47.
    Magruder JT, Crawford TC, Harness HL, et al. A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017;153(1):118–125.e1.CrossRefGoogle Scholar
  48. 48.
    Pölönen P, Ruokonen E, Hippeläinen M, Pöyhönen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000;90(5):1052–9.CrossRefGoogle Scholar
  49. 49.
    McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):250–8.CrossRefGoogle Scholar
  50. 50.
    Giglio M, Dalfino L, Puntillo F, Rubino G, Marucci M, Brienza N. Haemodynamic goal-directed therapy in cardiac and vascular surgery. A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2012;15(5):878–87.CrossRefGoogle Scholar
  51. 51.
    Aya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth. 2013;110(4):510–7.CrossRefGoogle Scholar
  52. 52.
    Osawa EA, Rhodes A, Landoni G, et al. Effect of perioperative goal-directed hemodynamic resuscitation therapy on outcomes following cardiac surgery: a randomized clinical trial and systematic review. Crit Care Med. 2016;44(4):724–33.PubMedGoogle Scholar
  53. 53.
    Kapoor P, Magoon R, Rawat R, et al. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth. 2017;20(1):83.CrossRefGoogle Scholar
  54. 54.
    Kapoor P, Magoon R, Rawat R, Mehta Y. Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker-based study”. Ann Card Anaesth. 2016;19(4):638.CrossRefGoogle Scholar
  55. 55.
    Karkouti K, Wijeysundera DN, Yau TM, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation. 2009;119(4):495–502.CrossRefGoogle Scholar
  56. 56.
    Thomson R, Meeran H, Valencia O, Al-Subaie N. Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury. J Crit Care. 2014;29(6):997–1000.CrossRefGoogle Scholar
  57. 57.
    Ebm C, Cecconi M, Sutton L, Rhodes A. A cost-effectiveness analysis of postoperative goal-directed therapy for high-risk surgical patients*. Crit Care Med. 2014;42(5):1194–203.CrossRefGoogle Scholar
  58. 58.
    Gibson W. Wikiquote. Published 2017. Accessed 8 May 2017.
  59. 59.
    Jankowski S, Covello J, Bellini H, Ritchie J, Costa D. The internet of things: making sense of the next mega-trend. Goldman Sachs Glob Invest Res. 2014:1–15.
  60. 60.
    Kaplan G, Bo-Linn G, Carayon P, et al. Bringing a systems approach to health. IOM Discuss Pap 2013:1–26.
  61. 61.
    Pronovost P, Ravitz A, Grant C. How systems engineering can help fix health care. Published 2017.
  62. 62.
    Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptoms instead of the disease? Ann Thorac Surg. 2017;104(4):1117–22.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Kevin Lobdell
    • 1
    Email author
  • Joe Mishkin
    • 1
  • Rakesh C. Arora
    • 2
    • 3
  • Rohan Mukund Sanjanwala
    • 2
  1. 1.Atrium HealthCharlotteUSA
  2. 2.Department of Surgery, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  3. 3.Cardiac Sciences ProgramSt. Boniface HospitalWinnipegCanada

Personalised recommendations