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Quality care outcomes in cardiac surgery: the role of evidence-based practice
1Department of Physiological Nursing, University of California, San Francisco, USA. leyj@sutterhealth.org
Insights
Preoperative clopidogrel significantly increased cardiac surgical bleeding and costs. Implementing a clinical practice guideline reduced clopidogrel use, leading to fewer complications and improved outcomes.
Area of Science:
- Cardiovascular Surgery
- Pharmacology
- Quality Improvement
Background:
- Clopidogrel is an antiplatelet medication with potential implications for surgical bleeding.
- Evaluating the impact of preoperative clopidogrel on cardiac surgery outcomes is crucial for patient safety.
- Quality improvement initiatives are vital for optimizing clinical practices.
Purpose of the Study:
- To assess the association between preoperative clopidogrel exposure and bleeding complications in cardiac surgery.
- To evaluate the effect of a clinical practice guideline on clopidogrel use and surgical outcomes.
- To determine the impact of clopidogrel on resource utilization and costs in cardiac surgery.
Main Methods:
- Utilized an internal database and established research methodologies for data collection and analysis.
- Conducted a quality improvement initiative led by a clinical nurse specialist.
- Implemented an interdepartmental clinical practice guideline to modify preoperative medication protocols.
Main Results:
- Preoperative clopidogrel use was linked to a 10-fold increase in reoperation rates for bleeding (8.3% vs. 0.85%) and higher blood product usage.
- Patients exposed to clopidogrel incurred average additional acute care costs of $2,680.
- Post-guideline implementation, clopidogrel exposure decreased significantly (39% to 6.3%), correlating with reduced bleeding and improved clinical benchmarks.
Conclusions:
- Preoperative clopidogrel is a significant risk factor for increased bleeding and complications in cardiac surgery.
- Evidence-based clinical practice guidelines, supported by internal data and advanced practice nurses, are effective in reducing medication-related risks.
- Comprehensive database systems are essential for monitoring and improving patient outcomes in surgical settings.
Abstract:
An internal database and research methods were used to evaluate the impact of clopidogrel on cardiac surgical bleeding. This quality improvement initiative, led by the clinical nurse specialist, showed that preoperative exposure to clopidogrel was associated with significant increases in chest tube output, blood product use, and reoperation for bleeding rates that were 10-fold higher than for control patients (0.85% versus 8.3%, P = 0.027). Acute care costs averaged $2,680 more for patients who received clopidogrel (P = 0.1936). After implementation of an interdepartmental clinical practice guideline, preoperative exposure to clopidogrel dropped from 39% to 6.3% (P = 0.0000). This drop was accompanied by reductions in chest tube output, blood product use, and bleeding complications, with improved achievement of clinical benchmarks. The availability of internal evidence to support achievement of best practices was an essential factor in the implementation of this interdepartmental change. Comprehensive database systems and advanced practice nurses are highlighted as essential components of evidence-based programs.
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