Process Improvement Initiative for the Perioperative Management of Patients With a Cardiovascular Implantable Electronic Device
Authors: Ellis Margaret K. Menzel , Treggiari Miriam M. , Robertson Jamie M. , Rozner Marc A. , Graven Peter F. , Aziz Michael F. , Merkel Matthias J. , Kahl Edward A. , Cohen Norman A. , Stecker Eric C. , Schulman Peter M. 
Published: March 2017

BACKGROUND:
Economic, personnel, and procedural challenges often complicate and interfere with efficient and safe perioperative care of patients with cardiovascular implantable electronic devices (CIEDs). In the context of a process improvement initiative, we created and implemented a comprehensive anesthesiologist-run perioperative CIED service to respond to all routine requests for perioperative CIED consultations at a large academic medical center. This study was designed to determine whether this new care model was associated with improved operating room efficiency, reduced institutional cost, and adequate patient safety.

METHODS:
We included patients with a CIED and a concurrent cohort of patients with the same eligibility criteria but without a CIED who underwent first-case-of-the-day surgery during the periods between February 1, 2008, and August 17, 2010 (preintervention) and between March 4, 2012, and August 1, 2014 (postintervention). The primary end point was delay in first-case-of-the day start time. We used multiple linear regression to compare delays in start times during the preintervention and postintervention periods and to adjust for potential confounders. A patient safety database was queried for CIED-related complications. Cost analysis was based on labor minutes saved and was calculated using nationally published administrative estimates.

RESULTS:
A total of 18,148 first-case surgical procedures were performed in 15,100 patients (preintervention period—7293 patients and postintervention period—7807 patients). Of those, 151 (2.1%) patients had a CIED in the preintervention period, and 146 (1.9%) had a CIED in the postintervention period. After adjustment for imbalances in baseline characteristics (age, American Society of Anesthesiologists physical status, and surgical specialty), the difference in mean first-case start delay between the postintervention and preintervention periods in the cohort of patients with a CIED was −16.7 minutes (95% confidence interval [CI], −26.1 to −7.2). The difference in mean delay between the postintervention and preintervention periods in the cohort without a CIED was −4.7 minutes (95% CI, −5.4 to −3.9). There were 3 CIED-related adverse events during the preintervention period and none during the postintervention period. Based on reduction in first-case start delay, the intervention was associated with cost savings (estimated institutional savings $14,102 annually, or $94.06 per CIED patient), with a return on investment ratio of 2.18 over the course of the postintervention period.

CONCLUSIONS:
Based on our experience, specially trained anesthesiologists can provide efficient and safe perioperative care for patients with CIEDs. Other centers may consider implementing a similar strategy as our specialty adopts the perioperative surgical home model.