Advancing cardiotomy suction practices for coronary surgery via multidisciplinary collaborative learning

James W Stewart 2nd; Donald Nieter; Xiaoting Wu; Alphonse DeLucia 3rd; Brittney N Graebner; Gaetano Paone; David C Fitzgerald; Timothy A Dickinson; Min Zhang; Francis D Pagani; Donald S Likosky

doi:10.1016/j.xjon.2023.11.005

Advancing cardiotomy suction practices for coronary surgery via multidisciplinary collaborative learning

JTCVS Open. 2023 Nov 21:17:121-144. doi: 10.1016/j.xjon.2023.11.005. eCollection 2024 Feb.

Authors

James W Stewart 2nd^{1

2}, Donald Nieter³, Xiaoting Wu⁴, Alphonse DeLucia 3rd⁵, Brittney N Graebner⁶, Gaetano Paone⁷, David C Fitzgerald⁸, Timothy A Dickinson⁹, Min Zhang¹⁰, Francis D Pagani^{3

4}, Donald S Likosky^{3

4}

Affiliations

¹ Department of Surgery, Yale School of Medicine, New Haven, Conn.
² Department of Surgery, University of Michigan, Ann Arbor, Mich.
³ Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich.
⁴ Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich.
⁵ Department of Cardiac Surgery, Bronson Methodist Hospital, Kalamazoo, Mich.
⁶ Perfusion Associates of Michigan, Saginaw, Mich.
⁷ Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
⁸ Cardiovascular Perfusion Program, College of Health Professions, Medical University of South Carolina, Charleston, SC.
⁹ Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
¹⁰ Department of Biostatistics, University of Michigan, Ann Arbor, Mich.

Abstract

Objective: Professional standards recommend stopping cardiotomy suction at the termination of cardiopulmonary bypass before protamine administration based on perceived safety concerns. This study evaluated a multidisciplinary collaborative quality-improvement intervention promoting this agreed-upon cardiotomy suction practice during coronary artery bypass grafting (CABG).

Methods: A statewide intervention (eg, unblinded surgeon and perfusionist feedback, evidence-based lectures, evaluating barriers to change) involved 32 centers participating in the PERForm (ie, Perfusion Measures and Outcomes) Registry to standardize cardiotomy suction practices at cardiopulmonary bypass termination during CABG. Four non-Michigan registry participating centers were not exposed to collaborative learning. Cardiotomy suction practice was defined as the absence of or stopping cardiotomy suction before protamine administration. The practice changes attributed to the intervention, including Michigan and non-Michigan comparisons, were evaluated with the change of time effect modeled using splines. Multivariable regression was used to evaluate the intervention's associated impact (eg, mortality, reoperation, transfusion).

Results: Among 10,394 patients undergoing CABG at Michigan centers, 80.7% achieved agreed-upon cardiotomy suction practices. The Michigan centers had nonsignificant changes in agreed-upon cardiotomy suction practices during the preintervention period (P = .24), with significant increased monthly change in practice thereafter, absent adjusted morbidity and mortality increases. The Michigan centers achieved a significantly greater adjusted monthly improvement in agreed-upon practices relative to non-Michigan centers within 7 months after the intervention (adjusted odds ratio for change of trends: 2.53, P < .001).

Conclusions: This initiative demonstrates the effectiveness of multidisciplinary collaborative quality improvement in advancing agreed-upon cardiotomy suction practices without negatively impacting clinical outcomes.

Keywords: cardiac surgery; cardiopulmonary bypass; outcomes; quality improvement.