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Welcome
Our esteemed STS expert Data Managers convene monthly in a dynamic and collaborative forum, where they lead the way in shaping the future of cardiac care. Through interactive case scenario analyses, lively open FAQ discussions, and insightful exchanges of best practices, they play a pivotal role in advancing both operational excellence and data abstraction strategies. Side by side with various cardiac program leaders, they not only contribute their expertise but also drive innovation and excellence in the field, making a tangible difference in patient outcomes and healthcare progress."
Frequently Asked Questions
• How hospitals evaluate patients for appropriate use of nurse sedation vs MAC vs GA?
• What are the average amounts of sedation used for nurse sedation TAVRs?
• What outcome data for nurse sedation vs MAC vs GA... complication rates, how often nurse sedation converts to MAC/GA, etc. do you used?
Thank you for all you do,
VCU
The choice of anesthesia provider is institutional preference. Unless axillary access all of our patients get MAC. Some programs are going for nurse provider for sedation…. but only few programs. Seldom one need to convert from MAC to GA.
I hope this helps.
We have a patient with prior Left Vertebral Occlusions with distal reconstruction. the TM says we
can count vertebral disease in the CVD section. Could the vertebral reconstruction count as a prior CV surgery?
She seems like she was definitely higher risk but wanted to check with you about counting the vertebral
reconstruction as a prior carotid surgery. I have always assumed that the carotids were NOT like the
coronaries...where...once occluded, always occluded? "Left subclavian artery stent, L vert occlusion with distal
recon,"
her carotids were clean by duplex study:
Right Carotid The right mid CCA is normal.
The right middle ICA is minimally to mildly stenosed (<39%).
The right ECA is normal.
The right vertebral flow is antegrade.
The right subclavian artery is triphasic.
Left Carotid The left middle CCA is minimally to mildly stenosed (<39%) with moderate homogeneous/
calcified plaque noted.
The left proximal ICA is minimally to mildly stenosed (<39%) with calcified plaque noted.
The left ECA is normal.
The left vertebral artery flow is antegrade.
The left subclavian is triphasic
My surgeon placed an Impella 5 L open insertion into the aorta for procedural support for a patient who had an AVR and CABG. He was under the impression from the people at the Impella course that this would drop the patient out of the CABG/AVR risk model. However, it does not when I enter the patient into the software with the Impella in the cath assist device (even though it was into the aorta but same difference I guess, no matter how you put it in?)
I visited our handy Proc Id chart and don't see Impella or any cath assist devices as part of the proc id chart.
Should the 5-liter Impella drop the patient out of the model. My surgeon was told that it would?
It would drop if I chose the VAD (Impella is listed in the VAD pick list but maybe that's an accident?) but the intention of that field is for durable VADs from reading the TM.
Setting for their TAVR procedures – Do they conduct TAVRs in a hybrid OR, hybrid cath lab, or just cath lab?
Teams question – With a surgeon present, do they also have members of the surgical team in TAVRs? (OR surg tech, OR RN, OR SA?) Or do they just use cath lab team members? We have been getting this question a lot lately
For the Beta Blockers from admission to 24 hours to surgery, does the clock really start with the admit to the outside hospital???? It can be hard to get the admit time much less which meds they are on: almost all our urgent patients are from OSH’s.
Yes, it does as per the TM - see below:
The intent is to capture beta blocker administration from hospital arrival up to 24 hours prior to skin incision time. Hospital arrival includes the first time the patient arrived to the acute hospital setting, to include the patient arrival time at a transferring hospital if applicable. The timeframe is from arrival up to 24 hours prior to skin incision start time (STStartDt).
For patients that arrive at the hospital prior to 24 hours to skin incision time, choose the name of the first routinely scheduled Beta Blocker given from hospital arrival up to 24 hours prior to skin incision from the selected list. If the patient is on a beta blocker that is not on the selection list, code ‘Other”. If unsure of the name of the beta blocker, code “Unknown”.
Do not code a one-time dose of Beta Blocker that is followed by a routinely scheduled Beta Blocker, unless the one-time dose is the only Beta Blocker given within this timeframe. For example, patient arrives at ED and is given a dose of Metoprolol 5 mg IV and then is transferred to your hospital where the patient is placed on 25 mg of oral Metoprolol 3 times a day, capture the Metoprolol 25 mg oral dose in this situation since it is the routinely scheduled medication.
If the patient was not given a Beta Blocker from hospital arrival up to 24 hours prior to skin incision, code Beta Blocker Contraindicated / Not Given.
For example, a patient arrived on 12/12/2023 at 1600 and their skin incision start date and time is 12/14/2023 at 0800. For this field consider the first routine beta blocker given from 12/12/2023 1600 up to 12/13/2023 0800.
Note: For patients who arrive as same day surgery patients or arrive at the hospital within 24 hours of skin incision time, code “Not given / Contraindicated / Unknown” for this field.
Melinda Offer, RN, MSN
Does any of your surgeons enter their own data for the STS or any registry? If so, what is your process? If not, any policies, opinions, or reservations as to why not?
Our surgeons at UVA do NOT enter their own data into STS. However, a few of them did enter their operative data at their previous institutions. STS would have no concerns with them entering their own operative data.
I do think it would it take some education to be sure that they knew the definitions of the risk factors and other fields if they did more than the operative section. This might be a good question to pose to Carole Krohn at STS?
Judy Smith - UVA
No, they do not enter – they are too busy
Vicki Silvius - Memorial Care
“It’s all done by the service line staff owned by the Manager, Patient Care Services/Cardiovascular Service line”. She ultimately reports to the Division Vice President of Cardiovascular Services at a system-wide level. Providers have time constraints to perform this task. In the Heart Hospital there were staff that performed data entry but roles shifted over the years – now report to the corporate office. Recommendation – keep inhouse close to providers to ensure that communication is established and maintained.
Rosalba Lozano – Sentara
Can cause concern that something may be missed. Definitions may not be known.
Beth Hart - Mary Washington
All in house at Carilion. Our providers do not input any data but I can easily reach out to the surgeons when needed.
Heather Miller – Carilion
Individuals within the department handles abstractions. Physicians do not enter data due to time constraints. When there are discrepancies, the team reach out to the provider and have quality meetings once a month to discuss formally. They are virtual, not in-house, works across the state. Providers are response to EPIC messages. Providers are responsive and open to editing their EPIC notes and making corrections. Changes are not changed in STS until it is changed in the patient record. Has a close relationship that include training/clarification/identifying fallouts as needed.
As abstractors identify issues, feedback is given at a one-on-one basis. A second-check spreadsheet used as tracking tool. Tracy reviews it and contacts surgeons as needed. Scorecard captured. Meetings for STS group, (AMI, EPDI, etc.) separate meetings, where data is presented, and fallout report reviewed in addition to trends (good or bad).
Tracy Nelson - Sentara
They may not be able to stay up to date with standards/definitions. Changes are not changed in STS until it is changed in the patient record.
Tracey Sheehan – Bon Secours
The Consensus
- Time constraints
o Entering data
o Keeping up with the definitions and changes
- Learning curve
The team agreed that this could lead to inaccuracies and time constraints, and suggested having dedicated staff manage the process. They also discussed their data abstraction and quality improvement processes, emphasizing the need for standardization and collaboration
How frequently are you giving thrombolytics therapies?
HCA (Dr. Konstance)
We see a lot of lytic patients and occasionally they get loaded with ticagrelor.
HCA (Dr. Patterson)
Our outside hospital routinely uses lytics prior to transport to us. I would say we get those a few times a month. In lytic patients we routinely use Plavix based on studies and guidelines. Once those patients transfer if they need salvage PCI and lytics are fresh in the system we keep the Plavix. IF they re-perfuse and we take them 24-48 hours later, it is operator dependent on whether we switch them to Brilinta at that point.
How frequently are you giving thrombolytics therapies?
Sentara RMH (Dr. Pollock)
At Harrisonburg, Sentara RMH, we very rarely give thrombolytics. I really don’t remember the last time.
We are starting our transition to first line Brilinta from Plavix and wondering if anyone has shared their algorithms for clinical decision making/treatments when it comes to Brilinta vs Plavix vs Tenecteplase for Acute STEMI Management?
Centra (Dr. O'Brien)
We use Plavix with TNK (300 mg under age 75, 75 mg if over that age). For non-TNK patients we used Effient.
Our Centra Southside and Sentara Halifax protocols are TNK as first line if no contraindications. We rarely use otherwise (mainly if long delay due to patient on table, severe weather, etc.)
Bon Secours (Gary Smith)
Only if transferring from outside non-PCI hospital where transportation can be an issue and first contact to balloon time estimated greater than 120 minutes. Averages 2 a month
Sentara RMH (Dr. Pollock)
...And we tend to use either Plavix or Prasugrel more than Brilinta. I think I may be the only person in the world who is concerned about this, but the Brilinta data was not good for North America And I don’t like the BID and I don’t like the shortness of breath associated with it. But I think nationwide Brilinta is far more commonly used.
Carilion (Dr. Kelley)
At Carilion-NRV, we have 2 referring facilities that use lytics on a more routine basis due to transfer distance, one uses TNK and the other Retavase.
For both lytic regimens, Plavix is the P2Y12 inhibitor given. No Brilinta or Effient for lytic patients. Plavix 300 loading dose is given for patients ages </= 75 and 75mg only for those > 75.
Approximately 10-20% of patients at our facility are treated with lytics, which comes from these referring hospitals.
We use Brilinta for our primary PCI patients, no Effient.
HCA (Dr. Patterson)
For our primary PCI patients we often give the Brilinta at the time of the procedure or in the ER depending on time to cath lab, understanding there is a slight chance patient may require CT surgery which would have to be delayed, but chances of that are < 10%.
• Has anyone found a sure-fire way to get LIPs to address cardiac rehab referrals? I’m guessing by now most have it in a discharge order set. We can’t get residents to use this set exclusively.
• Does anyone know the regulation regarding NP’s and PA’s placing a referral order for outpatient cardiac rehab? I assumed they could, but saw an article making me question this. Do NP’s and PA’s place the order at other sites?
We have a patient with prior Left Vertebral Occlusions with distal reconstruction. the TM says we
can count vertebral disease in the CVD section. Could the vertebral reconstruction count as a prior CV surgery?
She seems like she was definitely higher risk but wanted to check with you about counting the vertebral
reconstruction as a prior carotid surgery. I have always assumed that the carotids were NOT like the
coronaries...where...once occluded, always occluded? "Left subclavian artery stent, L vert occlusion with distal
recon,"
her carotids were clean by duplex study:
Right Carotid The right mid CCA is normal.
The right middle ICA is minimally to mildly stenosed (<39%).
The right ECA is normal.
The right vertebral flow is antegrade.
The right subclavian artery is triphasic.
Left Carotid The left middle CCA is minimally to mildly stenosed (<39%) with moderate homogeneous/
calcified plaque noted.
The left proximal ICA is minimally to mildly stenosed (<39%) with calcified plaque noted.
The left ECA is normal.
The left vertebral artery flow is antegrade.
The left subclavian is triphasic
My surgeon placed an Impella 5 L open insertion into the aorta for procedural support for a patient who had an AVR and CABG. He was under the impression from the people at the Impella course that this would drop the patient out of the CABG/AVR risk model. However, it does not when I enter the patient into the software with the Impella in the cath assist device (even though it was into the aorta but same difference I guess, no matter how you put it in?)
I visited our handy Proc Id chart and don't see Impella or any cath assist devices as part of the proc id chart.
Should the 5-liter Impella drop the patient out of the model. My surgeon was told that it would?
It would drop if I chose the VAD (Impella is listed in the VAD pick list but maybe that's an accident?) but the intention of that field is for durable VADs from reading the TM.
1. Setting for their TAVR procedures – Do they conduct TAVRs in a hybrid OR, hybrid cath lab, or just cath lab?
2. Teams question – With a surgeon present, do they also have members of the surgical team in TAVRs? (OR surg tech, OR RN, OR SA?) Or do they just use cath lab team members? We have been getting this question a lot lately
1. How does your hospital handle elective CABG pts with elevated HgbA1C above 7 or glucose out of control?
2. Our surgeon wants to admit elective pts the night before surgery for an insulin GTT. Is this common practice at your institution?
3. Also, for urgent cases is anything done?
We made referral to Cardiac Rehab an automatically checked item on our post-cath, post-PCI, and post-CABG order sets. We realize that it may result in sending a few extra referrals on patients with no significant CAD or who are otherwise not appropriate candidates, but our CR folks that make the calls help to sort that out. There are no perfect systems, but this seems to be working pretty well. Of course, we are constantly reminding and educating our providers about CR and what the guidelines say. And our NP's and PAs place orders for this and other situations as well. (Centra)
In a nutshell,
Education, Education, Education. This is a multifactorial process.
-Involving cardiac rehab in our efforts- Cardiac rehab sees the patient, educates them and provides the site the patient would like to attend in the note. If VCU they propose an order.
-This has created additional work for CR staff in the form of additional orders being entered ( Ex: type 2 etc.)
-If the patient is going to an outside hospital the NP or physician covering the patient faxes the order to the site.
-It is correct that an NP cannot sign off on the order, but the attending at discharge signs the chart.
-As for cardiac surgery we are still working on that piece. They typically prescribe cardiac surgery at the first post op appointment.
-We are working on a hard stop ( DES, diagnosis MI etc.) at dc within EPIC, but it is difficult to have the required documents sent with the order. (VCU)
This is the response from our CR Director re APPs signing orders:
No the requirement is still that a MD signature is required (CMS guidelines) the 2024 update now ables APP’s to supervise CR and PR vs just physician supervision but not sign the orders.
They can place the order for cosign
We have in place in EPIC when the order is placed it requires a cosign before the order will go through
And Yes this does seem crazy— ahh Government!
We also have it as a hard stop in the post PCI order sets.
We encouraged our nurses to design- and use a discharge check list for AMI / PCI patients. They are the second / final set of eyes to verify all GDMT is met. We addressed as not only a MD requirement, but that it is a team effort to- make sure pts are discharged on GDMT - this has been very helpful – but only as good as the participation and that the checklist is accurate and not just being boxes checked. Once people got used to it, we have pretty good compliance. I worked on this at Fairfax for several years – I am working to get same nursing buy-in for this at our other facilities. If dc RN identifies that CR has not been addressed, they contact the physician to place order or document a reason why order not placed. We also share our fallout reports with key partners.
We have our most utilized CR rehab programs as selections for referrals and the referral goes direct to that facility- for others, or if unknown program preference ( pt from out of state, etc), the referral goes to the Inova program which contacts the patient and assists in selection of appropriate program, and then sends referral information so that program can contact patient. Our CR department is fantastic and really supports the CR referral guidelinrequirement. (Inova)
Our cardiologists and CT surgeons have this ingrained to order. We have the occasional miss, but it’s rare. If I find a patient that has left without a referral, I will send the cardiologist a message in epic linked to the patient’s chart. (Bon Secours)