About The Division of Cardiac Surgery

"High-tech, Low stress, Patient-Focused Care"

The year 2004 was characterized by innovation and expansion for the Division. A new cardiac surgeon, Dr. Kevin G. Shortt, joined the staff from the Cleveland Clinic, and a new Physician Assistant, Rich Amato, was also recruited. The first minimally invasive aortic valve replacement operations (using sternal-sparing incisions) were successfully undertaken, and the number of middle-school students who participated in the UpClose Cardiac Surgery educational program quadrupled from the year before. A relationship with the Hartwick College Nursing Program was also forged in both education and research.

As we enter our third year of providing open-heart surgery to the citizens of rural Upstate New York, we are both pleased with our successes yet cognizant of the work which lies ahead in the complex field of Cardiac Surgery. The two philosophies which serve as the foundation of our program  - Patient-Focused Care and Continuous Quality Improvement - have allowed us to provide highly technical procedures in a setting which recognizes and addresses the anxieties generated in patients and families facing these operations. From mind-body relaxation training to one-on-one sessions with former patients, we offer programs which minimize the stress of the event while maximizing the clinical benefits each patient will obtain while under our care.

As a measure of the quality of care we are delivering, we continually compare our outcomes to known benchmarks and ‘best-practice’ models in the field. Utilizing an extensive divisional database with over 180 parameters, we are able to compare our aggregate results (for both coronary artery bypass grafting and for all open heart operations) to those of two large Cardiac Surgical databases: the Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database (which assembles data from over half of the open heart surgery programs in the country), and the New York State Cardiac Surgery Reporting System (to which all program in the state report). Throughout this document, reference will be made to these resources for comparison of our data, and as well to data from the 2003 report on the Solucient Top 100 Cardiovascular Hospitals in the country.

It is our hope that this report will convey our commitment to high-quality outcomes along with the personalized approach we provide in the care of our patients. We welcome your questions, feedback, and referrals to our office at Mary Imogene Bassett Hospital in Cooperstown, New York (607-547-4770).

The Division of Cardiac Surgery Staff

Patient Profiles

Although Bassett primarily serves an 8-county region (Chenango, Delaware, Fulton, Herkimer, Madison, Montgomery, Otsego and Schoharie counties), patients from 12 New York counties and two other states have undergone open heart surgery at Mary Imogene Bassett Hospital since the inception of the program. The average age of these patients was 67.4 years, with over 40% being 70 years or older.

Total patients by age group (2003-2004).	Prevelence of risk factors in CABG patients, by percent

Prevelence of risk factors in CABG patients, by percent

As unique as Bassett’s Cardiac Surgery Program is – Cooperstown being the second smallest rural community in the country to support an open-heart surgery program – so too are the patients it serves. In addition to being hearty and independent, the open-heart surgery patient population at Bassett is slightly older and has a higher prevalence of hypertension, a previous myocardial infarction, and obesity, when compared nationally.

Over the past decade, the presence of obesity in open-heart surgery patients has been associated with a number of adverse events, including the need for longer mechanical ventilation after surgery; more pulmonary, sternal and leg wound infections; a longer postoperative length of stay; a higher operative mortality rate; and shorter long-term survival. Nearly 40% of Bassett open-heart surgery patients were either obese (BMI 30 - 40) or morbidly obese (BMI > 40), and the percentage with morbid obesity was nearly twice the national average for CABG patients (STS 2001).

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Case Mix

Case mix, 2003-2004

Over the first two years, a total of 208 open heart surgery cases were performed at Mary Imogene Bassett Hospital. The case mix for these operations reflect national trends: approximately three-quarters (76.9%) were coronary artery bypass grafting alone, with the remainder predominately heart valve repair or replacement, with or without CABG. Other procedures included repair of atrial septal defects, removal of cardiac tumors, and repair of thoracic aortic pathology (aneurysms and dissections). Fifty-five percent were performed on either an urgent or emergency basis.

Use of the left internal mammary artery (LIMA) as a graft in CABG patients leads to greater long term survival than when leg veins alone are used as conduits. This difference is so striking that the percentage of patients in whom a LIMA is used has been recognized as a ’quality indicator’ for heart surgery programs. For Bassett CABG patients in 2004, the LIMA was used 98.9% of the time, greater than both state and national benchmarks.

Use of left internal mammary artery in CABG patients, by percent

In addition to the use of the left internal mammary artery, the surgeons at Bassett utilize radial arteries for conduits as well, due to their superior patency when compared to vein grafts. When vein grafts are utilized, they are routinely removed from the leg using endoscopic vein harvesting techniques (EVH) through a one-inch incision rather than the traditional length-of-the-leg incision. This less traumatic technique has been proven to be as safe and effective as the ‘open’ technique, yet with significantly fewer leg wound problems, such as infection, poor healing, and leg swelling. At Bassett, EVH has been used in 94.9% of patients, with none developing leg wound infections.

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Operative Mortality

By building a program on the principles of Evidence-Based Medicine and Continuous Quality Improvement, Bassett has been able to develop a program with superb outcomes. The observed in-hospital mortality for all CABG patients since the program began is only 1.2%, approximately one-half of the average CABG mortality found in the state, nationally, and in the Solucient Top 100 Cardiovascular Hospitals.

In-hospital mortality rates for CABG, by percent

For valve repair and replacement operations (both with and without CABG), the in-hospital mortality rate at Bassett for 2003 - 2004 was 2.8% versus the 2001 New York State rate of 6.9%. Likewise, for all open-heart surgery cases over the same time period, the Bassett in-hospital mortality rate was 1.4%, compared to a national rate of 3.5 % (STS, 1997 - 2000)

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Resource Utilization

Postoperative CABG length of stay outliners, by percent

For 2003 - 2004, 44.2 % of all patients were admitted through the ‘Same Day Admission’ process (not requiring hospitalization the night before surgery), giving a median preoperative length of stay of only 1 day. After surgery, the average length of stay for all CABG patients was 6.9 days, equal to national benchmarks (STS, 2001). The percentage of ‘CABG outliers’ (those discharged in less than 6 days or in more than 14 days) were also consistent with these standards, with nearly one-half discharged in less than 6 days, and less than 5% requiring hospitalization for more than 14 days after surgery.

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Postoperative Morbidity

Due to the advanced age and accompanying illness of those undergoing open-heart surgery in the twenty-first century, overall estimated operative risk has risen, though with a paradoxical steady decline in mortality rates due to improvements in intraoperative technology and postoperative care. Many patients though by virtue of their co-morbidities (including diabetes, peripheral vascular disease, renal dysfunction, or pulmonary disease) are at risk for a variety of complications following open-heart surgery.

For 2003-2004, the prevalence of all observed postoperative morbidities was at or below both state and national averages for Bassett patients. In fact, 95.8% of those undergoing CABG at Bassett since the beginning of the program have been free of any major complication (defined as death, stroke, respiratory failure, renal failure, deep sternal wound infection, or re-operation for bleeding), compared to 86.2% of CABG patients nationally (STS, 2001).

Postoperative morbidity in CABG patients, by percent (Bassett vs. benchmarks).	Postoperative infection rates vs. NNIS, by percent

Through a cooperative effort between the Division of Cardiac Surgery and the Infection Control Service, a priority is placed on maintaining anti-infective processes at a level consistent with evidence-based guidelines. Attention to practices before, during, and after surgery have led to an overall wound infection rate of 1.0%, which is superior to that found in the National Nosocomial Infection Survey (NNIS).

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Patient-Focused Care

"The key to patient care is caring for the patient"

The Cardiac Surgery service is invested in a philosophy of Patient-Focused Care. Innovative programs have been created to make the open-heart surgery experience a less stressful and more understandable one for our patients. These include:

Same Stay Surgery: Because some of our patients travel up to an hour or more to the hospital for the operation, a system was introduced that enables patients to come to the hospital the day before surgery for all of the required pre-operative testing. They may then stay overnight with family members at the Hannah Lee House next to Mary Imogene Bassett Hospital, avoiding a long, additional trip to the hospital the morning of surgery.

Pre-admission Discharge Planning: Preparing for discharge after the operation is, for some, as taxing as the hospitalization itself, particularly for family members. To minimize the stress, our case manager works with the patients and families before the operation to help make the transition home or to a rehabilitation center a smooth one.

Prepare for Surgery, Heal Faster: Patients scheduled to undergo open heart surgery are encouraged to participate in our complementary medicine program utilizing mind-body relaxation techniques. Bassett nurses trained in these skills work with patients using both written material and audio tapes. The program is designed to reduce anxiety about the operation, and has been shown to decrease the need for pain medication and lead to a shorter length of stay.

Partners at Heart: Patients who have undergone open heart surgery at Bassett have established a volunteer program in which past patients meet with future patients and their families to openly discuss their experience with the operation and the care afterwards. Coupled with tours of the Intensive Care Unit, this program is designed to help patients better understand what to expect from the upcoming surgery to lighten anxieties.

LifewatchR Home Rhythm Monitoring System: All patients are discharged home with a Lifewatch monitoring system which allows them to immediately record their heart rhythm if they experience palpitations or other symptoms. The rhythm is recorded by placing a pocket-sized card on the chest, and then transmitting it via telephone to a national center monitored around the clock by healthcare personnel, who in turn send the rhythm to the surgeon. This system eases the transition home by alleviating the fear of leaving the ’monitored environment’ of the hospital, and has also been found to decrease the need for return trips to the hospital.

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Continuous Quality Improvement

Recognizing that one of the challenges of a new Cardiac Surgery program is to maintain superb outcomes, a program of Continuous Quality Improvement (CQI) was built into the system from its inception. This process relies on real-time patient data acquisition and entry into the Bassett Cardiac Surgery Database to allow for continuous evaluation of outcomes, along with comparison to industry benchmarks and evidence-based guidelines. Immediate interventions may thus be designed and implemented to improve the processes of care, followed by re-measurement to determine the effects of prescribed interventions.

Quarterly CQI meetings are held to review relevant data and outcomes from the database. Participants at these meetings are those involved in the care of open-heart surgery patients, including Cardiologists, Cardiac Anesthesiologists, Perfusionists, Certified Registered Nurse Anesthetists, Anesthesiology Technicians, Cardiac Operating Room nursing staff and technicians, Intensive Care Unit and Special Care Unit nursing staff, Respiratory Therapists, and Case Managers.

In 2004, several opportunities for quality improvement were identified and subsequently subjected to the vigorous CQI process, producing the following results:

Time on mechanical ventilation after surgery: By designing improved processes of preoperative evaluation and postoperative care in cooperation with Pulmonologists, Intensivists, Respiratory Therapists, and ICU nursing staff, the median mechanical ventilation time was reduced from 14.5 hours to 7.0 hours.

Re-admission within 30 days of discharge: Through the work of a Re-admission Task Force, the 30-day re-admission rate fell from 19.4% in 2003 to 12.4% the following year. Process changes included improved discharge instruction forms, closer follow-up for higher-risk subgroups, and use of a home-based arrhythmia monitoring system.

Operating room time: At Cardiac Surgery OR Team meetings, team processes in the operating room were reviewed and refined in early 2004. This contributed to a 20.2% reduction in the average time for an open-heart surgical case from 2003 to 2004.

Blood component usage: With the help of Blood Bank personnel, red blood cell transfusion use in cardiac surgical patients was monitored. Staff education and reinforcement of protocols led to 22.6% fewer patients receiving transfusions from 2003 to 2004, and a 51.6% decline in the total number of transfusions dispensed.

Compliance with appropriate discharge medications: In 2003, compliance with evidence-based guidelines for discharging patients on aspirin, beta-blockers, and cholesterol-lowering agents was over 94%. With implementation of a new standardized discharge protocol and checklist in 2004, compliance for the year rose to 100%.

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Research and Publications

Division philosophy places an emphasis on contributions to the scientific body of knowledge, which has helped to produce both technical and physiologic advances in the field of Cardiac Surgery. Participation in a national, multi-institutional study on an alternative method of anti-coagulation during open heart surgery helped to establish the Cardiac Surgery Research Fund. This entity will serve as the basis for funding anticipated projects in 2005, including a study on the incidence of antibody formation to heparin in open heart surgery patients. Division staff are also working with nursing students from Hartwick College on a Senior Thesis Project examining the effects of complementary medicine (mind-body relaxation techniques) on outcomes and recovery in heart surgery patients.

Research (2004 - 2005)

Evaluation of Heparin Antibodies in an Open Heart Surgery Population: Preoperative Prevalence
and Postoperative Seroconversion (funded by the Bassett Cardiac Surgery Research Fund)

The Effects of Mind-Body Relaxation Techniques on Postoperative Outcomes and Recovery in
Open Heart Surgery Patients (Hartwick College Nursing Senior Thesis Project)

Does the Adherence to Secondary Prevention Guidelines by Open Heart Surgery Patients Impact
on the Health of Their Spouses or Significant Others?

Publications (2004)

Lancey RA, Pezzella AT. Factors affecting early exsanguination and death in blunt thoracic
aortic trauma. Asian Cardiovascular and Thoracic Annals, 2004: 12; 123-128Pezzella

AT, Ferraris VA, Lancey RA. Care of the adult cardiac surgery patient: Part I.
Current Problems in Surgery, 2004: 41; 458-516

Soller BR, His C, Favreau J, Cingo N, Lancey RA, Okike ON, Vander Salm J. Multi-
parameter fiber optic sensor for the assessment of intramyocardial perfusion. Journal of
Cardiac Surgery, 2004: 19; 167-174

Racz MJ, Hannan EL, Isom OW, Subramanian VA, Jones RH, Gold JP, Ryan TJ, Hartman A,
Culliford AT, Bennett E, Lancey RA, Rose EA. A comparison of short and long-term
outcomes following off-pump and on-pump coronary artery bypass graft surgery with sternotomy.
Journal of the American College of Cardiology, 2004: 43; 557-564

Lancey RA, McCormick MJ, Schaffer OP. Coronary bypass grafting and aortic valve
replacement in a patient with cold urticaria. Annals of Allergy, Asthma, and Immunology,
2004: 92: 273-275

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Educational Endeavors

Participating Schools, 2004 - 2005
Canajoharie Cherry Valley Cooperstown Delaware Valley Edmeston Fort Plain	Litle Falls Mt. Markham Richfield Springs Schenevus South Kortright Unatego

In keeping with the mission of Bassett Hospital as an academic center, staff from the Division were active in the training of both residents and medical students. Both second- and third-year general surgery residents join the Cardiac Surgery service for formal rotations as part of their training. In addition to sponsoring monthly Cardiac Surgery Grand Rounds and Morbidity and Mortality Conferences, staff members presented educational lectures to the Departments of Surgery and Medicine, as well as to Bassett nursing staff and to regional Emergency Medical Technicians.

The highly successful UpClose Cardiac Surgery educational program, which promotes heart-healthy habits in area seventh graders, uses both interactive presentations and videotaped or live demonstration of open-heart surgery cases at Bassett. The series, designed and taught by Division staff in conjunction with Tom Hohensee of the Bassett Community Heart Program, was presented to nearly four times as many students in the 2004 - 2005 school year than the year before. In all, over 1000 students from 13 different communities in the Bassett service area have participated in the program.

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Educational Presentations in 2004

Emergency Medical Services Second Saturday Lecture, Bassett Hospital
Thoracic Aortic Catastrophes (R. Lancey, MD) October, 2004
Cardiac Surgery 2003 Review (R. Lancey, MD) April, 2004

American Academy of Professional Coders Symposium, Bassett Hospital
Reimbursement Update (M. Coleman, RN) October, 2004

Surgery Grand Rounds, Bassett Hospital
Anticoagulation Principles in Open Heart Surgery (R. Lancey, MD) October, 2004

Cardiac Surgery Grand Rounds, Bassett Hospital
Aortic Dissections (S. Edelstein, PA) June, 2004
Principles of Cardiopulmonary Bypass (T. Wilcox, FNP) October, 2004

Medical Grand Rounds, Bassett Hospital
In Pursuit of Benchmarks: Cardiac Surgery at Bassett (R. Lancey, MD) April, 2004

General Surgery Residents Subspecialty Conference, Bassett Hospital
How to Handle a Failing Heart (R. Lancey, MD) June, 2004
Cyanotic and Noncyanotic Congenital Heart Disease (R. Lancey, MD) January, 2004

Nurse Practitioners Quarterly Meeting
Management of Atrial Fibrillation (M. Wrubleski, ACNP) June, 2004

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The Division of Cardiac Surgery

	Richard Amato, RPA-C is a graduate of South University in Savannah, GA where he earned a Bachelor of Science Degree in Physician Assistant Studies in 2002. He is a Certified Physician Assistant and a member of the American Academy of Physician Assistants. He joined the Division of Cardiac Surgery in 2004.

Maura Coleman, BSN received her BSN from Western Connecticut and worked in the Emergency Department at St. Vincent’s Medical Center in Bridgeport, CT. Prior to joining the Bassett Heart Care Institute as the Cardiac Case Manager in 2002, she worked for the Otsego County Public Health Office and as a staff nurse in the Bassett Hospital Intensive Care Unit.

Scott Edelstein, RPA-C graduated from the University of Alabama Surgical PA Program in 1996 after earning a Bachelors Degree in Biology from SUNY Purchase. A Certified Physician Assistant,, he joined Bassett in 2003 from Stanford University where he was a Senior Surgical PA in Cardiovascular Surgery. He is a member of the American Academy of Physician Assistants and the American Association of Physician Assistants in Cardiovascular Surgery.

Ginger Johnson, BS graduated from Cherry Valley-Springfield Central School with a Regents Diploma in 1998. She then earned a Bachelor of Science degree in 2002 from Nazareth College in Rochester. She has been the Administrative Assistant for the Division of Cardiac Surgery since 2002. I have played on the Bassett Healthcare co-ed Softball team for the last two summers.Currently live in Richfield Springs.

Robert A. Lancey, MD is Chief of Cardiac Surgery and Co-Director of the Bassett Heart Care Institute. An Associate Professor of Surgery at Columbia University, he has been granted Fellowship status in the American College of Surgeons, the American College of Chest Physicians, and the American College of Cardiology. He is Board Certified by both the American Board of Surgery and the American Board of Thoracic Surgery.

Kevin G. Shortt, MD is a staff surgeon in the Division of Cardiac Surgery and is Board Certified by both the American Board of Surgery and the American Board of Thoracic Surgery. He completed his General Surgical training at UMass Medical Center and his Thoracic Surgical training at the Baylor College of Medicine. He joined Bassett in 2004 from the Cleveland Clinic where he was a member of the Associate Staff in Cardiac Surgery.

Tobin Wilcox, FNP has earned a BSN from Syracuse University, a Masters Degree in Nursing from Yale University, and his Post-Masters Certificate as a Nurse Practitioner from SUNY Binghamton. He is Certified as a Family Nurse Practitioner and as a Clinical Nurse Specialist, and recently earned his RNFA Certificate from Rochester University

Maryellen Wrubleski, ACNP received her BSN from Loretto Heights College in Denver, and both her Masters Degree in Nursing and Nurse Practitioner training at the University of Massachusetts Medical School. She is certified as an Acute Care Nurse Practitioner. In addition to serving as the Bassett Heart Care Institute Clinical Director, she holds an adjunct teaching position at Hartwick College.

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