Maintaining order on a busy cardiac surgery service can be a daunting task. If you work in a practice where there are several surgeons and advance practice providers, every person is going to have a different idea about how to care for patients. It is true that there are many ways to treat a patient after cardiac surgery, and no medical problem can be solved with a cookie cutter approach. This being said, having a practice manual filled with guidelines can ensure that all patients are getting consistent care, provide new hires with an additional resource, and allow for the surgeons’ vision of how they want patients cared for to be realized without him or her always having direct patient contact.
Creating a practice manual from scratch will be a major undertaking, as it will have several different parts. There are many ways to break up the information. A good place to start is to outline a job description for each position on the service. This clearly defines everyone’s role, and will help new hires begin to learn the daily workings of the service. I also find it helpful to have a section dedicated to general patient management, and a description of how a patient would progress through the service given a normal postoperative course. Some points to touch on here would include evaluating preops, evaluating patients for transfer from ICU to step down, removal of chest tubes and pacing wires, care of incisions, standard medications used for postoperative pain management, and the process for discharging patients.
Care of the postoperative cardiac surgery ICU patient could be a manual all by itself. For this reason, I suggest breaking down your practice’s ICU care in detail. Talk to your surgeons, intensivists, and/or anesthesiologists to get their preference on things like dressing changes, ventilator management, central line placement and timing of removal, blood transfusions, hemodynamic monitoring, management of postoperative bleeding, and emergency bedside re-sternotomy if applicable. In a large practice, it can be difficult to get all surgeons on the same page. It is important to present this as an opportunity for all their patients to get the best, and most consistent, care. This may be a motivator for the practice to make some concessions, and come together to create common ground that can be developed into guidelines.
Another helpful section is to break down the management of common postoperative problems. Again, management will not always fit guidelines, but if gives practitioners a place to start. Covering topics like postoperative atrial fibrillation, ventricular arrhythmias, bradycardia, management of chest tubes, management of ileus, and care of spinal drains, if applicable, will create a fairly comprehensive resource to consult. In addition, outlining the way your practice performs common procedures such as thoracentesis, chest tube placement, central line insertion, placement of Swan-Ganz catheters, and placement of arterial lines will document an expectation as to how these procedures are to be performed.
Finally, any population that is not taken care of in a routine manner deserves a section outlining the points that are specific to that group’s care. This will certainly vary according to practice, but some examples are treatment of Maze patients, patients with radial artery grafts, postoperative fast track patients, ventricular assist device patients, medical management of Type B aortic dissections, and structural heart patients such as TAVR and TMVR.
Keeping a practice manual takes dedication, as it needs a fair amount of maintenance. It should be updated at least every year and, ideally, twice a year in order to keep up with the most current information. We email our practice manual to all new hires so that they can start to become familiar with our protocols and guidelines before they start work. It is also an excellent resource for students rotating through the service. The success of any practice manual relies on the ability of a group of surgeons to come to agreement on how they manage postoperative patients. I am not naive enough to think that all surgeons get along well enough to allow for such a thing, but if they can come to a consensus, it can be a great benefit to a practice.