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Cardiovascular Anesthesiology ServiceAs I assume charge of the Cardiac Anesthesia Division, I stand on the Shoulders of giants. I have been nurtured and mentored by the last two directors, Tom Gayeski MD, PhD, and Peter Bailey, MD. Each has made significant contributions to the division of cardiac anesthesiology such that it is a respected clinical and academic group with excellence in the fields of clinical care and education. My goals for the division are to improve the research activities of the division, reshape the educational curriculum in accordance with current ACGME guidelines, and maintain the current excellent standard of clinical care with continual updates of the cardiac manual and regular clinical meetings with the surgeons. Ideally, collaboration with the mitochondrial research interest group (MRIG) will enable the opening of a course of translational research bringing the exciting developments in our understanding of mitochondrial function in health and disease from bench to bedside. MPECardiac surgery is a highly competitive field in NY State and Rochester. Outcomes of CABG patients are published for public consumption. Strong Memorial Hospital has targeted global cardiac care as a "flagship" service. These factors make the care the cardiac surgical patient very "high profile". SMH is the only hospital in the greater Rochester offering full-service cardiac care which includes ventricular assist device (VAD) implantation, heart transplantation as well as a fully dedicated cardiac anesthesia service where all cardiac anesthesiologists are skilled in transesophageal echocardiography. The division of cardiac anesthesia is a well-organized service which uses a "service manual" to assist all clinicians, trainees and students. This collection of documents is not meant to serve as guide to evidence-based best practices established and used in delivering anesthetic care to cardiovascular patients. It is not intended to be a dogmatic cookbook, but a clinical decision-support resource. The manual will be continually and perpetually updated to reflect improvements in knowledge and technology as they develop. The cardiac anesthesia team members are: The contributions of each faculty person are delineated below under the section entitled, Faculty. The following report is divided into sections on Patient Care, PATIENT CAREPatient care on the cardiac anesthesia division is currently carried out by 8 faculty members, residents in training, with the assistance of a dedicated cardiac anesthesia technician. A cardiac anesthesia fellow may also be involved in the delivery of patient care.Care and team issues are discussed at monthly team meetings, which are scheduled when all faculty are available to maximize attendance and participation of all team members. Development of "care-maps" and "care-guides" that are evidence and/or consensus driven, either nationally, or within the institution, are frequently used and continue to be considered. These documents can be seen on the departmental intranet web-site or in the divisional packet each resident gets. These guides allow for the definition and incorporation of certain standards of care, especially those that are nationally recognized, to allow for surgeon's and patient's expectations to be met and care to be as consistently excellent as possible. Standards of care represent the highest standards and therefore defining any practice as a standard is done with much thought as to whether or not the evidence is strong enough to merit such a position. This usually requires application of sound defined methodology and allocation of significant resources. The documents we use should be considered as instructional guides for teaching purposes and care guides which do not replace clinical judgment but assist it. "Guides" exist for topics such as:
CARDIAC ANESTHESIA AND SURGICAL VOLUMES: The following data is provided to me from the division of Cardiothoracic surgery annually. Cardiac surgery volume continues to grow; the case mix is excellent for training purposes; the time to extubation (see below) and length of stay data are very good. Adult cases are over 900 for 2007 and are estimated to equal or exceed 1,000 for 2008. Pediatric cases were over 250 for 2004 and the volume of cases involving this patient population is also expected to grow. HEART TRANSPLANTATION AND VENTRICULAR ASSIST DEVICE PROGRAM Our heart transplant program is the only active program in upstate New York and as such SMH is positioned to be the regional leader in complete cardiac care. As ventricular assist devices, heart transplantation, and eventually total artificial hearts become standards of care in health care, SMH has the potential to be a regional center of excellence in these advanced care areas. Dr. Todd Massey, the chief of heart transplant surgery, is to be congratulated and supported for his dedication to this extremely difficult and demanding area of patient care. Our heart transplant survival rates are among the highest in New York State. PEDIATRIC CONGENTIAL HEART SURGERY As mentioned above our case volume for pediatric cardiac surgery is stable and growing. We anticipate performing close to 300 cases per year by 2008. Outcomes remain excellent with a recently published overall mortality that is very low based on data from NY congenital heart programs. The dedicated Pediatric cardiac ICU opened late in 2003 and is a state-of-the-art care unit for these patients. Cardiac surgical cases across the board continue to become more and more challenging as our cardiology colleagues pursue the development new therapies that can be effective and applied in the cardiac catheterization laboratory, thus avoiding the need for surgical intervention. QUALITY IMPROVEMENTFAST TRACK & TRACHEAL EXTUBATION: Although time to tracheal extubation is recognized to be only one step in the recovery of the cardiac surgical patient, it is also considered to be an important landmark. Our patients do very well in this regard. Even though our patient population is very complex, more than 50% of our cardiac surgical patients are extubated within 6 hours and stay less than 24 hours in the ICU after surgery. diac surgical patients stay less than 24 hours in the ICU after surgery.TECHNICAL SUPPORT: Our technical support staff is now organized to provide timely and very complete support so that care can be expeditiously delivered. Each cardiac room has a standard set-up to help in the provision of care. Technical support includes point-of-care blood tests such as thromboelastography and blood gas measurement. TRANSESOPHAGEAL ECHOCARDIOGRAPHY: All team members have passed the echo-certification test offered by the National Board of Echocardiography (PTeXAM). All team members are board certified in perioperative TEE or are preparing to apply. A comprehensive QA program for perioperative TEE is under development through the efforts of Scott Raffo, MD, and with the cooperation and assistance of Karl Schwarz from Cardiology. EDUCATIONANESTHESIA RESIDENTS:Direct one-on-one supervision of patient care in the cardiac division is practiced for virtually all patients. This allows for optimizing patient care and outcome while at the same time allowing for hands on teaching and resident learning and training. The educational program is approved by the Residency Program Director. Documents outlining the divisional educational goals and format are in the resident packet. The educational format and training are consistent with the recommendations of the Residency Review Committee of the ACGME. The educational program is comprehensive in that it covers the knowledge and skills primary or specific to the division's subspecialty nature as defined by the Joint In-training Content Outline of the ABA/ASA as detailed along with the corresponding recommended reading assignments and Wednesday morning conference topics. In addition, periodic additions to resident education, such as discussion of key words on the questions in the in-training exam or advanced knowledge test where residents did not perform well are listed and targeted for discussion. The educational program provides written learning material (content) which is consistent with the Joint-in-training (ABA / ASA) content outline for the specialty. This includes material from 2 texts and published articles but also includes the institutionally based "manual" referred to above to assist and guide residents through their rotation at the University of Rochester. The residents acquisition of knowledge during the rotation is assessed with a written test. Passing the test is required for passing the rotation. The ACGME competencies and specific goals that we as a Department determine are also used to assess residents. A complete description of the tools used to evaluate residents is modeled after the ACGME tool kit and is available in the service manual. The educational program includes faculty to resident feedback both on a daily basis (informal and/or formal) and departmental basis (formal). This is written and reported on every resident through the convenient use of the departmental web. Obtaining resident feedback concerning faculty teaching is done at the departmental level. CARDIAC ANESTHESIA FELLOWS: Adult Cardiothoracic Anesthesiology became an ACGME approved fellowship in 2006, and our program was accredited in 2007 for the 2008-09 academic year. Fellowships are common but competition for fellows is strong as most anesthesia residents are not willing to subject themselves (and their families) to more years of training after so many years of sacrifice. Our fellowship is tailored and defined. The curriculum the ACGME-approved guidelines originally proposed by the SCA. MEDICAL STUDENTS: Medical students rotate on a regular basis through the heart rooms to gain basic clinical knowledge and understanding of cardiovascular physiology, hemodynamic monitoring, and cardiovascular pharmacological therapy for various cardiac and surgical conditions. This program has been headed by Ellen Iannoli. FACULTYDr. Michael Eaton is director of the division of cardiac anesthesia, as well as the director of pediatric cardiac anesthesia. He actively participates in resident education both in the OR and in the classroom. He is the chair of the Department's research committee, directs the technical support services, and represents the department on the SMH therapeutics committee.Dr. Janine Shapiro is an important member of the pediatric and adult cardiac anesthesia teams. She also organizes the mock oral exams, annually one of the most valued educational experiences for the residents. Janine is also the Chair of the department's patient safety committee. Dr. David Stern organizes the clinical scheduling of all faculty for the service. He is very involved in the simulator center and participates in numerous educational activities in the center. Dr. Laurent Glance is an expert in outcomes research in critical care patients and is federally funded by the Agency for Health Care Research and Quality. He is active on numerous departmental committees. Dr. Ellen Iannoli is board certified in perioperative echocardiography, and has finished a cardiac anesthesia fellowship. She has a strong interest in teaching. Dr. Dawn Sweeney is a member of the pediatric cardiac anesthesia team. She is board certified in Pediatrics and Anesthesiology and is fellowship-trained in pediatric anesthesiology. She is the Pediatric Anesthesiology Fellowship Program Director. Her interests include resident/fellow education, and care of infants and children with congenital heart defects during non-cardiac surgery. RESEARCHDr. Glance is the recipient of an RO-1 through the Agency for Health Care Research and Quality (AHRQ) funded outcomes research involving large administrative databases generated by New York, California and other states exploring their relevance to quality of outcomes in cardiac surgery.Dr. Eaton is currently studying the renal effects of amicar and aprotinin in pediatric cardiac surgery, the utility of routine preoperative coagulation studies in adult CT surgery, as has just published a review of the use of antifibrinolytics in pediatric cardiac surgery. Dr. Eaton is the Chair of the Pediatric Cardiac Research interest Group at the U of R, and the Chair of the Electronic Communications Committee for the SCA. Ellen Iannoli as the new director of the Departmental QA Committee opens the door for quality of care studies within our institution. Importantly, the division is hoping that the efforts of our Chair with Drs. Sheu and Brookes will successfully recruit a translational researcher who can move our division forward in producing research efforts directed at mitochondrial function in heart disease which will be notable on a national level. |
