Leveraging The Vascular Quality Initiative To Reduce Length Of Stay Following Elective Carotid Endarterectomy And Endovascular Aortic Aneurysm Repair

Length of stay (LOS) is an important quality metric tracked by the Society for Vascular Surgery Vascular Quality Initiative (VQI). In 2021, our hospital was a high outlier for 'prolonged LOS' following carotid endarterectomy (CEA >1 day, 67% vs target 21%) and endovascular aortic aneurysm repair (EVAR >2 days, 36% vs target 22%). In response, we launched a year-long quality improvement (QI) initiative to reduce LOS following elective CEA and EVAR. We completed internal retrospective chart review of CEA and EVAR cases from 1/2021 to 3/2022 using data obtained from VQI. During the intervention phase (4/2022- 7/2023), a multidisciplinary team was formed to define the problem state and refine workflows. The Plan-Do-Study-Act QI method was used to address key drivers. Preoperative interventions included educating all patient stakeholders on LOS guidelines, increasing patient/family communication regarding discharge expectations, and implementing a high- risk discharge screening program. Following surgery, standardized recovery protocols, including early Foley catheter removal and physical therapy evaluation, were initiated. The primary outcomes, postoperative LOS and rates of 'prolonged LOS,' were compared pre- vs post-intervention using t-test and χ2 test, respectively. Comparing pre- and post-intervention, for CEA, mean LOS decreased from 2.2 to 1.2 days and 52.7 to 27.7 hours (Table I). For EVAR, mean LOS reduced from 2.3 to 1.5 days and 55.1 to 36.9 hours. Overall, for CEA patients, prolonged LOS rate decreased from 50% to 15% (P = .01), while for EVAR patients, it declined from 26% to 7% (P = .03). These findings were corroborated by the Fall 2023 VQI Regional Report, which demonstrated our reduction in LOS metrics for CEA and EVAR, below regional and national benchmarks (Fig 1). We also increased patients discharged within 1 day after surgery from 50% to 85% for CEA and 45% to 76% for EVAR (P = .01 for both), which has been associated with increased patient satisfaction and likelihood to recommend the hospital to others. VQI benchmarking identifies system-wide and surgeon-specific QI opportunities. Through multidisciplinary engagement of all stakeholders and implementing interventions across the care continuum, we were able to successfully reduce LOS for elective CEA and EVAR patients to below VQI targets. Reducing LOS in line with risk-adjusted regional and national standards increases access and system capacity, while improving efficiency, cost effectiveness, and patient-centered outcomes. Future work aimed at design and implementation of real-time LOS dashboards in electronic health records will improve the access to and sustainability of inpatient vascular care. TableDemographics and postoperative length of stay (LOS) for elective CEA and EVAR patientsPre-intervention period (1/2021-3/2022)Post-intervention period (4/2022-7/2023)P-valueCEAn = 22n = 26 Age, years73.4 ± 7.371.3 ± 8.6.37 Males12 (54.6%)15 (57.7%).83 LOS, days2.2 ± 3.11.2 ± 0.5.16 LOS, hours52.7 ± 75.727.7 ± 12.0.14 Prolonged LOS (>1 day)11 (50.0%)4 (15.4%).01EVARn = 31n = 41 Age, years72.0 ± 8.771.6 ±12.2.88 Males26 (83.9%)33 (80.5%).72 LOS, days2.3 ± 1.81.5 ± 1.5.06 LOS, hours55.1 ± 43.236.9 ± 35.5.05 Prolonged LOS (>2 days)8 (25.8%)3 (7.3%).03CEA, Carotid endarterectomy; EVAR, endovascular aortic aneurysm repair; LOS, length of stay.Values reported as mean ± standard deviation or number (%). Open table in a new tab