Leveraging the Vascular Quality Initiative to reduce length of stay following elective carotid endarterectomy and endovascular aortic aneurysm repair

Abstract

Objective

Length of stay (LOS) is a key quality metric for the Society for Vascular Surgery's Vascular Quality Initiative (VQI). In 2021, our hospital was an outlier for ‘prolonged LOS’ after 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 quality improvement initiative to reduce LOS following elective CEA and EVAR.

Methods

We completed a retrospective review of all CEA and EVAR cases (January 2021 to March 2022) using data obtained from VQI. During the intervention phase (April 2022 to July 2023), a multidisciplinary team defined the problem state, refined workflows, used the Plan-Do-Study-Act method to address key drivers, and maintained a prospective database of patients and LOS outcomes. Preoperative interventions educated patient stakeholders (eg, nurses, case managers, trainees) on LOS benchmarks, communicated expected discharge date and time to patients/families, and screened all patients for high-risk discharge, leading to prolonged LOS. After surgery, recovery protocols were standardized, including Foley catheter removal at midnight postoperative day 0 and physical therapy evaluation morning postoperative day 1. Primary outcomes, rates of prolonged LOS and mean LOS (days, hours), and secondary outcomes (discharge within 1 day, readmission, mortality) were compared pre- and postintervention.

Results

Overall, 120 patients were included (48 CEA, 72 EVAR) with 52 (22 CEA, 31 EVAR) preintervention and 67 (26 CEA, 41 EVAR) postintervention. Over the intervention, rate of prolonged LOS significantly decreased from 50% to 15% for CEA (P = .01) and 26% to 7% for EVAR (P = .03), while mean LOS decreased for CEA from 2.2 ± 3.1 days to 1.2 ± 0.5 days (52.7 ± 75.7 hours to 27.7 ± 12.0 hours) and for EVAR from 2.3 ± 1.8 days to 1.5 ± 1.5 days (55.1 ± 43.2 hours to 36.9 ± 35.5 hours). Patients discharged within 1 day from surgery significantly increased from 50% to 85% for CEA and 45% to 76% for EVAR (both P = .01). Balancing measures of 30-day readmission and mortality did not significantly increase following our intervention, with three readmissions overall and no deaths in either cohort. Our Fall 2023 VQI Regional Report confirmed these findings with reduced LOS for CEA and EVAR below regional and national targets.

Conclusions

VQI benchmarking identifies system-wide, surgeon-specific quality improvement opportunities. Through engaging multidisciplinary teams and implementing patient-centric interventions across the care continuum, we successfully reduced LOS for CEA and EVAR below VQI targets.