Improving Practice, Improving Outcomes
Understanding what’s best for the patient
Dr. Rakesh Arora was an active high school athlete in London, Ontario, until an injury forced him to the sidelines. When he recovered, he remained involved with sports by becoming an athletic trainer. During one football game, he was first on the scene to tend to a player who collapsed on the field, flat on his back. Arora raced out to ensure that the player’s airway was clear and that an ambulance had been called.
It was a turning point for the then-16-year-old Arora, who began to think about a career in medicine.
As a teenage athletic trainer, Arora was motivated to do what was best for the patient. Years later as a cardiac surgeon and researcher, he doesn’t just do what’s best for the patient. He, in fact, is at the forefront of determining what’s best, particularly for patients recovering from heart surgery.
“It’s not good enough to have heart surgery patients just survive through the procedure or the intervention, but really to thrive afterwards.”
“During my surgical training, it became obvious, when looking at how we did business after heart surgery, that the patients we were taking care of were getting older and sicker,” says Arora, Principal Investigator, Heart Failure Therapy, at St. Boniface Hospital’s Institute of Cardiovascular Sciences. “Though we’re very good at deciding who should have an operation, and how to do the operation on older and sicker patients very safely, the care after the operation was something where I thought there was a gap. It moved me to think, well, there must be a way we can do this better.”
That observation led Arora to become the first cardiac surgeon in Canada to also earn a fellowship in critical care medicine. Critical care (also known as intensive care) medicine, is the specialty focusing on patients who need close monitoring and whose organs may need support to function properly at sensitive times, typically after surgery.
Thriving, not just surviving
Since 2006, Arora and his research team have focused on a number of key initiatives to improve health outcomes and the overall hospital experience for cardiac surgery patients and their families. Among those are efforts to improve patient safety and improve communication among all stakeholders. And they are also looking at ways to shorten hospital stays and improve long-term results after heart surgery.
“It’s not good enough to have them just survive through the procedure or the intervention, but really to thrive afterwards,” says Arora. In the absence of solid data surrounding the patient experience before, during and after surgery, the cardiac surgeon decided to make clinical research his main focus.
One of the post-operative issues Arora and his team are investigating is delirium, a condition one in five heart patients experiences to a degree after surgery. Arora’s interest in post-operative delirium and confusion was stimulated in part by a letter of apology from a former patient who had expressed shame at his agitated and combative behaviour in the intensive care unit.
“This confusion we initially thought was quite benign and not a big deal; everyone gets a little bit of what we called ‘pump brain’ after being on the heart lung machine, and it gets better with time and there are no ill effects long term. We’ve learned that isn’t the case,” says Arora. “We’ve learned that when people get confused after an operation it’s a real signal of there being something pretty wrong. The same as if your lungs weren’t working, or your kidneys weren’t working. When your brain doesn’t work, that’s a problem. We’re now understanding that’s something we need to investigate more seriously.”
Resetting the brain chemistry
The delirium can be “scary” for a patient and his or her family, says Arora, and it can involve abnormal behaviour and hallucinations. He says that surrounding these patients with familiar, comforting things is part of addressing the confusion and reducing its severity. “One of the things we try to do to help combat that is not immediately reaching for drugs. Instead we really try to modify the patient’s surroundings and use non-drug therapies as a first line therapy. Family and friends can play an important role in this early process by bringing items that provide the patient with visual cues or auditory cues that remind them of home and loved ones. Bringing family members in as quickly as possible, using certain cues they may be comfortable with at home – such as books or TV or music, and doing things to stimulate the mind again is probably of pretty good importance to kind of reset the brain chemistry back to normal again.”
One of the keys to patient comfort and well-being, says Arora, is getting loved ones to the patient’s bedside as quickly as possible after heart surgery. There had typically been a four-to-five-hour gap between a patient’s arrival in the intensive care unit after surgery and the arrival of family. Thanks to the efficiencies advanced by Arora and his team as part of St-Boniface’s commitment to lean transformation, that gap has now shrunk to 40-60 minutes.
While you wait
Another important area that Arora is studying is how heart patients prepare themselves before surgery – particularly older adult patients who are more frail. Many patients simply sit at home, wait for their date, and become increasingly anxious.
“Thus far, we’ve not been very good at telling them what they should be engaging in. What often happens, people just sit home and wait in fear not knowing what else to do, waiting for their surgery for fear if they do too much they’ll actually make their condition worse,” says Arora. “We know that exercise is probably one of the best things we can do for ourselves. That’s where we’re tapping in on, to find ways we can engage people to do the same sort of healthy living things that anyone is supposed to do – but also while waiting for heart surgery.”
Another important piece of the puzzle is having the surgeon follow up with the patient a year after the surgery. In some cases, says Arora, patients are still struggling, perhaps with getting back to normal activities, or perhaps struggling emotionally – which also has an impact on the patient’s family. The surgeon’s follow-up can help address these issues.
Through medical research that will lead to better advice and care before heart surgery; new approaches to patient safety and post-operative critical care; and new approaches to patient follow-up, Arora and his team are improving health outcomes and turning surviving into thriving.
Dr. Rakesh Arora
Principal Investigator, Heart Failure Therapy,
St. Boniface Hospital’s Institute of Cardiovascular Sciences
Associate Professor of Surgery, Anaesthesia & Physiology, University of Manitoba