Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates

Precision medicine for cardiometabolic disease: a framework for clinical translation

Cardiometabolic disease is a major threat to global health. Precision medicine has great potential to help to reduce the burden of this common and complex disease cluster, and to enhance contemporary evidence-based medicine. Its key pillars are diagnostics; prediction (of the primary disease); prevention (of the primary disease); prognosis (prediction of complications of the primary disease); treatment (of the primary disease or its complications); and monitoring (of risk exposure, treatment response, and disease progression or remission). To contextualise precision medicine in both research and clinical settings, and to encourage the successful translation of discovery science into clinical practice, in this Series paper we outline a model (the EPPOS model) that builds on contemporary evidence-based approaches; includes precision medicine that improves disease-related predictions by stratifying a cohort into subgroups of similar characteristics, or using participants' characteristics to model treatment outcomes directly; includes personalised medicine with the use of a person's data to objectively gauge the efficacy, safety, and tolerability of therapeutics; and subjectively tailors medical decisions to the individual's preferences, circumstances, and capabilities. Precision medicine requires a well functioning system comprised of multiple stakeholders, including health-care recipients, health-care providers, scientists, health economists, funders, innovators of medicines and technologies, regulators, and policy makers. Powerful computing infrastructures supporting appropriate analysis of large-scale, well curated, and accessible health databases that contain high-quality, multidimensional, time-series data will be required; so too will prospective cohort studies in diverse populations designed to generate novel hypotheses, and clinical trials designed to test them. Here, we carefully consider these topics and describe a framework for the integration of precision medicine in cardiometabolic disease.

Trends in Cardiovascular Surgery in South Korea: A Nationwide Cohort Study from 2010 to 2019

OBJECTIVES

We aimed to investigate mortality and its associated factors in cardiovascular surgery-associated intensive care unit (ICU) admissions in South Korea from 2010 to 2019.

DESIGN

Population-based cohort study.

SETTING

Data from the National Health Insurance Service database in South Korea were used in this study.

PARTICIPANTS

All adult patients admitted to the ICU associated with cardiovascular surgery in South Korea between January 1, 2010 and December 31, 2019 were analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 62,794 ICU admissions associated with cardiovascular surgery were included in the analysis (median value of age: 65 years; 58.0% men). This included patients who underwent coronary artery bypass grafting (CABG) only (n = 10,704), valve-only surgery (n = 35,812), CABG + valve surgery (n = 3,230), aortic procedures (n = 7,968), and others (n = 5,080). The number of cardiovascular surgeries associated with ICU admissions was 4,409 in 2010, which gradually increased to 10,366 in 2019. The aortic procedure group had the highest 1-year mortality rate after cardiovascular surgery (15.7%), followed by the CABG + valve (13.2%), others (11.5%), CABG-only (9.5%), and valve-only (8.7%) groups. Invasive life support procedures during the ICU stay and hospital admission through the emergency room were potential risk factors for 1-year mortality after cardiovascular surgery.

CONCLUSIONS

Cardiovascular surgery-associated intensive care admissions gradually increased from 2010 to 2019 in South Korea. Among these patients, the highest 1-year mortality rate was observed in the aortic procedures group, followed by the CABG + valve, others, CABG-only, and valve-only groups.

Correlation between transhepatic and subcostal inferior vena cava ultrasonographic images for evaluating fluid responsiveness after cardiac surgery

BACKGROUND

Echocardiographic monitoring during the postoperative period following cardiac surgery is essential because patients often develop hemodynamic instability from hypovolemia and other causes. Therefore, predicting fluid responsiveness by measuring respirophasic variation in the inferior vena cava (IVC) is essential in this population. Yet it is not always possible to evaluate using the traditional subcostal view.

METHODS

This cross-sectional study of 36 consecutive adult patients who underwent cardiac surgery included those in whom it was possible to adequately visualize the IVC in both the subcostal and transhepatic views. The maximum and minimum diameters and respirophasic variation were measured in each view. These views were then correlated and the capacity of the transhepatic view to predict fluid responsiveness was evaluated.

RESULTS

There was a strong positive correlation between IVC maximum and minimum diameters and respirophasic variation according to subcostal and transhepatic views. Evaluation of IVC respirophasic variation indices using the transhepatic view also showed high sensitivity for predicting fluid responsiveness.

CONCLUSION

There is a correlation between the transhepatic and subcostal views for determining maximum and minimum IVC diameters, and distensibility and variability indices for predicting fluid responsiveness in postoperative cardiac surgery patients.

Regional Right Ventricular Function Assessed by Intraoperative Three-Dimensional Echocardiography Is Associated With Short-Term Outcomes of Patients Undergoing Cardiac Surgery

Background

The assessment of right ventricular (RV) function in patients undergoing elective cardiac surgery is paramount for providing optimal perioperative care. The role of regional RV function assessment employing sophisticated state-of-the-art cardiac imaging modalities has not been investigated in this cohort. Hence, this study investigated the association of 3D echocardiography-based regional RV volumetry with short-term outcomes.

Materials and Methods

In a retrospective single-center study, patients undergoing elective cardiac surgery were included if they underwent 3D transesophageal echocardiography prior to thoracotomy. A dedicated software quantified regional RV volumes of the inflow tract, apical body and RV outflow tract employing meshes derived from 3D speckle-tracking. Echocardiographic, clinical and laboratory data were entered into univariable and multivariable logistic regression analyses to determine association with the endpoint (in-hospital mortality or the need for extracorporeal circulatory support).

Results

Out of 357 included patients, 25 (7%) reached the endpoint. Inflow RV ejection fraction (RVEF, 32 ± 8% vs. 37 ± 11%, p = 0.01) and relative stroke volume (rel. SV) were significantly lower in patients who reached the endpoint (44 ± 8 vs. 48 ± 9%, p = 0.02), while the rel. SV of the apex was higher (38 ± 10% vs. 33 ± 8%, p = 0.01). Global left and right ventricular function including RVEF and left ventricular global longitudinal strain did not differ. In univariable logistic regression, tricuspid regurgitation grade ≥ 2 [odds ratio (OR) 4.24 (1.66–10.84), p < 0.01], inflow RVEF [OR 0.95 (0.92–0.99), p = 0.01], inflow rel. SV [OR 0.94 (0.90–0.99), p = 0.02], apex rel. SV [OR 1.07 (1.02–1.13), p < 0.01] and apex to inflow rel. SV ratio [OR 5.81 (1.90–17.77), p < 0.01] were significantly associated with the endpoint. In a multivariable model, only the presence of tricuspid regurgitation [OR 4.24 (1.66–10.84), p < 0.01] and apex to inflow rel. SV ratio [OR 6.55 (2.09–20.60), p < 0.001] were independently associated with the endpoint.

Conclusions

Regional RV function is associated with short-term outcomes in patients undergoing elective cardiac surgery and might be helpful for optimizing risk stratification.

Evaluating Quality in Adult Cardiac Surgery

National and institutional quality initiatives provide benchmarks for evaluating the effectiveness of medical care. However, the dramatic growth in the number and type of medical and organizational quality-improvement standards creates a challenge to identify and understand those that most accurately determine quality in cardiac surgery. It is important that surgeons have knowledge and insight into valid, useful indicators for comparison and improvement. We therefore reviewed the medical literature and have identified improvement initiatives focused on cardiac surgery. We discuss the benefits and drawbacks of existing methodologies, such as comprehensive regional and national databases that aid self-evaluation and feedback, volume-based standards as structural indicators, process measurements arising from evidence-based research, and risk-adjusted outcomes. In addition, we discuss the potential of newer methods, such as patient-reported outcomes and composite measurements that combine data from multiple sources.

Most deaths in low-risk cardiac surgery could be avoidable

It is observed that death rates in cardiac surgery has decreased, however, root causes that behave like triggers of potentially avoidable deaths (AD), especially in low-risk patients (less bias) are often unknown and underexplored, Phase of Care Mortality Analysis (POCMA) can be a valuable tool to identify seminal events (SE), providing valuable information where it is possible to make improvements in the quality and safety of future procedures. Our results show that in São Paul State, only one third of AD in low-risk cardiac surgery was related to specific surgical problems. After a revisited analysis, 75% of deaths could have been avoided, which in the pre-operative phase, the SE was related judgment, patient evaluation and preparation. In the intra-operative phase, most occurrences could have been avoided if other surgical technique had been used. Sepsis was responsible for 75% of AD in the intensive care unit. In the ward phase, the recognition/management of clinical decompensations and sepsis were the contributing factors. Logistic regression model identified age, previous coronary stent implantation, coronary artery bypass grafting + heart valve surgery, ≥ 2 combined heart valve surgery and hospital-acquired infection as independent predictors of AD.

Artificial Intelligence for Intraoperative Guidance: Using Semantic Segmentation to Identify Surgical Anatomy During Laparoscopic Cholecystectomy

OBJECTIVE

To develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC).

SUMMARY BACKGROUND DATA

Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively.

METHODS

Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by four high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection-over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation.

RESULTS

AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20) and 0.94 (±0.03) respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21) and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19) and 0.65 (±0.22), respectively.

CONCLUSIONS

AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.

Perioperative care in cardiac surgery

As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.

Technical factors affecting cardiac surgical mortality in Australia

Aim

Examination of potentially avoidable issues in surgical deaths can provide a basis for quality improvement. Perioperative technical factors in cardiac surgery may lead or contribute to patient mortality. Using data from a well-established and comprehensive national surgical mortality audit, we aimed to identify and describe clinical management issues leading to mortality in Australian cardiac surgical patients.

Methods

Retrospective analysis of a cardiac surgical dataset from the Australian and New Zealand Audit of Surgical Mortality (February 2009 to December 2015) was undertaken. Clinical management issues related to technical factors were analyzed using a thematic analysis approach. Technical clinical management issues were categorized based on the most common themes, followed by qualitative analysis of each theme.

Results

We identified 256 patients with least one technical management issues (total 270). Injury to structures was the most common theme ( n = 115, 44.9%), followed by unaddressed surgical pathology ( n = 39, 15.2%) and inadequate myocardial protection ( n = 34, 13.2%). More specifically, the most common structural injury involved the right ventricle, with the aorta and femoral vessels also commonly injured. The most common unaddressed surgical pathology was incomplete coronary revascularization, followed by systolic anterior motion of the mitral valve during mitral repair. Graft failure occurred during coronary artery bypass graft surgery, with a poor target vessel being a common issue.

Conclusion

Technical factors in cardiac surgery resulting in potentially avoidable mortality constitute an important subset of deaths. These findings can inform various stakeholders to improve the quality and safety of surgical care.

Measuring the quality of perioperative care in cardiac surgery

Quality of care is of increasing importance in health and surgical care. In order to maintain and improve quality, we must be able to measure it and identify variation. In this narrative review, we aim to identify measures used in the assessment of quality of care in cardiac surgery and to evaluate their utility. The electronic databases Pubmed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and CINAHL were searched for original published studies using the terms 'cardiac surgery' and 'quality or outcome or process or structure' as either keywords in the title or text or MeSH terms. Secondary searches and identification of references from original articles were carried out. We found a total of 54 original articles evaluating measurements of quality. While structure, process, and outcome indicators remain the mainstay of quality measurement, new and innovative methods of risk assessment have improved reliability and discrimination. Continuous assessment provides a promising method of both maintaining and improving quality of care. Future studies should focus on long-term and patient-centred outcomes, such as quality-of-life measures.

Factors Influencing Team Behaviors in Surgery: A Qualitative Study to Inform Teamwork Interventions

BACKGROUND

Surgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members' nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations suggests that team behaviors are also contingent on psychosocial, cultural, and organizational factors. This study examined factors influencing surgical team behaviors to inform more contextually sensitive and effective approaches to optimizing surgical teamwork.

METHODS

This qualitative study of cardiac surgical teams in a large United States teaching hospital included 34 semistructured interviews. Thematic network analysis was used to examine perceptions of ideal teamwork and factors influencing team behaviors in the operating room.

RESULTS

Perceptions of ideal teamwork were largely shared, but team members held discrepant views of which team and leadership behaviors enhanced or undermined teamwork. Other factors affecting team behaviors were related to the local organizational culture, including management of staff behavior, variable case demands, and team members' technical competence, and fitness of organizational structures and processes to support teamwork. These factors affected perceptions of what constituted optimal interpersonal and team behaviors in the operating room.

CONCLUSIONS

Team behaviors are contextually contingent and organizationally determined, and beliefs about optimal behaviors are not necessarily shared. Interventions to optimize surgical teamwork require establishing consensus regarding best practice, ability to adapt as circumstances require, and organizational commitment to addressing contextual factors that affect teams.

Postoperative Remote Automated Monitoring: Need for and State of the Science

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.

Measuring Decision-Making During Thyroidectomy: Validity Evidence for a Web-Based Assessment Tool

BACKGROUND

Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them.

METHODS

An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from four institutions completed a 33-item assessment, developed based on a cognitive task analysis and expert Delphi consensus. Sixteen items required subjects to make annotations on still frames of thyroidectomy videos, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test," VCT). Seven items were short answer (SA), requiring users to type their answers, and scores were automatically calculated based on their similarity to a pre-populated repertoire of correct responses. Test-retest reliability, internal consistency, and correlation of scores with self-reported experience and training level (novice, intermediate, expert) were calculated.

RESULTS

Twenty-eight subjects (10 endocrine surgeons and otolaryngologists, 18 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.96; n = 10) and internal consistency (Cronbach's α = 0.93). The assessment demonstrated significant differences between novices, intermediates, and experts in total score (p < 0.01), VCT score (p < 0.01) and SA score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.95, p < 0.01), between total case number and VCT score (ρ = 0.93, p < 0.01), and between total case number and SA score (ρ = 0.83, p < 0.01).

CONCLUSION

This study describes the development of novel metrics and provides validity evidence for an interactive Web-based platform to objectively assess decision-making during thyroidectomy.

What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance

OBJECTIVE

To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance.

BACKGROUND

Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety.

METHODS

Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items.

RESULTS

A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals.

CONCLUSIONS

This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

Differences in Hospital Risk-standardized Mortality Rates for Acute Myocardial Infarction When Assessed Using Transferred and Nontransferred Patients

BACKGROUND

One in 5 patients with acute myocardial infarction (AMI) are transferred between hospitals. However, current hospital performance measures based on AMI mortality exclude these patients from the evaluation of referral hospitals.

OBJECTIVE

To determine the relationship between risk-standardized mortality for transferred and nontransferred patients at referral hospitals.

RESEARCH DESIGN

This is a retrospective cohort study.

SUBJECTS

Fee-for-service Medicare claims from 2011 for patients hospitalized with a primary diagnosis of AMI, at hospitals admitting at least 15 patients in transfer.

MEASURES

Hospital-specific risk-standardized 30-day mortality rates (RSMRs) for 2 groups of patients: those admitted through transfer from another hospital, and those natively admitted without a preceding or subsequent interhospital transfer.

RESULTS

There were 304 hospitals admitting at least 15 patients in transfer. These hospitals cared for 77,711 natively admitted patients (median, 254; interquartile range, 162-321), and 11,829 patients admitted in transfer (median, 26; interquartile range, 19-46). Risk-standardized mortality rates were higher for natively admitted patients than for those admitted in transfer (mean, 11.5%±1.2% vs. 7.2%±1.1%). There was weak correlation between hospital performance as assessed by RSMR for patients natively admitted versus those admitted in transfer (Pearson r=0.24, P<0.001); when performance was arrayed by quartile, 102 hospitals (33.6%) differed at least 2 quartiles of performance across the 2 patient groups.

CONCLUSIONS

For Medicare patients with AMI, hospital-specific RSMRs for natively admitted patients are only weakly associated with RSMRs for patients transferred in from another hospital. Current AMI performance metrics may fail to provide guidance about hospital quality for transferred patients.

Ten Years Experiences With Preoperative Evaluation Clinic for Day Admission Cardiac and Major Vascular Surgical Patients: Model for "Perioperative Anesthesia and Surgical Home"

Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

OBJECTIVES

Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient.

DATA SOURCE AND SYNTHESIS

Narrative review of relevant English-language peer-reviewed medical literature.

CONCLUSIONS

Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.

Rate of Major Anesthetic-Related Outcomes in the Intraoperative and Immediate Postoperative Period After Cardiac Surgery

OBJECTIVES

To examine anesthesia-centered outcomes in a large cohort of patients undergoing coronary artery bypass grafting (CABG) or valvular heart surgery.

DESIGN

A retrospective study with univariate and multivariate logistic regression to identify independent predictors for mortality.

SETTING

Diverse setting including university, small, medium, and large community hospitals.

PARTICIPANTS

All patients undergoing CABG or valve surgery in the National Anesthesia Clinical Outcomes Registry (NACOR) from the Anesthesia Quality Institute.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Common anesthesia-centered outcomes including arrhythmia, cardiac arrest, death, hemodynamic instability, hypotension, inadequate pain control, nausea/vomiting, seizure, stroke, reintubation and transfusion were reported. All outcomes, consistent with NACOR data entry, were defined as occurring intraoperatively or during phase I or II recovery in the PACU. Death occurred in 0.15% of CABGs and 0.23% of valve surgeries. Age less than 18, American Society of Anesthesiologists physical status (ASA PS) classification of 5, and mean case duration greater than 6 hours were associated with increased mortality (p<0.05). The presence of a board-certified anesthesiologist was associated with decreased odds for mortality.

CONCLUSIONS

Death was a rare outcome in this cohort, reflecting the infrequent occurrence of intraoperative or immediate postoperative death. The presence of a board-certified anesthesiologist represented a modifiable risk factor for reducing mortality risk.

A novel method of personnel cooling in an operating theatre environment

An optimized theatre environment, including personal temperature regulation, can help maintain concentration, extend work times and may improve surgical outcomes. However, devices, such as cooling vests, are bulky and may impair the surgeon's mobility. We describe the use of a low-cost, low-energy 'bladeless fan' as a personal cooling device. The safety profile of this device was investigated by testing air quality using 0.5- and 5-µm particle counts as well as airborne bacterial counts on an operating table simulating a wound in a thoracic operation in a busy theatre environment. Particle and bacterial counts were obtained with both an empty and full theatre, with and without the 'bladeless fan'. The use of the 'bladeless fan' within the operating theatre during the simulated operation led to a minor, not statistically significant, lowering of both the particle and bacterial counts. In conclusion, the 'bladeless fan' is a safe, effective, low-cost and low-energy consumption solution for personnel cooling in a theatre environment that maintains the clean room conditions of the operating theatre.

Relationship between preventable hospital deaths and other measures of safety: an exploratory study

OBJECTIVE

To explore associations between the proportion of hospital deaths that are preventable and other measures of safety.

DESIGN

Retrospective case record review to provide estimates of preventable death proportions. Simple monotonic correlations using Spearman's rank correlation coefficient to establish the relationship with eight other measures of patient safety.

SETTING

Ten English acute hospital trusts.

PARTICIPANTS

One thousand patients who died during 2009.

RESULTS

The proportion of preventable deaths varied between hospitals (3-8%) but was not statistically significant (P = 0.94). Only one of the eight measures of safety (Methicillin-resistant Staphylococcus aureus bacteraemia rate) was clinically and statistically significantly associated with preventable death proportion (r = 0.73; P < 0.02). There were no significant associations with the other measures including hospital standardized mortality ratios (r = -0.01). There was a suggestion that preventable deaths may be more strongly associated with some other measures of outcome than with process or with structure measures.

CONCLUSIONS

The exploratory nature of this study inevitably limited its power to provide definitive results. The observed relationships between safety measures suggest that a larger more powerful study is needed to establish the inter-relationship of different measures of safety (structure, process and outcome), in particular the widely used standardized mortality ratios.

Quality, patient safety, and the cardiac surgical team

After more than a decade of attention, the risks inherent in cardiac surgery have been well documented, but examples of effective interventions to reduce this risk remain scarce. The need is great, because the patient population is vulnerable and the potential consequences of poor outcomes are ever present and significant. This article reviews a decade of discussion surrounding quality and safety issues in cardiac surgery, and concludes with examples of strategies that have shown great promise for improving cardiac surgery quality and safety.

Preventable mortality evaluation in the ICU

Mortality is the most widely measured outcome parameter. Improvement of this outcome parameter in critical care is nowadays expected not to come from new technologies or treatment, but from delivering the right care at the right moment in a safe way. The measurement of mortality as an outcome parameter confronts us with a problem in providing follow-up to the results. Especially when proven structure and process interventions are applied already, the cause of a suboptimal performance cannot be deduced easily. One possibility is to evaluate the causes of death and to judge preventability. In this article we explore the opportunities and difficulties of a tool to evaluate preventable mortality in the ICU.

Incidence and predictors of 30-day hospital readmission rate following percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Postdischarge outcomes after percutaneous coronary intervention (PCI) are important measurements of quality of care and complement in-hospital measurements. We sought to assess in-hospital and postdischarge PCI outcomes to (1) better understand the relation between acute and 30-day outcomes, (2) identify predictors of 30-day hospital readmission, and (3) determine the prognostic significance of 30-day hospital readmission. We analyzed in-hospital death and length of stay (LOS) and nonelective cardiac-related rehospitalization after discharge in 10,965 patients after PCI in the Dynamic Registry. From 1999 to 2006 in-hospital death rate and LOS decreased. Thirty-day cardiac readmission rate was 4.6%, with considerable variability over time and among hospitals. Risk of rehospitalization was greater in women and those with congestive heart failure, unstable angina, multiple lesions, and emergency PCI. Conversely, a lower risk of rehospitalization was associated with a larger number of treated lesions. Patients readmitted within 30 days had higher 1-year mortality than those free from hospital readmission. In conclusion, although in-hospital mortality and LOS after PCI have decreased over time, the observed 30-day cardiac readmission rate was highly variable and risk of readmission was more closely associated with underlying patient characteristics than procedural characteristics.

Establishing quality review of cardiac and respiratory arrest in a pediatric intensive care unit

Cardiac arrest in children is a rare event; however, the outcomes following resuscitation are universally disappointing. Despite widespread recognition of its importance, there is no standard approach to conducting reviews surrounding critical resuscitation events. A standardized approach to the review of respiratory and cardiac arrests occurring in the pediatric intensive care unit focusing on processes of care and team performance was undertaken at a single pediatric academic medical center. Data collection and quality improvement tools were created, and a formal code review was established. Improvement in code team performance was observed. Clinician documentation improved, and multiple system redesigns were implemented that ultimately resulted in fewer clinician concerns. The rate of successful resuscitation was consistent with current published benchmarks. The development of an interdisciplinary code review process focusing on the procedure of resuscitation can identify critical issues that may impede successful resuscitation.

Hospital-level associations with 30-day patient mortality after cardiac surgery: a tutorial on the application and interpretation of marginal and multilevel logistic regression

Background

Marginal and multilevel logistic regression methods can estimate associations between hospital-level factors and patient-level 30-day mortality outcomes after cardiac surgery. However, it is not widely understood how the interpretation of hospital-level effects differs between these methods.

Methods

The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) registry provided data on 32,354 patients undergoing cardiac surgery in 18 hospitals from 2001 to 2009. The logistic regression methods related 30-day mortality after surgery to hospital characteristics with concurrent adjustment for patient characteristics.

Results

Hospital-level mortality rates varied from 1.0% to 4.1% of patients. Ordinary, marginal and multilevel regression methods differed with regard to point estimates and conclusions on statistical significance for hospital-level risk factors; ordinary logistic regression giving inappropriately narrow confidence intervals. The median odds ratio, MOR, from the multilevel model was 1.2 whereas ORs for most patient-level characteristics were of greater magnitude suggesting that unexplained between-hospital variation was not as relevant as patient-level characteristics for understanding mortality rates. For hospital-level characteristics in the multilevel model, 80% interval ORs, IOR-80%, supplemented the usual ORs from the logistic regression. The IOR-80% was (0.8 to 1.8) for academic affiliation and (0.6 to 1.3) for the median annual number of cardiac surgery procedures. The width of these intervals reflected the unexplained variation between hospitals in mortality rates; the inclusion of one in each interval suggested an inability to add meaningfully to explaining variation in mortality rates.

Conclusions

Marginal and multilevel models take different approaches to account for correlation between patients within hospitals and they lead to different interpretations for hospital-level odds ratios.

Process Review of a Departmental Change from Conventional Coronary Artery Bypass Grafting to Totally Arterial Coronary Artery Bypass and Its Effects on the Incidence and Severity of Postoperative Stroke

Background: We evaluated the process of changing from conventional coronary artery bypass grafting (CABG) to totally arterial off-pump coronary artery bypass (TOPCAB) at a single heart center in Germany.Methods: We (1) used multivariate statistical methods to assess real-time monitoring of OPCAB effects, (2) conducted a case review to assess preventable deaths and identify areas of improvement, (3) conducted a team survey, and (4) evaluated benchmarking results.Results: All surgeons and assistants (n = 18) at this center were involved and were guided by the department head and one of the consultants, who was trained in this procedure in 2004 at the Leuven OPCAB school. The frequency of OPCAB operations increased abruptly in 2005 from 5% to 43% and then increased gradually to 67% (n = 546) by 2008 (total, 1781 OPCAB cases and 1563 on-pump cases). The in-hospital and 30-day mortality rates for OPCAB surgeries (n = 10 [0.6%] and 21 [1.2%], respectively) were lower than for on-pump surgeries (n = 27 [1.7%] and 26 [1.7%], respectively). Stroke rates were also lower for OPCAB surgeries (7 cases [0.4%] versus 15 cases [1%]). The lower risk of stroke in the OPCAB group was significant (P < .05) after risk adjustment. Monitoring curves and case reviews demonstrated a preventable death percentage of at least 30%. The attitude of the team was mostly positive because of the promising results (eg, fewer strokes, increasing TOPCAB popularity, and a top national rank).Conclusions: The change from conventional CABG to TOPCAB was effective in decreasing the incidence and severity of stroke, in developing a team routine and a positive team attitude, and in producing excellent benchmarking results. The presence of a training and communication deficiency at the beginning of the study suggested an area for further improvement. After 6 years TOPCAB had largely replaced conventional CABG.

Impact of Independent Data Adjudication on Hospital-Specific Estimates of Risk-Adjusted Mortality Following Percutaneous Coronary Interventions in Massachusetts

Background—

As part of state-mandated public reporting of outcomes after percutaneous coronary interventions (PCIs) in Massachusetts, procedural and clinical data were prospectively collected. Variables associated with higher mortality were audited to ensure accuracy of coding. We examined the impact of adjudication on identifying hospitals with possible deficiencies in the quality of PCI care.

Methods and Results—

From October 2005 to September 2006, 15 721 admissions for PCI occurred in 21 hospitals. Of the 864 high-risk variables from 822 patients audited by committee, 201 were changed, with reassignment to lower acuities in 97 (30%) of the 321 shock cases, 24 (43%) of the 56 salvage cases, and 73 (15%) of the 478 emergent cases. Logistic regression models were used to predict patient-specific in-hospital mortality. Of 241 (1.5%) patients who died after PCI, 30 (12.4%) had a lower predicted mortality with adjudicated than with unadjudicated data. Model accuracy was excellent with either adjudicated or unadjudicated data. Hospital-specific risk-standardized mortality rates were estimated using both adjudicated and unadjudicated data through hierarchical logistic regression. Although adjudication reduced between-hospital variation by one third, risk-standardized mortality rates were similar using unadjudicated and adjudicated data. None of the hospitals were identified as statistical outliers. However, cross-validated posterior-predicted P values calculated with adjudicated data increased the number of borderline hospital outliers compared with unadjudicated data.

Conclusions—

Independent adjudication of site-reported high-risk features may increase the ability to identify hospitals with higher risk-adjusted mortality after PCI despite having little impact on the accuracy of risk prediction for the entire population.

Improving cardiac surgical care: a work systems approach

Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.

Pay for performance in the intensive care unit--opportunity or threat?

OBJECTIVE

Ongoing evidence of poor-quality healthcare has stimulated the development of provider reimbursement schemes linked to the delivery of high-quality care. Our objective was to describe these programs and their potential implementation in intensive care units (ICUs).

SOURCES

MEDLINE (2000-May, 2008) and personal files.

STUDY SELECTION

We selected empirical studies, narrative and systematic reviews, and commentaries addressing pay-for-performance programs.

DATA EXTRACTION

Using a narrative review format, we discuss the definition of pay-for-performance, describe current implementations, suggest challenges of applying these programs to the ICU setting, and discuss alternative quality improvement programs.

DATA SYNTHESIS

The ICU will likely become a target for pay-for-performance plans, considering the high cost of care, development of ICU quality-of-care measures, and interest from healthcare regulators and funders. Existing plans applied outside the ICU have varied in the amount of financial incentive and targeted provider and quality measures. Evaluations are sparse. Implementation challenges specific to the ICU include selecting evidence-based and feasible quality of care measures, motivating the entire interdisciplinary team, integrating multifaceted behavior change strategies, and developing informatics infrastructure for timely audit and feedback. Other incentive-based alternatives to improve ICU quality of care include a "centers of excellence" approach (referral of patients to centers with excellent outcomes), public reporting of ICU outcomes, and payments to hospitals for participating in quality improvement programs.

CONCLUSIONS

Participation in pay-for-performance programs is a potential opportunity for intensivists and ICU teams to improve outcomes for their patients in partnership with regulatory agencies and healthcare funders. Because many aspects of optimal design of these programs in ICUs are unknown, robust evaluations of their effect on healthcare quality should be integrated into any implementations.

Publicly reported provider outcomes: the concerns of cardiac surgeons in a single-payer system

BACKGROUND

Provider outcomes reports are an important part of quality improvement efforts. The positive and negative impact of such reports on the delivery of care has not been extensively explored.

METHODS

A survey of Ontario cardiac surgeons was performed in September 2003 to understand their concerns regarding performance reports. The questionnaire addressed the use of evidence-based practices, the impact of public-provider profiling on clinical practice and the improvement of current report cards. The survey was conducted with the distribution of a fiscal 2000/2001 cardiac surgery report card.

RESULTS

There was a 95% (52 of 55 cardiac surgeons) survey response rate, of which 80% were high-volume surgeons with a case volume of more than 200 cases per year. Seventy-four per cent of surgeons had more than five years of experience. The majority of surgeons believed that performance reports influenced cardiologist referrals (84%) and patient choices (80%). A minority (48%) of surgeons believed that the reporting of inhospital mortality was very or extremely useful, but a majority (83%) believed mortality rates indicated the relative performance of a cardiac surgeon. The majority of surgeons believed that routine upcoding of data (84%) and inadequate risk adjustment (75%) were weaknesses of present performance reports. Surgeons were divided regarding whether the institutional performance should continue to be publicly reported (51% agreed with public reporting).

CONCLUSIONS

In a single-payer system, performance reports breed provider concerns similar to those seen in market-driven systems including high-risk patient avoidance and upcoding of data. Regardless, providers recognize that institutional performance reports, irrespective of public or confidential reporting, are important in continuous quality improvement.