Comprehensive Quality Improvement Program for Intraoperative Transesophageal Echocardiography: Development, Implementation, and Initial Experience

OBJECTIVE

To develop and implement a comprehensive transesophageal echocardiography (TEE) quality improvement (QI) program and assess for potential improvements in TEE performed by cardiac anesthesiologists.

DESIGN

Prospective institutionally approved QI program.

SETTING

Academic tertiary care center.

PARTICIPANTS

The study comprised cardiac anesthesiologists.

INTERVENTIONS

An instrument comprising 15 quality measures to assess TEE examinations pre- and post-cardiopulmonary bypass (CPB) was developed for the present study. TEE examinations before the introduction of the QI program were assessed retrospectively, and examinations performed after its introduction were reviewed prospectively over a 2-year period.

MEASUREMENTS AND MAIN RESULTS

A total of 118 TEE studies were analyzed, 48 and 70 studies before and after introduction of the TEE QI program, respectively. Half of the studies were performed pre-CPB, and half of them were performed post-CPB. Multivariate linear mixed regression models were used to assess the effect of the QI program. Interrater variability was assessed among internal reviewers by means of the Shrout-Fleiss reliability intraclass correlation coefficient. Five quality measures demonstrated a significant improvement in studies after CPB after implementation, including 3 imaging criteria (left ventricle, tricuspid valve, and pulmonary artery) and 2 documentation criteria (completeness of demographic/clinical data and timely reporting of documentation). The inter-rater variability analysis yielded an average intraclass correlation coefficient of 0.90 before and 0.78 after the QI program initiation, consistent with excellent agreement among the 4 reviewers.

CONCLUSIONS

The present study demonstrated the ability to create and implement a formal QI program for intraoperative TEE in an academic tertiary care cardiac surgical group. The initial data showed significant improvement in several quality measures related to TEE performance.

A standardized imaging protocol improves quality and reduces practice variability in echocardiographic assessment of ventricular function by first-year pediatric cardiology fellows

BACKGROUND

Echocardiography education for pediatric cardiology fellows has been a recent focus leading to the implementation of "boot camps." Less is described about continuing education through fellowship and improving image quality. We noticed practice variation in echocardiograms assessing ventricular function performed on nights and weekends. Thus, we implemented a standardized protocol and assessed its impact on imaging and reporting completeness.

METHODS

We created an imaging protocol for the assessment of ventricular function in the acute setting. The protocol included demographic information, a list of images to be obtained, and the methods to quantify ventricular function. The protocol was explained to first-year fellows and distributed on an electronic quick reference card. Echocardiograms independently performed by first-year fellows during their first 4 months of on-call time were assessed pre- and postintervention using a standard rubric.

RESULTS

Compliance with demographic reporting was high pre- and postintervention, but significantly improved after the standardized protocol (P < 0.001). Use of the protocol increased the median number of unique images obtained per echocardiogram from 13 to 17 (out of 23 required views, P < 0.001). Particularly improved was the performance of quantitative evaluations of function, including Simpson's method for left ventricular ejection fraction (four chamber: 40% vs 67%, P < 0.001; two chamber: 33% vs 67%, P < 0.001) and tricuspid annular plane systolic excursion (45% vs 80%, P < 0.001).

CONCLUSIONS

The introduction of a standardized imaging protocol and its distribution to first-year fellows resulted in improvements in echocardiographic reporting completeness and increased the quality of information obtained by providing more quantitative assessments of ventricular function.