International Journal for Quality in Health Care, 2015, 27(4), 255–259 doi: 10.1093/intqhc/mzv040 Advance Access Publication Date: 9 June 2015 Article
Article
Towards excellence in cardiac surgery: experience from a developing country Downloaded from http://intqhc.oxfordjournals.org/ at UNIVERSITY OF PITTSBURGH on August 2, 2015
AAMIR SAIFUDDIN, SYED SHAHABUDDIN, SHAZIA PERVEEN, SHUMAILA FURNAZ, and HASANAT SHARIF Aga Khan University Hospital, Karachi, Pakistan Address reprint requests to: Syed Shahabuddin, Section of Cardiothoracic Surgery, Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan. Tel: +92-21-3486-4708; Fax: +92-21-34934294; E-mail: [email protected] Accepted 13 May 2015
Abstract Objective: The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark. Design: Cross-sectional ( prospectively collected data analysed and compared retrospectively). Setting: Aga Khan University Hospital, Karachi, Pakistan. Participants, interventions and main outcome measures: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons’ National Cardiac Database (STS-NCD). Results: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%). Conclusions: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world. Key words: quality improvement, patient outcomes, cardiac surgery, database
Introduction Coronary artery bypass grafting (CABG) is a widely studied and performed procedure with comparable results internationally. However, performance measurement and continued endeavour to improve is required in such major procedures like CABG to maintain the standard and quality. Guidelines applied in practice as a quality improvement intervention program may improve the adherence to key quality indicators and lead to improved care; however, for sustainability of such quality improvement continuous audit, feedback and concentrating on specific proven care components will be required. [1] On a national
or international level, large databases that pool and analyse prospectively acquired information from a wide range of hospitals can offer accurate data about proven care component and current standards [2] and provide specific outcome goals to which developing program can aspire with clinical benchmarks may constantly be redefined which can lead to improved outcomes [3]. At a smaller level, departmental audits allow objective assessment of hospital-, and even surgeon-, specific performance, which can be used to drive regional progress and enhance patient care. These findings can be contrasted with large databases and used to compare local practice with accepted standards of care. The most comprehensive such database for isolated
© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved
255
Saifuddin et al.
256 CABG is the National Adult Cardiac Surgery Database (NCD) using statistics from the USA [4]. Intricate analysis of this vast amount of information means that accurate representations of surgical mortality and perioperative complications in the USA are available [5]. We aimed to compare the outcomes of isolated CABGs from our database with those from the STS-NCD, to scrutinize our practice and to ascertain whether or not Western levels of achievement are possible in the developing world.
Methods
Operative procedure All of the surgeons used a standard operating strategy involving aorto-atrial (right) cardiopulmonary bypass (CPB) using heart lung machine. After induction of anaesthesia, a median sternotomy approach was used. The conduits were harvested and CPB was established using right atrial and aortic cannulae, following systemic heparinization (300 µ/kg). Myocardial protection was achieved with moderate hypothermia (28–32°C) and blood cardioplegia, given anterogradely via the aortic root. This was enhanced with topical cooling. Distal coronary anastomoses were performed on a still heart. After completion of the grafting on coronaries and rewarming, the aortic cross-clamp was removed and the proximal ends of the vein grafts were anastomosed to the aorta under a partially occluding clamp. In selected cases, a single-clamp technique was used for both distal and proximal anastomoses. Once the reperfusion was established through the grafts, the heart was gradually weaned from the heart lung machine and subsequent chest closure was carried out.
Data acquisition There were 2198 isolated CABGs performed at AKUH between January 2006 and December 2010 inclusive. An institutional approval letter was acquired for this study. A dedicated senior research officer collected information relating to patient characteristics and perioperative outcomes for all of these procedures prospectively on a data collection form (>250 variables) and transferred to a soft version into the computer. This was entered into Microsoft Access™ and analysed using IBM SPSS Statistics™ software, version 19. The relevant categories of the data collected are listed below within the results tables. The acquisition and analysis of information for the STS database are described in detail elsewhere [4]. It is based on 774 881 isolated adult CABGs performed between 1 January 2002 and 31 December 2006 at 819 centres in the USA. The bivariate relationships between
Results The pre-operative (Table 1), perioperative (Table 2) and post-operative (Table 3) data sets are summarized below. Between January 2006 and December 2010 inclusive, 2198 isolated CABG procedures were performed in AKUH. They comprised 1537 (69.9%) elective cases, with the rest being either urgent, where an operation during the same hospitalization would minimize the risk of further clinical deterioration, or emergent, where patients have a high degree of cardiac compromise and need surgery without delay, as per the definitions of the STS. Demographically, a higher proportion of males and diabetics underwent operations at AKUH compared with the STS cohort. The rates of smoking, obesity, dyslipidaemia and hypertension, the other main cardiovascular risk factors, were higher in the American
Table 1 Demographics and pre-operative risk factors in patients undergoing isolated CABG from January 2006 to December 2010 (n = 2198)
Age in years
Article
Towards excellence in cardiac surgery: experience from a developing country Downloaded from http://intqhc.oxfordjournals.org/ at UNIVERSITY OF PITTSBURGH on August 2, 2015
AAMIR SAIFUDDIN, SYED SHAHABUDDIN, SHAZIA PERVEEN, SHUMAILA FURNAZ, and HASANAT SHARIF Aga Khan University Hospital, Karachi, Pakistan Address reprint requests to: Syed Shahabuddin, Section of Cardiothoracic Surgery, Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan. Tel: +92-21-3486-4708; Fax: +92-21-34934294; E-mail: [email protected] Accepted 13 May 2015
Abstract Objective: The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark. Design: Cross-sectional ( prospectively collected data analysed and compared retrospectively). Setting: Aga Khan University Hospital, Karachi, Pakistan. Participants, interventions and main outcome measures: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons’ National Cardiac Database (STS-NCD). Results: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%). Conclusions: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world. Key words: quality improvement, patient outcomes, cardiac surgery, database
Introduction Coronary artery bypass grafting (CABG) is a widely studied and performed procedure with comparable results internationally. However, performance measurement and continued endeavour to improve is required in such major procedures like CABG to maintain the standard and quality. Guidelines applied in practice as a quality improvement intervention program may improve the adherence to key quality indicators and lead to improved care; however, for sustainability of such quality improvement continuous audit, feedback and concentrating on specific proven care components will be required. [1] On a national
or international level, large databases that pool and analyse prospectively acquired information from a wide range of hospitals can offer accurate data about proven care component and current standards [2] and provide specific outcome goals to which developing program can aspire with clinical benchmarks may constantly be redefined which can lead to improved outcomes [3]. At a smaller level, departmental audits allow objective assessment of hospital-, and even surgeon-, specific performance, which can be used to drive regional progress and enhance patient care. These findings can be contrasted with large databases and used to compare local practice with accepted standards of care. The most comprehensive such database for isolated
© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved
255
Saifuddin et al.
256 CABG is the National Adult Cardiac Surgery Database (NCD) using statistics from the USA [4]. Intricate analysis of this vast amount of information means that accurate representations of surgical mortality and perioperative complications in the USA are available [5]. We aimed to compare the outcomes of isolated CABGs from our database with those from the STS-NCD, to scrutinize our practice and to ascertain whether or not Western levels of achievement are possible in the developing world.
Methods
Operative procedure All of the surgeons used a standard operating strategy involving aorto-atrial (right) cardiopulmonary bypass (CPB) using heart lung machine. After induction of anaesthesia, a median sternotomy approach was used. The conduits were harvested and CPB was established using right atrial and aortic cannulae, following systemic heparinization (300 µ/kg). Myocardial protection was achieved with moderate hypothermia (28–32°C) and blood cardioplegia, given anterogradely via the aortic root. This was enhanced with topical cooling. Distal coronary anastomoses were performed on a still heart. After completion of the grafting on coronaries and rewarming, the aortic cross-clamp was removed and the proximal ends of the vein grafts were anastomosed to the aorta under a partially occluding clamp. In selected cases, a single-clamp technique was used for both distal and proximal anastomoses. Once the reperfusion was established through the grafts, the heart was gradually weaned from the heart lung machine and subsequent chest closure was carried out.
Data acquisition There were 2198 isolated CABGs performed at AKUH between January 2006 and December 2010 inclusive. An institutional approval letter was acquired for this study. A dedicated senior research officer collected information relating to patient characteristics and perioperative outcomes for all of these procedures prospectively on a data collection form (>250 variables) and transferred to a soft version into the computer. This was entered into Microsoft Access™ and analysed using IBM SPSS Statistics™ software, version 19. The relevant categories of the data collected are listed below within the results tables. The acquisition and analysis of information for the STS database are described in detail elsewhere [4]. It is based on 774 881 isolated adult CABGs performed between 1 January 2002 and 31 December 2006 at 819 centres in the USA. The bivariate relationships between
Results The pre-operative (Table 1), perioperative (Table 2) and post-operative (Table 3) data sets are summarized below. Between January 2006 and December 2010 inclusive, 2198 isolated CABG procedures were performed in AKUH. They comprised 1537 (69.9%) elective cases, with the rest being either urgent, where an operation during the same hospitalization would minimize the risk of further clinical deterioration, or emergent, where patients have a high degree of cardiac compromise and need surgery without delay, as per the definitions of the STS. Demographically, a higher proportion of males and diabetics underwent operations at AKUH compared with the STS cohort. The rates of smoking, obesity, dyslipidaemia and hypertension, the other main cardiovascular risk factors, were higher in the American
Table 1 Demographics and pre-operative risk factors in patients undergoing isolated CABG from January 2006 to December 2010 (n = 2198)
Age in years
