ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 52 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Methods
   Results
   Discussion
   Conclusions
   Acknowledgements
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed1537    
    Printed46    
    Emailed2    
    PDF Downloaded199    
    Comments [Add]    
    Cited by others 2    

Recommend this journal

 


 
Table of Contents
JANAK MEHTA AWARD  
Year : 2015  |  Volume : 18  |  Issue : 1  |  Page : 52-57
Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: A single center experience in a developing economy


1 Department of Anesthesia, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
2 Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
3 Department of Pediatric Cardiac Surgery, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India

Click here for correspondence address and email

Date of Web Publication1-Jan-2015
 

   Abstract 

Background: The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world. Objective: We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution. Methods: The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection. Results: The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance. Conclusions: The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.

Keywords: Developing country; outcomes; quality improvement

How to cite this article:
Balachandran R, Kappanayil M, Sen AC, Sudhakar A, Nair SG, Sunil G S, Raj R B, Kumar RK. Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: A single center experience in a developing economy. Ann Card Anaesth 2015;18:52-7

How to cite this URL:
Balachandran R, Kappanayil M, Sen AC, Sudhakar A, Nair SG, Sunil G S, Raj R B, Kumar RK. Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: A single center experience in a developing economy. Ann Card Anaesth [serial online] 2015 [cited 2019 Nov 14];18:52-7. Available from: http://www.annals.in/text.asp?2015/18/1/52/148322



   Introduction Top


Congenital heart surgery is rapidly evolving in developing nations with increasing surgical volumes and better outcomes. Developing economies face the issues of a huge burden of congenital heart disease, limited infrastructure, lack of dedicated pediatric cardiac programs, limited numbers of trained personnel, suboptimal funding and lack of health insurance policies. [1] In addition to these several preoperative and postoperative factors contribute to morbidity and mortality in children with congenital heart disease. There is a paucity of data on outcomes from the developing world due to lack of robust databases. In an attempt to address the challenges that emerging congenital heart programs in developing nations are facing, a group of physicians attending the Global Forum on Humanitarian Medicine in cardiology and cardiac surgery in Geneva initiated the concept of a quality improvement project for the developing nations. [2] The collaborative began its pilot year in 2008 with 5 participating centers. They formed a comprehensive congenital heart surgery database with the goal of bench-marking data from various centers in developing countries that would facilitate introspection and scope for improvement in outcomes at each center.

The pediatric heart program at our institute has been addressing high surgical volumes as well as increasing complexity of congenital heart disease over the past decade. The members of the pediatric heart program felt the need of an efficient system for collection and analysis of surgical outcomes that could be benchmarked with international standards. An important additional goal was to identify areas requiring potential improvement for providing quality care to children with congenital heart disease. We joined the International Quality Improvement Collaborative (IQIC) in January 2010 agreeing to the collaborative protocol. In this paper, we aim to assess the impact of IQIC on the postoperative outcomes after congenital heart operations at our institute.


   Methods Top


General information about International Quality Improvement Collaborative

The IQIC functions with an objective to create tailored quality improvement strategies to reduce mortality and major complications for developing world programs. They also aim to employ a telemedicine platform to facilitate distance-learning, dialogue and to disseminate knowledge and skills. The collaborative strives to achieve these goals by targeting the key drivers of mortality by improving team based practice through nurse empowerment, reducing surgical site infections (SSIs) and bacterial sepsis and promoting safe perioperative practices.

The quality improvement strategies for each of the key drivers that impacted mortality were disseminated among participating centers through a series of educational sessions that advanced from beginning, intermediate and advance-level of learning and acquisition of skills [Figure 1]. The educational sessions were telecast as live webinars in fixed timelines every year. The recorded webinars and learning modules were also made available to all centers for in-house training of nursing personnel and pediatric critical care team.
Figure 1: Key driver diagram

Click here to view


Data collection

A team-based approach was used to collect data. Physicians in the operating room and Intensive Care Unit (ICU) used preprinted data sets to capture patient data at respective locations. Senior member of the key contact team verified and completed the data before final electronic entry by nonmedical personnel into IQIC central database in accordance with the collaborative data protocol. Data were source verified during a series of data auditing trips from 2010 to 2012.

Institutional database

Demographic data and clinical data of patients undergoing congenital heart surgery were prospectively entered into the database including information on the preoperative status, clinical diagnosis, surgical risk category (Risk Adjustment for Congenital Heart Surgery (RACHS-13)) [3] , surgical procedure, and surgical outcomes namely, in-hospital mortality, ICU stay, duration of mechanical ventilation, bacterial sepsis, SSI and 30 day survival. The data of 1,702 consecutive patients ≤18 years of age undergoing congenital heart surgery during the period January 2010 to December 2012 were included. The preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The postoperative outcomes included in- hospital mortality, duration of ventilation, duration of intensive care unit stay, bacterial sepsis and SSI. Bacterial sepsis was defined as any two clinical signs of sepsis (fever or hypothermia, tachycardia, hypotension, tachypnea, leukocytosis or leucopenia) with a positive blood culture. SSI was defined as an infection that could be sub classified as superficial incisional SSI, deep incisional SSI or mediastinitis. Formal Centers for Disease Control and Prevention [4] definitions of all the three sub classifications were used, and positive cultures were not required if all other clinical indicators suggested significant infection. In-hospital mortality was defined as any death occurring during a patient's hospital stay prior to postoperative discharge. The entire cohort was divided into three groups according to the year of the surgical procedure (2010, 2011, 2012) for analysis of trends in outcomes over the period of 3-year after joining the collaborative.

Statistical methods

The data were expressed as mean ± standard deviation or median and range as appropriate. The data were analyzed using  SPSS statistics, version 17.0 (SPSS Inc. Chicago, IL, USA). For comparing the categorical variables between the cohorts of each year, Pearson Chi-square test was used. Continuous variables between the groups were tested using ANOVA. The mean values of variables namely duration of ventilation and ICU stay did not follow a normal distribution to permit comparison between groups. Hence, analysis of mean log values of ICU stay and duration of ventilation was done, and statistical significance was tested using ANOVA. A P < 0.05 was considered to be significant.


   Results Top


Of the 1,702 consecutive patients ≤18 years, 771 (45.3%) were females, and 931 (54.7%) were males. The median age was 8 months (0.03-216). The median weight at surgery was 6.1 kg (1-100). The distribution of surgical procedures as per RACHS-1 classification included category 1, 13.5% (n = 230), category 2 47.9% (n = 815), category 3, 29.9% (n = 509), category 4, 7.6% (n = 129), category 5 n = 2 (0.1%), category 6, 0.6% (n = 11). Six patients could not be assigned RACHS category. Analysis of postoperative outcome for the entire cohort showed in-hospital mortality 3.1%, median ICU stay 100 h (1-1960) and a median ventilation duration of 23 h (1-999). 11.9% had bacterial sepsis, and 6.4% had SSI. The year-wise comparison between cohorts operated in each year was performed to analyze the trends in outcomes over three years [Figure 2].
Figure 2: Outcome trends over three years: Mortality and infection data

Click here to view


When analyzing the homogeneity between the cohorts of 3 years, the number of patients, age and gender distribution was comparable between the groups [Table 1] and [Table 5]. The surgical case mix and complexity as per the RACHS-1 model were also comparable between the groups [Table 2].
Table 1: Gender distribution in the yearly cohorts


Click here to view
Table 2: Surgical case distribution by RACHS - 1 model


Click here to view


On analysis of outcomes over the 3 years it was found that the decline in mortality from 4.3% in 2010 to 2.9% in 2011 and to 2.2% in 2012 was not statistically significant (P = 0.125) [Table 3]. There was a significant decline in bacterial sepsis from 2010 through 2012 (15.1% in 2010, 11.9% in 2011 and 9.6% in 2012, P < 0.05) SSIs decreased from 11.1% in 2010, to 6.8% in 2011 and to 2.4% in 2012, P < 0.001 [Table 4]. To permit comparison of non normal data of ICU stay and ventilator duration, the mean log values were taken. The mean log ICU stay was 4.72 ± 0.74 in 2010, 4.790 ± 70 in 2011, 4.39 ± 0.79 in 2012 (P < 0.001) There was a statistically significant decrease in ICU stay in 2012 compared to the previous 2 years. The mean log values of ventilator duration did not differ significantly between the 3 years (3.38 ± 1.07, 3.4 0 ± 99, 3.3 ± 1.04, P = 0.235).
Table 3: Mortality data


Click here to view
Table 4: Bacterial sepsis and SSI


Click here to view
Table 5: Age, weight, ICU stay and ventilation hours


Click here to view


Standardized mortality ratio taking IQIC database as reference population decreased from 0.65 (confidence interval [CI]; 0.52-0.78) in 2010 to 0.35 (CI; 0.22-0.47) in 2012.


   Discussion Top


There is increasing awareness for the need for evaluation of data and qualitative assessment of program performance while treating congenital heart disease. Some of the various quality improvement measures suggested for pediatric cardiac care include establishment of multi-institutional databases, data verification and validation processes, and the development of complexity stratification and risk assessment for congenital heart disease. [5] The IQIC for Congenital Heart surgery in developing countries originated to facilitate a collaborative of health care teams from around the world creating a culture of patient safety and quality for children undergoing congenital heart surgery in developing countries. [4] As a part of the collaborative in addition to sharing our patient data, we participated in the distance-learning processes through the monthly webinars coordinated by Boston Children's Hospital through the IQIC platform. The learning modules were also used for in-house training of nurse and physician staff. We also successfully piloted and implemented a safe surgical checklist [6] for congenital heart surgery at our institute.

The most striking outcome improvement, which we identified, was a substantial reduction of bacterial sepsis and SSIs. Bacterial sepsis occurred in 11.9% of the entire cohort. But the analysis of yearly trends showed a significant reduction in bacterial sepsis from 15.1% in year 2010 to 11.9% in 2011 and to 9.6% in 2012. Similarly, SSI decreased significantly from 11.1% in 2010 to 2.4% in 2013. An analysis of the annual reports of 2010, which was the 1 st year after joining the collaborative, provided insight into the fact that our infection rates were above average for other contemporary sites in the collaborative. This prompted specific intervention measures to decrease bacterial sepsis namely enhancement of hand hygiene techniques, nurse education about preventing blood stream infection and SSIs, increasing compliance with the safe surgical checklist and the bundle checklist for prevention of catheter related blood stream infection. Though we could not exactly determine the specific intervention, which brought about the reduction in infection rates, a multimodal approach along with increased awareness of the care team toward this potential complication might have brought about the difference over the time period.

Though it could be argued that this outcome benefit may reflect just a general improvement of the unit, there is a strong possibility that IQIC could have directly influenced these outcomes, since the specific areas that showed improvement were given key emphasis through IQIC educational initiatives.

Mortality is one of the most frequently quoted measures of quality improvement. But the validity of mortality rate as a quality indicator is questionable when the event rates are too low, or surgical volumes are less. [7] We have found that our mortality rates declined from 2010 through 2012. This did not reach statistical significance probably due to the fact the our unit had already matured with lower mortality rates in par with acceptable standards by 2010 and further reduction would not have been possible unless there was a huge reduction in the number of deaths. Additionally, standardized mortality ratio taking IQIC database as a reference population showed a significant reduction in the mortality rates of our institution. A study done by Larrazabal et al. [8] demonstrates substantial improvement in outcomes after congenital heart surgery in Guatemala in which they showed the feasibility of measurement of risk-adjusted mortality in pediatric cardiac programs in the developing world.

The analysis of ICU stay showed a decline from 2011 to 2012. Though ICU stay is a known quality measure it may be influenced by many confounding factors like availability of beds in the step down unit, difference in discharge practices and team consensus. [9] Hence, the validity of this variable in our context is questionable. The ventilation hours also did not decrease significantly between the cohorts in the consecutive years. We did not implement any major change in our ventilation and extubation practices in the intensive care unit over the past 3 years, and this probably was the reason for the observed similar values over the 3 years.

Morbidity and complications like infections are also useful as quality measures and can be used as targets for improvement initiatives. [10] These events are more common than mortality and can be directly influenced by the standard of care. Health care associated infections are a major cause of morbidity and mortality in any population. In addition to this, infections can potentially escalate health care associated costs and consume resources, which can be detrimental in a limited resource environment. The fact that IQIC database captures the infectious complications and that the event rates are higher makes it a useful quality indicator in a developing world program. The fact that outcome analysis have been suggested as part of cost benefit analysis of pediatric cardiac intensive care programs carries particular relevance in developing economies where cost efficiency is vital for appropriate resource utilization. [11]

Large multicenter quality improvement initiative can go a long way toward implementing changes in individual centers. [12] The sharing of outcomes about quality improvement successes at one center can positively influence other centers to improve their standards as well. The availability of bench-marking data through the IQIC project facilitates comparison of our data between other centers and enhances program performance at a comprehensive level.

Limitations of the study

This paper is a prospective observational study aimed to track outcomes and trends. Though the infection emerged as a major morbidity, we have not specifically looked into the risk factors involved with increased bacterial sepsis. This is being planned and executed as a separate research project. Though we were able to demonstrate improved outcomes over the 3-year period after joining the collaborative, we have not compared the outcomes to an era where IQIC collaboration was nonexistent. This would have added more credibility to associating the improvement in outcomes with a quality improvement project. We have also not specifically looked at the standardized infection rates, and only the raw rates are computed.


   Conclusions Top


The enrolment into a multicenter congenital heart surgery database is likely to have facilitated improved outcomes in terms of reduction in bacterial sepsis and SSIs, reduction in length of ICU stay and a trend toward decreasing mortality in a pediatric heart program in a limited resource setting. In developing nations with inherent limitations of lack of proper data capturing systems for analysis and improvement, the utilization of internationally accepted congenital heart surgery databases is a worthwhile investment.


   Acknowledgements Top


We deeply acknowledge the contributions of the IQIC team in Boston, MA, USA and Children's HeartLink, MN, USA

 
   References Top

1.
Kumar RK, Shrivastava S. Paediatric heart care in India. Heart 2008;94:984-90.  Back to cited text no. 1
    
2.
Jenkins KJ, Castaneda AR, Cherian KM, Couser CA, Dale EK, Gavreau K, et al. Reducing mortality and infections after congenital heart surgery in the developing world. Pediatrics 2014;134:e1422-30.  Back to cited text no. 2
    
3.
Jenkins KJ. Risk adjustment for congenital heart surgery: The RACHS-1 method. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004;7:180-4.  Back to cited text no. 3
    
4.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. American Journal of Infection Control 1999:27;97-134.  Back to cited text no. 4
    
5.
Jacobs JP, O'Brien SM, Pasquali SK, Jacobs ML, Lacour-Gayet FG, Tchervenkov CI, et al. Variation in outcomes for benchmark operations: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2011;92:2184-91.  Back to cited text no. 5
    
6.
Croti UA, Jenkins KJ, Braile DM. Checklist in pediatric cardiac surgery in Brazil: An useful and necessary adaptation of the Quality Improvement Collaborative International Congenital Heart Surgery in Developing Countries. Rev Bras Cir Cardiovasc 2011;26:511-5.  Back to cited text no. 6
    
7.
Welke KF, Karamlou T, Ungerleider RM, Diggs BS. Mortality rate is not a valid indicator of quality differences between pediatric cardiac surgical programs. Ann Thorac Surg 2010;89:139-44.  Back to cited text no. 7
    
8.
Larrazabal LA, Jenkins KJ, Gauvreau K, Vida VL, Benavidez OJ, Gaitán GA, et al. Improvement in congenital heart surgery in a developing country: The Guatemalan experience. Circulation 2007;116:1882-7  Back to cited text no. 8
    
9.
McMillan TR, Hyzy RC. Bringing quality improvement into the intensive care unit. Crit Care Med 2007;35:S59-65.  Back to cited text no. 9
    
10.
Welke KF, Diggs BS, Karamlou T, Ungerleider RM. Measurement of quality in pediatric cardiac surgery: Understanding the threats to validity. ASAIO J 2008;54:447-50.  Back to cited text no. 10
    
11.
Chang AC. Pediatric cardiac intensive care: Current state of the art and beyond the millennium. Curr Opin Pediatr 2000;12:238-46.  Back to cited text no. 11
    
12.
Tchervenkov CI, Jacobs JP, Bernier PL, Stellin G, Kurosawa H, Mavroudis C, et al. The improvement of care for paediatric and congenital cardiac disease across the World: A challenge for the World Society for Pediatric and Congenital Heart Surgery. Cardiol Young 2008;18 Suppl 2:63-9.  Back to cited text no. 12
    

Top
Correspondence Address:
Amitabh Chanchal Sen
Department of Anesthesia, Amrita Institute of Medical Sciences and Research Centre, Kochi 682 041, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.148322

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

This article has been cited by
1 Mobile health technology transforms injury severity scoring in South Africa
Richard Trafford Spence,Eiman Zargaran,S. Morad Hameed,Pradeep Navsaria,Andrew Nicol
Journal of Surgical Research. 2016; 204(2): 384
[Pubmed] | [DOI]
2 On-table Extubation after Open Heart Surgery in Children: An Experience from a Tertiary Care Hospital in a Developing Country
Mehar Hoda,Anwarul Haque,Fareena Aijaz,Mohammad I. Akhtar,Amina Rehmat,Muneer Amanullah,Babar S. Hasan
Congenital Heart Disease. 2015; : n/a
[Pubmed] | [DOI]



 

Top