performance improvement in congenital heart surgery

8/14/2019 performance improvement in congenital heart surgery

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lactate(mmol/L) Performance Improvement in a

Congenital Heart Surgical Program:Measuring and Improving Outcomes

after Congenital Heart Surgery

Anthony F. Rossi, MD

Director, Cardiac Intensive Care ProgramMiami Childrens Hospital, Miami, FL USA
http://gifarchiv.com/index.php?news1=send.php&image=rootx/Jahreszeiten/Sommer/palmen.gif&lang=enhttp://gifarchiv.com/index.php?news1=send.php&image=rootx/Jahreszeiten/Sommer/palmen.gif&lang=enhttp://gifarchiv.com/index.php?news1=send.php&image=rootx/Jahreszeiten/Sommer/palmen.gif&lang=en


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FLA

One Program

Two Campuses

A Single Vision


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%mortality

Surgical Center

Congenital Heart Surgical Outcomes: STS DataCongenital Heart Surgical Outcomes: STS Data

Harvest of Outcomes for Congenital Heart SurgeryHarvest of Outcomes for Congenital Heart Surgery

in Large Volume Centers 2001-2004in Large Volume Centers 2001-2004

The performance of individual cardiac surgical programs is blinded to all reviewers. As of today,accurate and timely outcomes data for individual congenital heart surgery programs isunavailable to the consumer, except in states such as New York or California.

3.9% is theaveragemortality forpatientsundergoing

congenital heartsurgeryaccording to theSTS. Over ofthe largevolumeprograms in the

STS exceed thismortality rate.


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Improving Outcomes after CHSImproving Outcomes after CHS

Be blessed with an outstanding CVBe blessed with an outstanding CV

surgeonsurgeon

Hire a second!Hire a second!

Redmond Burke and Robert Hannan, congenital heart surgeons

at Miami Childrens Hospital. You can not have excellence in acongenital heart surgical program without outstanding surgery.


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WHY NOT ZERO PERCENTWHY NOT ZERO PERCENT

MORTALITY?MORTALITY?

Redmond Burke, 2000Redmond Burke, 2000

Mortality is not, and will never be, an acceptableMortality is not, and will never be, an acceptable

outcome for any patient after CHS, at any time.outcome for any patient after CHS, at any time.

This philosophy must be the cornerstone of allThis philosophy must be the cornerstone of allcongenital heart surgery programs.congenital heart surgery programs.

Unfortunately, mortality as an outcome is far tooUnfortunately, mortality as an outcome is far too

often accepted as a necessary evil in someoften accepted as a necessary evil in some

programs.programs.


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Improving Performance in a CongenitalImproving Performance in a Congenital

Heart Surgery ProgramHeart Surgery Program

Performance Assessment/PerformancePerformance Assessment/Performance

Improvement RelationshipImprovement Relationship

Point of Care Testing-Goal DirectedPoint of Care Testing-Goal Directed

Medical TherapyMedical Therapy Electronic Medical Record andElectronic Medical Record and

Information TechnologyInformation Technology

Team ResonanceTeam Resonance


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You want to be an Olympic 1500 meterYou want to be an Olympic 1500 meter

Champ. You should:Champ. You should:

Run hard every day. Measure nothing. ShowRun hard every day. Measure nothing. Show

up for the race. Hope for the best.up for the race. Hope for the best.

Measure your 1500 m time once a year andMeasure your 1500 m time once a year and

race.race. Measure your 1500 m time repeatedly over theMeasure your 1500 m time repeatedly over the

year.year.

Measure your 1500 m time, your split times,Measure your 1500 m time, your split times,

your technique repeatedly. Make adjustmentsyour technique repeatedly. Make adjustmentsin technique accordingly and repeatedly.in technique accordingly and repeatedly.


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You want to have the best outcomesYou want to have the best outcomes

after CHS. You should:after CHS. You should:

Try hard every day. Measure nothing. SubmitTry hard every day. Measure nothing. Submit

your raw data to the STS. Hope for the best.your raw data to the STS. Hope for the best.

Measure your mortality data once a year andMeasure your mortality data once a year and

submit your data to the STS.submit your data to the STS. Measure your mortality data repeatedly overMeasure your mortality data repeatedly over

the year.the year.

Measure your mortality data, your LOS, yourMeasure your mortality data, your LOS, your

technique, and any objective outcome variabletechnique, and any objective outcome variablerepeatedly over the year and in real-time.repeatedly over the year and in real-time.

Make adjustments in technique accordingly andMake adjustments in technique accordingly and

repeatedly.repeatedly.


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Real-Time Performance AssessmentReal-Time Performance Assessment

Continued quality improvement requiresContinued quality improvement requires

continued outcome assessmentcontinued outcome assessment

You cant know where youre going untilYou cant know where youre going until

you know where youve come fromyou know where youve come from Outcome assessment must be timelyOutcome assessment must be timely

(real-time)(real-time)

Accurate and unbiasedAccurate and unbiased


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Measuring Performance in a CardiacMeasuring Performance in a Cardiac

Surgical ProgramSurgical Program

Performance Improvement can onlyPerformance Improvement can only

come as the result of the accurate,come as the result of the accurate,

objective and timely measurement ofobjective and timely measurement of

data.data. Performance Assessment can be of anPerformance Assessment can be of an

individualindividual procedure orprocedure or programmaticprogrammatic

performance assessment.performance assessment.

Performance Outcomes must bePerformance Outcomes must be

transparenttransparent and easily accessible toand easily accessible to allallteam members and the public.team members and the public.


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May 7, 2004 -- ALBANY - A groundbreaking state study of pediatricheart surgery in New York shows University Hospital of Brooklyn had the

worst mortality rate in the state - in a program that has since been halted.

The state Health Department's report covering the years 1997-1999

summarizes risk factors and outcomes for pediatric patients undergoing

surgery to correct congenital heart defects.According to the report, 11 out of 92 children who underwent congenital

heart surgery at University Hospital of Brooklyn during the study period

died.

The hospital's mortality rate when adjusted for risk was 17.08 percent, the

highest in the state and significantly higher than the 5.35 percent

statewide rate.

This report was released in 2004. It reports the outcomes of patientsThis report was released in 2004. It reports the outcomes of patients

operated on years earlier. Dont we owe it to our patients to make theseoperated on years earlier. Dont we owe it to our patients to make these

decisions and review that data in a more timely fashion?decisions and review that data in a more timely fashion?
http://www.nypost.com/


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Mortality as outcome measure is reported in real-timefrom web-based medical record. The data must betransparent to ALL!

Every American should have access to a fullEvery American should have access to a fullrange of information about the quality ofrange of information about the quality of

their health care options. HHS Secretarytheir health care options. HHS Secretary

James Leavitt 2006James Leavitt 2006


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Miami ChildrensHospital has taken aLeading role inoutcomes reporting.

Data from our webbased medical recordis reported in real-timewhen the outcomesreporting page isopened.

Access to our real-time

outcomes reporting pageis available with a singlemouse click.


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Risk adjusted outcomes may be reported in real-timefrom medical record, for programmatic performanceassessment

Miami ChildrensMiami Childrens

Hospital real-timeHospital real-time

outcomes report.outcomes report.

FromFrom

pediatricheartsurgery.compediatricheartsurgery.com

liMCH CUSUM M li

1995 2004


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MCH CUSUM Mortality 1995-2004MCH CUSUM Mortality 1995-2004::The CUSUM mortality graph allows youThe CUSUM mortality graph allows youto track the performance of your congenital heart program. Aberrations into track the performance of your congenital heart program. Aberrations in

performance are readily apparent in this graphic representation, much moreperformance are readily apparent in this graphic representation, much more

readily than might be apparent to the casual observer. Our database calculates areadily than might be apparent to the casual observer. Our database calculates a

CUSUM graph of our performance in real-time.CUSUM graph of our performance in real-time.

CUSUM MORTALITY 1995-2004

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0 500 1000 1500 2000 2500 3000

case number

mortalitynumber

4% Mortality

2% Mortality1/1/01

The value of this technique for evaluating congenital heart outcomes was first described by professor Marc DeThe value of this technique for evaluating congenital heart outcomes was first described by professor Marc De

Leval in 1994.De Leval MR, et al. Analysis of a cluster of surgical failures. Application to a series of neonatalLeval in 1994.De Leval MR, et al. Analysis of a cluster of surgical failures. Application to a series of neonatal

arterial switch operations.arterial switch operations.J Thorac Cardiovasc SurgJ Thorac Cardiovasc Surg 1994;107: 914-23.1994;107: 914-23.


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STS CHS 2006 data harvest: 3.9% mortality

Zone of Acceptable Performance

Zone of Enhanced Performance

4.9% mortality

2.9% mortality

MCH CUSUM 2/02-12/06

CUSUM data may be used to access performance of an individualor program over time. Deviation from accepted norms arereadily apparent.


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Effect of Various Changes in ProgrammaticEffect of Various Changes in Programmatic

Philosophy on CHS OutcomesPhilosophy on CHS Outcomes

CUSUM MCH CHS

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case number

mortalitynu

ERA 1

ERA 2

ERA 3

ERA 4

ERA 1: 6/95-12/2000

ERA 2: new ICU Leadership

ERA 3: point of care testing introduced

ERA 4: i-rounds EMR introduced

STS 2006 data harvest avg mortality NA (3.9%)

2% mortality line


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Tracking Outcomes in a VisiblyTracking Outcomes in a Visibly

Intuitive FashionIntuitive Fashion

Interval b/w Death after CHS

R2 = 0.1377

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1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103 109

Mortality Number

casesb/w

mortality

MCH CHS deaths: 1995-2007MCH CHS deaths: 1995-2007


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Improving OutcomesImproving Outcomes

Performance Assessment/performancePerformance Assessment/performance

Improvement relationshipImprovement relationship

Point of care testing-goal directedPoint of care testing-goal directed

therapytherapy EMR/ITEMR/IT


bombarded with clinical data often confusingbombarded with clinical data often confusing


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bombarded with clinical data, often confusingbombarded with clinical data, often confusing

an already complicated problem.an already complicated problem. This canThis can

often lead to the dreaded :often lead to the dreaded : Paralysis ofParalysis of

AnalysisAnalysis

Ultimately, two questions are paramount:Ultimately, two questions are paramount: Are we good?Are we good? Are we headed in the right direction?Are we headed in the right direction?


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Traditional MCH ICU Lab Services: What aTraditional MCH ICU Lab Services: What a

mess!mess!

Blood Drawn

From Pt.

Placed in TubeNurse

Tube Packaged

WardClerk

Transported to Lab

Transporter

Lab Performs Test

LabTech

DoctorReviews Lab Results

Lab EntersTest Result

LabClerk

Pt carePt carealtered as neededaltered as needed

-7 STEPS-7 STEPS-5 CAREGIVERS-5 CAREGIVERS


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i-Stat POC: Introduced to all MCH ICUs ini-Stat POC: Introduced to all MCH ICUs in

20012001

-Blood DrawnFrom Pt.

-Test Run at

-Bedside

-2 STEPS-2 STEPS-2 Caregivers-2 Caregivers

Nurse

ResultsTo

Doctor

Doctor

Pt carePt carealtered asaltered as

neededneeded


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Common Cardiac Surgical Procedures

Arterial switch operation

Repair of tetralogy of Fallot

VSD closure

ASD closure

AVC repair

Rastelli operation

Norwood operation

Bi-Glenn

Fontan

Repair IAA

BTS

Central shunt

Ross

MV replacement

AV replacement

Aortic Valvotomy

Konno Ross-Konno

Repair TAPVC

Repair coarctation

Repair DORV

Senning

Mustard

Double switch


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Maintain optimal tissue oxygen delivery

Single Goal of PO CareSingle Goal of PO Care


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The constant tug of warThe constant tug of war

between DO2 and VO2between DO2 and VO2


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DO2/VO2: Relationship of oxygen delivery to oxygenDO2/VO2: Relationship of oxygen delivery to oxygen

onsumptiononsumption

O2 O2 O2

O2 O2

O2

We normally deliver 5 times as much oxygen to our tissues than we useWe normally deliver 5 times as much oxygen to our tissues than we use


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Relation of DO2 to VO2

DO2

VO2

critical point of DO2critical point of DO2

(VO2 , lactate )(VO2 , lactate )

5/12/1**

**Decreasing CV Reserve


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DO2=CI x Hb x SaO2DO2=CI x Hb x SaO2

CI usually impossible to measureCI usually impossible to measure

because of intracardiac shuntingbecause of intracardiac shunting small patient size makes CIsmall patient size makes CI

measurements impracticalmeasurements impracticalUse indirect measures of DO2

Can You Measure DO2 Following CHS?


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Lactate is Predictive of OutcomeLactate is Predictive of Outcome

after CHSafter CHS

Children after cardiac surgery Initial lactate > 4.2 mmol/l - mortality 100%

(Siegel et al.1996) Initial lactate > 4.5 mmol/l - mortality 79%

(Hatherhill et al.1997)

Infants after cardiac surgery

Initial lactate > 7mmol/l - mortality 55% Maximum lactate > 9mmol/l - mortality 86%

(Chefitz et al. 1997)

In 2001 we asked ourselves


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In 2001, we asked ourselvesthe following questions:

If lactate is useful in predictingIf lactate is useful in predicting

outcomes in pts after CHS couldoutcomes in pts after CHS could

lactate be used as a target goal forlactate be used as a target goal for

medical management in this ptmedical management in this pt

population?population?

Can GDT be applied to pts afterCan GDT be applied to pts after

CHS?CHS?


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January 2001: The PremiseJanuary 2001: The Premise

Establish near patient testing of routineEstablish near patient testing of routinecritical care lab values with rapid turn-critical care lab values with rapid turn-around-timearound-time Clinician can react quickly to changing physiologicClinician can react quickly to changing physiologic

conditionsconditions Establish blood lactate measurement asEstablish blood lactate measurement as

objective indicator of oxygen debtobjective indicator of oxygen debt Establish clinical guidelines which areEstablish clinical guidelines which are

directed at normalizing blood lactate levelsdirected at normalizing blood lactate levels

(thereby minimizing oxygen debt)(thereby minimizing oxygen debt) The combination of the above would increaseThe combination of the above would increase

survival after congenital heart surgerysurvival after congenital heart surgery

L t t M tL t t M t


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Initial Lactate > 2.2Initial Lactate > 2.2

No ChangeNo Change Increase in LactateIncrease in Lactate Decrease in LactateDecrease in Lactate

< 5< 5 > 5> 5

Repeat in 4 hrsRepeat in 4 hrs Escalate Medical RxEscalate Medical Rx

Escalate Medical RxEscalate Medical Rx

Repeat in 4 hrsRepeat in 4 hrs

Repeat in 4 hrsRepeat in 4 hrs

Repeat Q 4 HrsRepeat Q 4 Hrs

LactateLactate >> 1010

CPSCPSLactate < 5Lactate < 5 Lactate 5-10Lactate 5-10

Escalate Medical RxEscalate Medical RxRepeat in 4 hrsRepeat in 4 hrs

Repeat q4hrs x 4

CPS = Cardiopulmonary SupportCPS = Cardiopulmonary Support

Consider

Lactate ManagementLactate Management

ProtocolProtocol


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Lactate ManagementLactate Management

Lactate Normalor

DiminishingNo Changes


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PatientsPatients

ERA AgeRangeMedian

WeightRangeMedian

TotalPts

< 1mth

> 1 mth

6/95-6/01 0-72 yrs

311 d

0.5-127kg7.9 kg

1656 321 1335

7/01-10/03

0-72 yrs166 d

P


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Effect of GDT and POC on 30d MortalityEffect of GDT and POC on 30d Mortality

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all pts >1 mth < 1 mth

% Mortality Pre/Post i-Stat

6/95-6/01

7/01-703

all pts > 1 mth < 1 mth

% mortality 6/95-6/01 4.7 2.6 13

(% reduction) 7/01-10/03 2.1 1.5 4.2(55%)(55%) (68%)(68%)(42%)(42%)

P


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POCT/GDTPOCT/GDT

EMR/ITEMR/ITTeam ResonanceTeam Resonance


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AdvancesAdvancesin IT in the CICUin IT in the CICU

1997 Emtek System1997 Cardioaccess Database

2000 Palm Pilot 2001 CICU Component

Cardioaccess

2002 I-rounds

2001 POC I-stat

2003 Tablet PC

1995 CHS Excel Database

Real-time database


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For decades, tracking the performance of an individual patient through their hospital courseFor decades, tracking the performance of an individual patient through their hospital course

was done on a series of hand written index cards. All of the patients most valuablewas done on a series of hand written index cards. All of the patients most valuable

information, potentially life saving information was kept on these. Is this how we shouldinformation, potentially life saving information was kept on these. Is this how we should

track human performance today, with stakes as high as life and death? We wouldnt do it fortrack human performance today, with stakes as high as life and death? We wouldnt do it for

our bank accounts, we shouldnt do it with patients lives. Sadly, many hospitals continue toour bank accounts, we shouldnt do it with patients lives. Sadly, many hospitals continue to

track data like this today.track data like this today.


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Tracking the performance of an individual patient at MCH today: A visual representation of a patients

postoperative progression. I-stat (Abbott) allows the blood lactate level to be obtained and measured in the

operating room and at the bedside. The data is downloaded into our LIS and displayed graphically and in real-

time (i-Rounds, Teges).


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Tracking the performance of an individual patient. I-stat (Abbott) allows

the blood lactate level to be obtained and measured at the bedside. The

data is downloaded into our LIS and displayed graphically and in real-

time (i-rounds, Teges).


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Tracking the performance of an individual patient. A graphic representation

of a patients postoperative progression. Data is available in real-time,

anywhere in the world internet access is available.


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This is how data is often shared between clinicians in a busy hospital. Can the risk for a serioumedical error be more apparent?

Cli k th h t iti l i f ti Thi i h d t iCli k th h t iti l i f ti Thi i h d t i


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Click through to critical information: This is how data isClick through to critical information: This is how data is

shared at Miami Childrens Hospital utilizing the i-Roundsshared at Miami Childrens Hospital utilizing the i-Rounds

web-based medical record.web-based medical record.

Data captured automatically or enteredData captured automatically or entered

at the point of care.at the point of care.


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The Visual Representation of DataThe Visual Representation of Data

Our methods for sharing and displaying dataOur methods for sharing and displaying data

have been based on the inspired work ofhave been based on the inspired work of

Edward TufteEdward Tufte

Certain methods for displaying and analyzingCertain methods for displaying and analyzing

data are better than othersdata are better than others

Superior methods are more likely to produceSuperior methods are more likely to produce

truthful, credible and precise findingstruthful, credible and precise findings

Inspired design can actually cause theInspired design can actually cause themeaningful right numbers to flash out frommeaningful right numbers to flash out from

statistical murkstatistical murk Edward TufteEdward Tufte

Visual Representation of Performance: First 500 vsVisual Representation of Performance: First 500 vs


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Visual Representation of Performance: First 500 vs.Visual Representation of Performance: First 500 vs.

Last 500 Cases: It is readily apparent that ourLast 500 Cases: It is readily apparent that our

performance has improved dramaticallyperformance has improved dramatically


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Sparklines in CHSSparklines in CHS

Data Intense, Simple, Word-SizedData Intense, Simple, Word-Sized

GraphicsGraphics

High resolution graphics embedded in aHigh resolution graphics embedded in a

context of words, numbers and imagescontext of words, numbers and images Sparklines give us some chance to learnSparklines give us some chance to learn

from the flood of data generated byfrom the flood of data generated by

modern scientific monitoring andmodern scientific monitoring andsurveillance technologiessurveillance technologiesEdward Tufte, 2004Edward Tufte, 2004


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Sparkline data analysis is used to graphically display data over time
http://gifarchiv.com/index.php?news1=send.php&image=rootx/Jahreszeiten/Sommer/palmen.gif&lang=en


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p y g p y p y

Sparklines: Data-intense, small, high resolution graphics (Tufte 2006)

Sparkline of vitalSparkline of vital

signs data,signs data,

available toavailable to

clinician in real-clinician in real-time viatime via

an i-phonean i-phone


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Current

1996

SparklineSparkline

representing currentrepresenting current

and pastand pastperformance of aperformance of a

congenital heartcongenital heart

surgical program.surgical program.


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POCT/GDTPOCT/GDT

EMREMR Team ResonanceTeam Resonance


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There is no I in TEAMThere is no I in TEAM

We share equally in the success and failure ofWe share equally in the success and failure ofevery patient as an individualevery patient as an individual

and the Program as a wholeand the Program as a whole


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pharmacistpharmacist

PAPA

CICUCICU

ANPANP

CVSCVS

ANPANP

nursenurse

fellowfellow



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