Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart diseaseCentral MessagePerspective
Bill Walsh, MB BCh, BAO, FCAI, FJFICMI,
Brigitte Mueller, PhD,
S. Lucy Roche, MB ChB, MRCPCH, MD,
Rafael Alonso-Gonzalez, MD,
Emily Somerset, MSc,
Minako Sano, MD,
Milca Villagran Schmidt, MD,
Edward Hickey, MD, FRCS(C),
David Barron, MBBS, MD, FRCP,
Jane Heggie, MD, FRCP(C)
Affiliations
Bill Walsh, MB BCh, BAO, FCAI, FJFICMI
Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Address for reprints: Bill Walsh, MB BCh, BAO, FCAI, FJFICMI, Department of Anaesthesia and Pain Medicine, Children's Health Ireland at Temple St, Temple St, Dublin 1, D01 XD99, Ireland.
Brigitte Mueller, PhD
Ted Rogers Computational Program, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
S. Lucy Roche, MB ChB, MRCPCH, MD
Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
Rafael Alonso-Gonzalez, MD
Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
Emily Somerset, MSc
Ted Rogers Computational Program, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
Minako Sano, MD
Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
Milca Villagran Schmidt, MD
Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
Edward Hickey, MD, FRCS(C)
Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
David Barron, MBBS, MD, FRCP
Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
Jane Heggie, MD, FRCP(C)
Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
Objectives: A quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. Methods: We performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. Results: In-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. Conclusions: Both in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.
