End of Year Results Presented by G J Grötte and Suzanne Chaisty
Heart Surgery 2005 – 2006 End of Year Results
Consultant Surgeons
Introduction
Last year was disappointing as far as volume was concerned. You will see later that many operating slots were lost due to blocked CSITU beds. Our patients are sicker, have more co- morbidities and stay longer in hospital, especially in CSITU.
CSITU - Cardiac Surgery Intensive Care Unit
Introduction Continued
Presently we have 8 CSITU beds. In Dec 2006, we will have an additional 5 beds. Furthermore these beds will be complemented by a 3rd Cardiac Theatre. This is a very important development, considering the 18 week wait (from referral to treatment) to be implemented in 2008.
Heart Surgery 2005-2006
Total Number of Cases per Consultant per year
Comment: KEM, BP & RIRH have 4 operating sessions/week. The rest 3
Comment: Perhaps a reduction in Non Elective work due to more Non Elective PCI (Percutaneous Coronary Intervention)
Operation Priority All Cases
Operation Priority 1st Time CABG
As you will see later non-elective CABG carries a much higher mortality than elective CABG. We should therefore try to aim for roughly equal share of non elective surgery
Sex Distribution
Validation of the EuroSCORE
In-house Monthly validation exercises are carried out by all 6 surgeons.
The casenotes are checked against the information entered on our database
EuroSCORE (European System for Cardiac Operative Risk Evaluation)
EuroSCORE is a simple, objective and up-to-date system for assessing the risk of heart surgery, based on one of the largest, most complete and accurate databases in European cardiac surgical history. The logistic EuroSCORE is a reasonable overall predictor for contemporary cardiac surgery, but over-estimates observed mortality. There is variation in its accuracy at predicting risk in different surgical subgroups. The logistic EuroSCORE should be recalibrated before it is used to gain reassurance about outcomes, and caution should be exercised when using it to compare hospitals or surgeons with different operative casemix.
EuroSCORE is a simple, objective and up-to-date system for assessing the risk of heart surgery, based on one of the largest, most complete and accurate databases in European cardiac surgical history.
The logistic EuroSCORE is a reasonable overall predictor for contemporary cardiac surgery, but over-estimates observed mortality. There is variation in its accuracy at predicting risk in different surgical subgroups. The logistic EuroSCORE should be recalibrated before it is used to gain reassurance about outcomes, and caution should be exercised when using it to compare hospitals or surgeons with different operative casemix.
Bridgewater B, Grötte G, Bhatti F, Grayson A, Fabri B, Au J, Jones M 2006, http://heart.bmjjournals.com/cgi/content/abstract/hrt.2005.083204
Risk Stratification Average Logistic EuroSCORE 1st CABG
Risk Stratification Average Logistic EuroSCORE All Cases
Comment: See previous slide
Pure CABG vs Total number of Procedures
Comment: There has been a descrease in Pure CABG, hopefully this will level out. Interestingly during the first 5 months of this financial year the figure is 58% (Good news for the Surgeons) ** CABG - Coronary Artery Bypass Graft.
Comment: There has been a descrease in Pure CABG, hopefully this will level out. Interestingly during the first 5 months of this financial year the figure is 58% (Good news for the Surgeons)
** CABG - Coronary Artery Bypass Graft.
Pure Coronary Artery Bypass Grafts 438 (540) pts Total No Grafts 1462 (1817) = Grafts per patient 3.34 (3.36) () = Previous Year
Opcab
Conversions Comment: Conversion rate <1%
Other than Pure CABG
Comment: Steady increase in Pure Valve patients
CABG & Other
Number of Valves used Valve insertion rate 0.33% (0.33%)
Comment: Steady increase in Valve repair
Pure Valve Single Valve Surgery 144 (137)
Multiple Valve Surgery 17 (17)
Valve & Other excluding CABG 49 (21)
Valve & CABG +/- other 130 16% (15%)
CABG & VALVE & LVA
Miscellaneous operations
Pure Aortic Surgery
Operations Performed by SpR with Consultant Assistance (no of months at MRI)
Our aim is for year 5-6 SpR's to perform over 80 cardiac operations per year. It should be noted that in another well known UK Cardiac unit during 04-05 only 15% of operations were done by Trainees. The SpR mortality rate of 1% is very acceptable. This dispels the myth that Consultants should do the operations themselves, rather than SpR’s, in order to “protect their figures”
Percentage of All Cases done by Trainees 37% (35%)
Comment: Virtually all Operations with Consultant Assistance
Percentage of 1st time CABG done by Trainees-2005-06 Average 52% (50%)
Comment: It is said that a Trainer is one who delegates >= 30% Virtually all Operations preformed with Consultant assistance
Lost Theatre slots 170 (40)
Cardiac Surgery Unit Stay
Out in 24 hours
Complications
Comment: Mediastinitis rate quadrupled but still in line with average National figure. We carried out an Audit last calendar year. Predisposing factors for Mediastinitis, Include:- Older Patients, Poor Ejection Fraction, High Euroscore, Renal Impairment/Dialysis, IABP, Chest Reop, Tracheostomy, Length of time to Extubation
GI Complications
Comment: Mesenteric Infarction rate gratifyingly low, but a deadly complication
Complications Stroke
Aortic Balloon Pump (IABP)
Comment: A dramatic improvement in Mortality
Renal Failure
Reopen Bleeding/Tamponade All Cases 4.7% (5.5%)
Elderly Patients Aged 70 or over ctd.
Mortality Elderly Group
Mortality Death within Base Hospital on that Admission for most common operations (Numbers too small for other procedures)
OVERALL
Elective operations
Non elective operations
First time CABG
Elective 1st time CABG
Non Elective 1st time CABG
Redo CABG
Cusum Curves
Essentially they show crude versus risk adjusted (predicted) Mortalities, using a complex formula.
Y axis = Cumulative Deaths. X axis = Cumulative No of operations. The Yellow line represents cumulative predicted mortality The Light Blue line represents cumulative observed mortality The Pink and Dark Blue lines represent Upper and Lower 95% confidence limits of observed mortality. A Unit or a Surgeon is under performing if the yellow line drops below the dark blue line. Neither the Unit as a whole nor individual Surgeons are under performing.
Therefore on the following slide (see arrows) the first Cusum shows that 43 patients were predicted not to survive. As there were only 28 deaths we performed better than predicted. Remember! Surgeons can have both good, bad and indifferent years, and any Surgeon or Unit’s performance should be assessed over a period of no less than three years
Rates of survival following Heart Surgery in Great Britain This link will take you to a the Healthcare Commission Website which provides information about rates of survival from different Centres in Great Britain 3 years ending March 2005. http://heartsurgery.healthcarecommission.org.uk/Unit.aspx?ID=RW3MR&OT=2