Matte Gregory S, Riley Daniel, LaPierre Robert, Howe Robert, Anderson Mark, Boyle Sharon, Durham Linda, Regan William, Pigula Frank
Children's Hospital Boston, Department of Cardiovascular Surgery, 300 Longwood Avenue, FA-144, Boston, MA 02115, USA.
J Extra Corpor Technol. 2010 Jun;42(2):158-62.
Several authors have described methods to track perfusion and cardiac surgical morbidity and mortality as well as perfusion accidents. There is currently not a standard definition of a perfusion accident nor is there a standard reporting threshold for events which do not directly cause known morbidity. We propose the term non-routine events (NREs) instead of accidents, and provide a working definition and reporting threshold for such. This paper describes the program which we developed to track perfusion NREs within the Cardiovascular Program at Children's Hospital, Boston. NREs are categorized by type (technique, equipment, or patient-related) and bypass period (pre-cardiopulmonary bypass, bypass, or post-cardiopulmonary). NRE outcomes are also classified by the level of discussion or change in perfusion practice after multidisciplinary review. We have documented during a 44 month interval that 42% (29/69) of reported NREs occur during the bypass period and are equipment related and thus, efforts to improve practice should focus there. We have also seen a generally decreasing incidence of NREs requiring either a change in perfusion practice or a new protocol during this time period. We believe that our regular multidisciplinary meetings to discuss NREs have increased awareness among the entire team about potential problems in the program and that intuitively, it has improved patient safety.
几位作者描述了追踪灌注情况、心脏手术发病率和死亡率以及灌注事故的方法。目前，对于灌注事故既没有标准定义，对于那些不会直接导致已知发病率的事件也没有标准报告阈值。我们提议用“非常规事件（NREs）”一词取代“事故”，并为此提供一个实用定义和报告阈值。本文描述了我们在波士顿儿童医院心血管项目中开发的用于追踪灌注非常规事件的程序。非常规事件按类型（技术、设备或与患者相关）和体外循环阶段（体外循环前、体外循环期间或体外循环后）进行分类。非常规事件的结果也根据多学科审查后灌注实践的讨论程度或变化进行分类。我们记录了在44个月的时间段内，报告的非常规事件中有42%（29/69）发生在体外循环期间且与设备相关，因此，改进实践的努力应集中在这方面。在此期间，我们还发现需要改变灌注实践或制定新方案的非常规事件的发生率总体呈下降趋势。我们认为，我们定期召开的多学科会议来讨论非常规事件，提高了整个团队对项目中潜在问题的认识，并且直观地讲，这提高了患者安全性。
