Yeh Mary J, Bjornlund Elsa, Gauvreau Kimberlee, Ali Fatima, Aslam Nadeem, Batlivala Sarosh P, Berman Darren, Bocks Martin L, Chenault Kristin, Doyle Thomas, Gudausky Todd, Hainstock Michael, Holzer Ralf, Ibla Juan, O'Byrne Michael L, Quinn Brian P, Shahanavaz Shabana, Sharma Ruchik, Trucco Sara M, Whiteside Wendy, Bergersen Lisa, Armstrong Aimee K
Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
Section of Pediatric Cardiology, Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan.
Pediatr Cardiol. 2025 Jan 14. doi: 10.1007/s00246-024-03738-9.
The C3PO collaborative, with a history of successful quality improvement (QI) initiatives, leveraged registry participants to develop a multi-center QI initiative to reduce adverse events (AEs) in congenital cardiac catheterization. A 32-person, interdisciplinary working group analyzed audited data for all congenital cardiac catheterization cases from 2014-2017. The primary outcome was the occurrence of any high-severity (level 3/4/5) AE. Cases were organized from shortest to longest duration, and level 3/4/5 and 4/5 AE rates were summarized for each procedure duration decile. Observations from the root cause analysis were used to inform the creation of a key driver diagram and determine change strategies and implementation tools. To facilitate pre-procedure communication and risk assessment, an online risk calculator was developed using 2014-2019 data. Between 2014-2017, 14,717 cases were entered from 10 sites. Level 3/4/5 AEs occurred in 732 (5.0%) cases, while 4/5 AEs occurred in 224 (1.5%) cases. The key driver diagram defined three drivers: (1) Pre-Procedure Risk Assessment, (2) Possibly Preventable Events, and (3) Procedure Length Optimization. Actionable change strategies organized around five communication timepoints were developed in interdisciplinary discussions. Pre-case risk calculator outputs were available as a case summary print out and incorporated into a calendar for weekly schedule planning. Pre-intervention (2019) and preliminary intervention period data (2020-2021) are presented here. Through improved resource planning, the protocol equips catheterization teams to respond efficiently to AEs and possibly prevent escalation into dangerous events. This protocol provides reproducible interventions that can be adapted to local practice.
C3PO协作组在质量改进（QI）举措方面有着成功的历史，利用登记参与者开展了一项多中心QI举措，以减少先天性心脏导管插入术的不良事件（AE）。一个由32人组成的跨学科工作组分析了2014年至2017年所有先天性心脏导管插入术病例的审核数据。主要结果是任何高严重程度（3/4/5级）AE的发生情况。病例按持续时间从短到长进行整理，并汇总每个手术持续时间十分位数的3/4/5级和4/5级AE发生率。根本原因分析的观察结果用于指导关键驱动因素图的创建，并确定变革策略和实施工具。为便于术前沟通和风险评估，利用2014年至2019年的数据开发了一个在线风险计算器。2014年至2017年期间，从10个地点录入了14717例病例。732例（5.0%）发生了3/4/5级AE，而224例（1.5%）发生了4/5级AE。关键驱动因素图确定了三个驱动因素：（1）术前风险评估，（2）可能可预防的事件，以及（3）手术时长优化。在跨学科讨论中制定了围绕五个沟通时间点的可操作变革策略。术前风险计算器的输出结果可作为病例总结打印出来，并纳入每周日程安排规划的日历中。本文展示了干预前（2019年）和初步干预期（2020年至2021年）的数据。通过改进资源规划，该方案使导管插入术团队能够有效应对AE，并可能防止其升级为危险事件。该方案提供了可复制的干预措施，可根据当地实践进行调整。
