Quality and Safety

Introduction

Cardiac surgery has been a high risk endeavor ever since its inception. Although John Gibbon is credited with developing the first artificial oxygenator, and his first procedure (an atrial-septal defect closure) was a success, the next 4 patients Dr. Gibbon operated on did not survive and Gibbon never again performed open heart surgery (Gott, 2005). Of the first 10 ventricular septal defects closed by the pioneering cardiac surgeon Walt Lillehei in 1954 only 6 survived (Moller, Shumway, & Gott, 2009). Although morbidity and mortality were significant when surgical techniques and post-operative care were still in their infancy, progressive refinement of surgical techniques, strategies for heart preservation, and advances in cardiopulmonary bypass and overall perioperative care have made cardiac surgery routine enough for overall coronary artery bypass graft (CABG) mortality to fall to 2% (Ferguson, 2012).

Physicians have taken advantage of these incremental improvements in cardiac surgery techniques by performing more difficult procedures on sicker patients. Combined coronary bypass and multiple valve procedures, mechanical assist device insertion, and minimally invasive cardiac surgery have dramatically increased both the complexity and risk of modern cardiac surgery. Patients undergoing these procedures are routinely exposed to numerous therapeutic and diagnostic interventions that increase the risk of harm including central venous access, mechanical ventilation, and arterial pressure monitoring. Increasing numbers of consultants and medications also increase the complexity of care and raise the likelihood of adverse events.

That such complex care can be delivered so effectively is no accident. Cardiac surgery has a long history of focusing on quality improvement. In addition to frequent use of protocols and a limited set of procedures, cardiac surgeons have relied heavily on large clinical databases such as those created by the Society of Thoracic Surgeons (STS) and the New York State Department of Health to better understand risk factors and outcomes. The STS database in particular, to which 95% of cardiac surgeons send data, has been risk-adjusted for >20 years and has undergone multiple updates of the risk adjustment algorithm. Finally, government-sponsored initiatives such as the Surgical Care Improvement Program have led physicians to focus on quality and safety in care processes, including glycemic control, appropriate use of beta blockade and antibiotics, and best practices with respect to central line, and urinary catheter use. This chapter will discuss theoretical approaches to quality improvement, review current strategies for creating and maintaining quality and safety in the cardiac ICU, including safety culture, bundles, the influence of external quality programs, and large database analysis. Future strategies for maintaining and improving cardiac surgery quality will be discussed.