Heart Surgery 2003 to 2004
End of Year Results

Presented by G J Grötte and Suzanne Chaisty

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Heart Surgery 2003 to 2004

Consultant Surgeons
G J Grotte
D J M Keenan
N J Odom
R I R Hasan
B Prendergast
K E McLaughlin since (1st Jan 04)

 


Introduction
For the 3rd year running we now present our latest figures for Open Heart Surgery. Again risk stratified, named individual Surgeon mortality figures are included. To our knowledge the only other unit who has presented this is Papworth Hospital in January 2004. Comments in yellow will be made where appropriate. The waiting list for Open Heart Surgery at the MRI is now 3 months.








Payment by Results

“Funding should be tied explicitly to agreed levels of workload, and a failure to deliver should result in funding being withdrawn”

 

National Tariff

- National Tariff based on the NHS reference cost
- Adjustment for “market force factor” to take account of Regional differences in cost.

CABG Elective £ 8080
CABG Non elective £ 9863
Valve procedure Elective £10199
Valve procedure Non elective £13836

Presently our CABG costs is 20% above the National Tariff, but we are working on reducing our costs. There is evidence the National Tariff may be increased.

 

 

Heart Surgery 2003- 2004

NHS Patients 898
Waiting List initiative (WLI) patients by MRI Surgeons (off site) 131
TOTAL 1029
Target 1066  
Target set too high, more realistic target set for this year








 

Total Number of Cases per Consultant per year

Three case days no longer done by DJMK and RIRH. Since January 2004 Three Surgeons have a two whole operating days a week, the rest one and a half

 

Operation Priority
The WLI pts are not included in these results


The non elective workload will almost certainly increase with increased number of patients referred with Acute Coronary Syndrome (ACS)


Operation Priority %
All patients done at MRI

There should be better distribution of non elective work amongst Surgeons as non elective surgery carries a higher mortality.

Sex Distribution

No change over the last seven years







Risk Stratification


- Its unfair to use crude mortality figures when measuring individual Surgeons mortality as it will penalise Surgeons who operate on higher risk cases.

- It is the high risk patients who generally benefit most from Surgery, and they should not necessarily be turned down.

- We have used the Parsonnet Score for the last seven years as a means of measuring predicted mortality, and more recently the Euroscore. The Pars score over predicts mortality. Therefore it has been adjusted locally to 0.51 i.e. our standard is to perform about 50% better than the Parsonnet score.

- This standard will soon be reviewed and most likely be made tighter.The National Audit Cardiac Surgical Database Report for 2003 suggests a good prediction of mortality should be 0.33 of the crude Pars score. We will consider this for next years report.

 

Risk Stratification (previous years)

All Procedures
Parsonnet (Crude)
Euroscore
All cases
10
(8.5)
4.1
(3.7)
GJG
10
(9.1)
4.2
(3.7)
DJMK
11.1
(8.4)
4.5
(3.7)
NJO
10
(8.2)
4.5
(3.7)
RIRH
10.2
(8.3)
4.1
(3.6)
BP
9.2
(8.6)
3.7
(3.7)
KEM
7.1
  
3.3
  

Again this year we are operating on higher risk patients compared with last year.


 

 

Risk Stratification (previous years)

1st Time CABG
Parsonnet (Crude)
Euroscore
All cases
7.2
(6.6)
3.0
(2.9)
GJG
6.6
(7.1)
2.9
(2.8)
DJMK
8.4
(6.2)
3.3
(2.8)
NJO
7.0
(6.6)
3.4
(2.3)
RIRH
6.8
(6.3)
2.9
(3)
BP
7.6
(6.7)
3.0
(3.1)
KEM
5.9
  
2.6
  

 

Pure Coronary Artery Bypass Grafts 660pts
Total No Grafts 2267. Grafts per patient = 3.43

Gone are the days of Grafts x 6, 7 or 8




Pure Coronary Artery Bypass Grafts 660pts


 
#
%
Average previous years
MIDCAB (ant/lat)
6
1%
(2%)
OFF PUMP STERNOTOMY CABG
235
36%
(42%)
ON PUMP (3 conversions to pump)
419
64%
(56%)
MALE CABG
535
81%
(78%)
FEMALE CABG
125
19%
(22%)
First time CABG
623
94%
(95%)
Redo CABG
36
6%
(5%)
Reredo CABG
1
Non Elective CABG
187/660
28%
(27%)
Non Elective CABG Males
154/732
21%
(26%)
Non Elective CABG Females
33/297
11%
(19%)

MIDCAB appears to becoming extinct PTCA/Stent is taking over





 

Pure Coronary Artery Bypass Operations 660 (CABG)

Radial Artery
19
 
3%
(4%)
Internal mammary/thoracic
593
  
90%
(88%)
Arterial Grafts
x1
 
79%
(76%)
 
x2
  
9%
(10%)
 
x3
  
2%
(2%)
 
x4
2
   
 
x5
0
  
(1%)
Saphenous Veins only    
9%
(11%)
95% of pts had at least one arterial anastomosis (89%). There is recent evidence that radial artery patency is not as good as first thought.








 

 

Average number grafts per patient

- OPCAB 3.15
- On pump CAB 3.6














 

Other than Pure CABG

There is an increase in Valve operations probably due to increased surgery on an ageing population







CABG & Other

 
#
Average previous years
CABG & LV Aneurysm
3
(8)
CABG & CAROTID
5
(6)
CABG & VSD
1
(1)
CABG & ASD
3
(1)
CABG & PERICARDECTOMY
1
(1)
CABG & Closure pulm artery fistula
1
 
CABG & Repair Aortic Dissection
1
 
CABG & Atrial Myxoma
1
 
TOTAL
16
 






Number of Valves used
Valve insertion rate 0.33% (0.24%,0.24%)

Increased usage of Biological Valves. 1/3 of our patients has a Valve inserted, compared with 1/4 in previous years.







Single Valve Surgery 190 (129)

 
#
%
Average previous year
 
Aortic Valve Replacement
      
125
Male
66
53%
(60%)
 
Female
59
47%
(40%)
 
Mechanical Valve Replacement
57
46%
(65%)
 
Emergency/Urgent
30
24%
(21%)
 
Age 70 or over
51
40%
(25%)
 
Mitral Valve Replacement
    
29
Male
5
17%
(36%)
 
Female
24
83%
(64%)
 
Tricuspid Valve Replacement
      
1 (0)
Pulmonary Valve Replacement
      
2 (1)
Mitral Valve Repair
      
31 (17)
Aortic Valve Repair/Commisurotomy
      
2(1)




 

 

 

Multiple Valve Surgery   22  (13)

 
#
Average of previous year
 
DOUBLE VALVE REPLACEMENT     21 (13)
AVR/MVR
17
(11)
 
Mitral & Tricuspid Repair/Replace
4
(2)
 
       
TRIPLE VALVE REPLACEMENT/REPAIR     1 (0)




 







 

 

 

Valve & Other excluding CABG

AVR & ASD 2 (1)
AVR & VSD 2
AVR & Pericardectomy 1
MVR & ASC AORTA 0 (1)
AVR & AORTOPLASTY 3 (1)












 

 

Valve combined with CABG
108   10% (10%)

  # Prev year
AVR & CABG 76     7% 7%
MVR/REPAIR & CABG 32 (30)
MVR & CABG & CAROTID 0 (1)
OTHER VALVE COMBINATIONS & CABG 0 (1)














 

Miscellaneous operations 45 (32)

Congenital # Previous year
ASD 5 (8)

MISC Adult 		4 (2)
Acquired    
ROSS 12 (2)
Root Replacement 9 (12)
Root &Hemiarch 1 (2)
Ascending Aorta 3 (4)
Trauma 2 (1)
Pericardectomy 6 (1)
Atrial Myxoma 1  
Asc Hemi 2  






Operations Performed by Specialist Registrars (SpR) with Consultant Assistance
(no of months at MRI)



















2002-3
Overall 41%

Percentage of Total Consultant Operations performed by SpR's excluding WLI

2003-4
Overall 29%

Somewhat disturbing trend
Registrar Consultant

 

 


Cancellations
(Lost Theatre Slots) : 80    9% (13%)

 
#
Previous years
No CSU/PCU bed
25
(21)
No ITU bed
2
(17)
No Anaesthetist
2
(39)
No Surgeon
4
(2)
Preceding Case ran over
8
(5)
Thoracic List Replaced Cardiac
10
(30)
Patient Medically unfit
11
(11)
Others (some of these due to MRSA and other infections, but no patients came to any harm)
18
(1)

Significant descrease in lost slots, mainly due to increased Anaesthetic cover.

 

Cardiac Surgery Intensive Care Unit Stay (CSITU)

Out in 24 hours 77% (75%)
Out in 48 hours 87% (89%)
Readmissions to CSITU from High dependency Unit (HDU)/Ward3 2% (2.5%)

Low readmission rate to CSITU due to low inappropriate fast tracking












 

Complications

  # % Previous years
Full Tracheostomy 21 2% (1.2%)
Sternal Rewiring 6 0.6% (0.6%)
Mediastinitis req stern debridement 4 0.4% (0.4%)
Pulmonary Embolism 1 0.1% (1)
Atrial Fibrillation 299 29% (26%)

Incidence of Mediastinitis remains gratifyingly low. Atrial fibrillation still a problem like other units.










 

GI Complications

   
%
Previous years
Ileus  
0.3%
(0.1%)
Mesenteric Infarct  
0.3%
(0.1%)
GI Bleed  
0.7%
(0.7%)
Pseudo Obstruction  
0.1%
(0%)
Ischemic Bowel  
0.2%
(0.3%)











 

Complications - Stroke
CVA 10 1% (0.8%)
Previous TIA
1 (2)  
Previous CVA
2 (1)  
       
TIA 6 0.6% (0.6%)
Post op Incidence of Permanent stroke
in 1st time CABG 		0.6% (0.8%)
       







Complications : Renal Failure

Mild/Moderate (Creatinine >200)
22
2%
(2%)
Preoperative Renal Problems
3
 
(2)
No Pre op Renal Problems
19
 
(22)
1st time CABG  
1.6%
(1.3%)
Renal Failure (Req Dialysis/filtration)
24
2%
(2%)
Preoperative Renal Problems
3
 
(7)
No Pre op Renal Problems
21
 
(13)
1st time CABG  
1.6%
(0.6%)
       






Complications (IABP) Intra Aortic Balloon Pump

TOTAL 34 3.3% (1.8%)
MORTALITY 11 36% (36%)
IABP POST OP 20 1.9% (1.1%)
MORTALITY 9 45% (46%)
IABP PRE OP 14 1.36% (0.7%)
MORTALITY 2 14% (22%)

Pre op IABP may benefit survival but often different patient population








 

Conversions

On pump Sternotomy
418 (524)
Off pump Sternotomy
236 (376)
Conversion to pump
3 (3)
Deaths
0 (1)
Very low conversion rate










Reopen Bleeding/Tamponade
5.5% ( 4.9%)

Reopening rate too high particularly among a few Surgeons







Reopen Other Reasons 1.3% (1.5%)







 

Elderly Patients
(Aged 70 or over)

TOTAL 352 /1029 34% (32%)
Female   142 40% (33%)
Male   210 60% (67%)
Non Elective   114 33% (30%)
PURE CABG  197 56% (70%)
Non Elective CABG   76 22% (23%)

AVR 		47 13% (12%)
AVR&CABG 46 13% (11%)
AVR,CABG or Both   290 82% (90%)
Age 80 or over 50 4.6% (3.4%)
Average Pars 80 or over 27.4   (25.6)

Slow and steady increase in Octogenarians




Mortality
Death within Base Hospital on that Admission

 
#
%
Previous Year
OVERALL 33/1029 3.2% (2.8%)
Routine operations 16/756 2.1% (1.7%)
Urgent/Emergency operations 17/273 6.2% (6.0%)
Pure CABG 11/660 1.6% (2.3%)
First time CABG 11/623 1.8% (2.3%,)
Redo CABG 0/36 0% (2.2%)
Elective 1st time CABG 4/443 0.1% (1.4%)
Mortality Males 16/732 2.1% (2.8%)
Mortality Females 17/297 5.7% (2.8%)
AVR 0/125 0% (1.0%)
MVR /repair 1/60 1.6% (0%)
CABG & VALVE 11/108 10% (7.4%)
Mortality Elderly Group 21/352 5.9% (6%)
Mortality Elderly Pure CABG 7/197 3.5% (5.4%)
Elderly 80 and over 4/50 8% (4.8%)
Mortality Opcab 3/242 1.2% (0.5%)
Mortality Oncab 8/418 1.9% (3.6%)

Downward trend in Female Mortality not repeated this year



Cusum Curves

This is a means of analysing a Unit’s or an individual Surgeon’s performance over time.
Y axis = Cumulative Deaths.
X axis = Cumulative No of operations.

The Yellow line represents cumulative predicted mortality adjusted to 0.51 of the Parsonnet score. (NW Regional standard)

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 overlaps or drops below the dark blue line

Neither the Unit as a whole nor individual Surgeons are under performing

 

 

01 April 1997 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

01 April 2003 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

01 April 2003 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

01 April 2003 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

01 April 2003 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

01 April 2003 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

01 April 2003 - 31 March 2004
  

Low CI

Upper CI

Cumulative Parsonnet 0.51

Cumulative Mortality

 

 

 

 

 

 

 

In August 2001 Manchester Royal Infirmary was granted our Society's Quality Accreditation in Adult Cardiac Surgery for 5 years when we will have to re-apply

 

Quality Assurance Declaration

The following Declaration, which is signed up to by all the Surgeons, Managers and Medical Director of the Central Manchester and Children’s University Hospitals NHS Trust, outlines our plans to ensure the highest quality of Surgery in the Cardiothoracic Surgery Department.

1. All the healthcare personnel involved in the processing of Cardiac Surgical patients will enter specific data as dictated by the Northwest Audit Steering Group, into the Cardex software programme so that all patients have complete sets of data available for analysis.

2. It will be the responsibility of the data team to ensure the completeness of the data and, in particular, to track down and keep up to date the mortality.

3. Validation exercise of this data will take place twice a year.


4. Personalised risk stratification of mortality data will be provided by our data team to each Cardiac Surgeon every 3 months, by means of a CUSUM curve, and this data will be discussed within the Department quite openly. Mortality for the purposes of this declaration will be regarded as death in the base hospital on that admission. The data will consist of the following
a) Expected mortality benchmarked to 0.51 of the Parsonnet score
b) Regional performance. The data will be provided for both first time CABG operations and all operations
c) Observe mortality with 95% confidence limits will be provided for in-house use and, again, this will be provided for both first time CABG operations and for all operations.

 

Every 6 months this data will be made available to the Heart Centre Clinical Governance Committee with a copy to the Medical Director of the Trust.

6. If an individual’s results remain outside the proper confidence limits at 2 consecutive 3-month review points, the individual will be invited to discuss this data with a committee (the Mentoring Committee) formed of the following a) Clinical Director of the Heart Centre
b) Medical Director of the Trust
c) 2 other Cardiothoracic Surgeons from within the Trust
d) A Consultant Cardiac Anesthetist
e) Directorate Manager

7. The aim of this meeting will be to constructively examine all issues which could assist the individual surgeon and the Trust in understanding why these results are outside the confidence limits. It is not meant to be an inquisitorial meeting. This committee will nominate a “mentor” who is an in-house consultant Cardiothoracic surgeon. The role of this mentor will be the following
a) To comprehensively oversee the work of the particular surgeon over the next 3 months. Case mix, surgical decision making, operative strategy, Theatres, anesthesia, junior support, Interim care management, further post-operative care
b) To review the case mix for this particular surgeon over this period of time.
c) The mentor will investigate the theatre set-up when this particular surgeon is working so that other factors such as anesthesia, perfusion, general backup both in the theatre and in the Intensive Care Unit are considered.
d) Further post-operative care will be monitored, such as in the Progressive Care Unit and ward.

 

 

The mentor will continue overseeing the work of this surgeon for the first 3 months. If the results after 3 months are satisfactory then these restrictions will be lifted and the mentor will no longer be required to oversee all of these various aspects. However, results will be reviewed again at 6-months and it will be expected that the particular surgeon will remain within the confidence limits. If, on the other hand, the results after a 6-month period have defaulted or, if the results fall outside the confidence limits after a further period of time then the mentoring process will continue on and will remain under constant scrutiny of the Mentoring Committee.

8. Using this mechanism no Surgeon should approximate to the Society of Thoracic and Cardiovascular Surgeons threshold for action which is 0.7 of the expected Parsonnet score. However, should one of the surgeons exceed the 0.7 mark then obviously communication will take place with the Society as necessary

Signed:

Mr G Grotte
Consultant Cardiothoracic Surgeon
Mr N Odom
Consultant Cardiothoracic Surgeon 
Mr B Prendergast
Consultant Cardiothoracic Surgeon
Mr D Keenan Consultant Consultant Cardiothoracic Surgeon
Mr R Johnson
Medical Director Central Manchester & Manchester Children’s University Hospitals NHS Trust
Mr R Hasan
Consultant Cardiothoracic Surgeon
Mrs. J Youart
Directorate Manager
Manchester Heart Centre


 


We achieve our goals at the MRI




The End