[A quality improvement program in cardiac surgery. Four-year experience from the Ospedali Riuniti of Trieste].

Background: Dissatisfaction with clinical outcomes prompted an intervention to assess and improve processes and outcomes in a cardiac surgery unit.

Methods: Starting on September 1st, 1998, 1836 consecutive patients requiring a heart operation in our unit were prospectively enrolled by recording a series of anamnestic, clinical and procedural descriptors in a dedicated database. Expected mortality rates were estimated by means of nine different stratification models, one of which also allowed the prediction of excess intensive care unit and total hospital length of stay. Communication within the team has been re-engineered during the time frame studied. Some procedures have been modified and some others newly introduced according to a problem-oriented approach.

Results: One hundred and twenty-one patients died before discharge or within 30 days of the operation. The overall observed mortality rate (6.6%) was not significantly different from the predicted estimates (relative risk-RR 0.9, 95% confidence interval-CI 0.7-1.2 compared with EuroSCORE and RR 1.2, 95% CI 0.9-1.6 compared with the "Provincial Adult Cardiac Care Network" model). Two out of seven "dedicated" coronary surgery models predicted a mortality rate significantly lower than observed. Both rates of intensive care and total postoperative length of stay exceeding predefined thresholds turned out to be significantly higher than the predicted estimates: 14.3 vs 10.1% for intensive care (RR 1.4, 95% CI 1.2-1.7) and 13.6 vs 10.6% for total postoperative stay (RR 1.3, 95% CI 1.1-1.5). During the study period the yearly raw mortality rate gradually decreased, for the series as a whole, from 9.5% during the year 1999 to 4.1% during the year 2002, and for the coronary surgery sample from 6.5 to 2.1%, with no significant differences from the expected estimates over the 3 most recent years. A similar trend was noted for both intensive care unit and total hospital length of stay.

Conclusions: Implementing an internal continuous quality improvement program effectively assisted in improving surgical outcomes by motivating people involved, drawing attention to procedures to be re-engineered and by providing the proper benchmarks for assessing the results.