Guidelines for continuous quality improvement in the cardiac catheterization laboratory. Laboratory Performance Standards Committee of the Society for Cardiac Angiography & Interventions

Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences

Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.

UTERINE ARTERY EMBOLISATION: CONTINUOUS QUALITY IMPROVEMENT REDUCES RADIATION DOSE WHILE MAINTAINING IMAGE QUALITY

The purpose of this study was to introduce a continuous quality improvement (CQI) program for radiation dose optimisation during uterine artery embolisation (UAE) and assess its impact on dose reduction and image quality. The CQI program investigated the effects of optimising radiation dose parameters on the kerma-area product (KAP) and image quality when comparing a 'CQI intervention' group (n = 50) and 'Control' group (n = 50). Visual grading characteristics (VGC) analysis was used to assess image quality, using the 'Control' group as a reference. A significant reduction in KAP by 17% (P = 0.041, d = 0.2) and reference air kerma (Ka, r) by 20% (P = 0.027, d = 0.2) was shown between the two groups. The VGC analysis resulted in an area under the VGC curve (AUCVGC) of 0.54, indicating no significant difference in image quality between the two groups (P = 0.670). The implementation of the CQI program and optimisation of radiation dose parameters improved the UAE radiation dose practices at our centre. The dose reduction demonstrated no detrimental effects on image quality.

Overcoming Obstacles in Designing and Sustaining a High-Quality Cardiovascular Procedure Environment

Accurate evaluation of the quality of invasive cardiology procedures requires appraisal of case selection, technical performance, and procedural and clinical outcomes. Regrettably, the medical care delivery system poses a number of obstacles to developing and sustaining a high-quality environment. The purposes of this viewpoint are to summarize the most common impediments, followed to summarize the most common impediments, followed by the optimal ways to design and sustain a quality assurance program to overcome these barriers. A 7-step program to create and implement an effective quality assurance program is outlined.

Morbidity and Mortality Conference for Percutaneous Coronary Intervention

Background—

Morbidity and mortality conference is a common educational and quality improvement activity performed in cardiac catheterization laboratories, but best practices for case selection and for maximizing the effectiveness of peer review have not been determined.

Methods and Results—

We reviewed the 10-year percutaneous coronary intervention morbidity and mortality conference experience of an academic medical center. Cases were triggered for review by the occurrence of prespecified procedural events. Summary reports from morbidity and mortality conference discussions were linked to clinical data from the Duke Databank for Cardiovascular Disease to compare baseline and procedural characteristics and to assess postdischarge outcomes. Of 11 786 procedures, from 2004 to 2013, 157 (1.3%) were triggered for review. The most frequent triggering events were cardioversion/defibrillation (72, 0.6%), unplanned use of mechanical circulatory support (64, 0.5%), and major dissection (41, 0.3%). Selected procedures were more likely to include high-risk features, such as ST-segment–elevation myocardial infarction, cardiogenic shock, and multivessel disease, and were associated with higher mortality at 30 days. Only a minority of triggering events were caused by controversial or unacceptable physician behavior.

Conclusions—

This 10-year experience outlines the processes for conduct of an effective percutaneous coronary intervention morbidity and mortality conference, including a novel approach to case selection and structured peer review leading to actionable quality interventions. The prespecified clinical triggers, captured in the natural workflow by laboratory staff, identified complex cases that were associated with poor patient outcomes.

Quality criteria for cardiac images: an update

The DIMOND II and III Cardiology Groups have agreed on quality criteria for cardiac images and developed a scoring system, to provide a tool to test quality of coronary angiograms, which was demonstrated to be of value in clinical practice. In the last years, digital flat panel technology has been introduced in cardiac angiographic systems and the radiological technique may have been influenced by the better performance of these new detectors. This advance in digital imaging, together with the lesson learned from previous studies, warranted the revision of the quality criteria for cardiac angiographic images as formerly defined. DIMOND criteria were reassessed to allow a simpler evaluation of angiograms. Clinical criteria were simplified and separated from technical criteria. Furthermore, the characteristics of an optimised angiographic technique have been outlined.

Implementation and application of a continuous quality improvement (CQI) program for the cardiac catheterization laboratory: One institution's 10-year experience

There is consensus that a continuous quality improvement (CQI) program is essential in optimizing patient outcomes in the cardiovascular catheterization laboratory. A CQI method was described in guidelines produced by the Society for Cardiovascular Angiography and Interventions (SCAI) in 1993 and 1997. However, little information is available in the medical literature to determine the implementation and application of this approach in a modern catheterization program. This presentation describes the lessons learned from one institution's 10 year CQI experience by using the SCAI blueprint.

A study to validate the method based on DIMOND quality criteria for cardiac angiographic images

A method based on image quality criteria (QC) for cine-angiography was developed to measure the quality of cine-angiograms (CA). A series of 30 CA for left ventriculography (LV) and left and right coronary angiography (LCA, RCA) have been scored and 172 readings were obtained. Standard deviation of quality scores indicated the reproducibility of the method. Each part of CA was examined separately, giving scores for LV, LCA and RCA and a total score (TS), with clinical (C) and technical (T) criteria defined and examined separately. In 83% of the studies TS was >0.8 and with standard deviation from 0.02 to 0.21. In general, LV had a lower score and greater disagreement compared with RCA and LCA. Disagreement was greater in T, compared with C. In conclusion, these results indicate that QC, translated into a scoring system, yields reproducible data on the quality of cardiac images.

Ethical issues for invasive cardiologists: Society for cardiovascular angiography and interventions

In view of the major impact of medical economic forces, rapidly changing technology, and other pressures on invasive cardiologists, the Society for Cardiovascular Angiography and Interventions determined that a statement of the ethical issues confronting the modern invasive cardiologist was needed. The various conflicts presented to the cardiologist in his or her roles as practicing clinician, administrator of the catheterization laboratory, educator, or clinical researcher were reviewed. In all instances, the major concern was determined to be the welfare of the patient no matter how forceful the pressures from various outside force or concerns for personal advancement might be.

Quality criteria for cardiac images in diagnostic and interventional cardiology

The quality of cardiac imaging plays a pivotal role in clinical decision-making and depends mainly on the technical performance of the imaging system and on angiographic technique. The Italian Society of Invasive Cardiology and The Italian Society of Physics in Medicine have set quality criteria giving precise guidelines regarding how an angiogram should appear provided that good equipment and correct angiographic technique are used. The criteria have been reviewed by the European Concerted Action DIMOND Cardiology group and are reported here to provide a reference standard for images for the most common procedures in daily practice.

[Continuous practice and advanced training in interventional cardiology. Recommendations for the assessment and maintenance of proficiency in interventional cardiology. A statement for physicians and advanced training units from the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology]

This report reflects the interest of the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology in increasing quality, safety and applicability of percutaneous procedures, by giving scientific keys aimed at improving related functions of teaching or planning in this field and enhancing competence and prestige of Spanish interventional cardiologists. The purpose of the document is to describe the importance of current interventional cardiology, to identify quality references and to establish minimum acceptable requirements for assessing and maintaining the competence of practicing or providing advanced training in this discipline. To achieve this goal, a search for a gold standard of the different techniques of general interventional practice was carried out, and predictors of postprocedural outcome were analyzed, as well as their relation with different kinds of circumstances. This analysis identified coronary angioplasty as the standard on which recommendations regarding competence in overall interventional cardiology standards of quality and assessment and maintenance of proficiency must be based. On the other hand, the strong influence of experience and knowledge of results has been documented, especially in high-risk or high-complexity settings. On this basis, the report establishes specific recommendations about proficiency for practice and advanced training. It also suggests that interventional cardiology should be considered as a subspecialty, of cardiology requiring specific credentials.

Lessons learned from the review of cardiac catheterization laboratories: a report from the Laboratory Survey Committee of the Society for Cardiac Angiography and Interventions

The Laboratory Survey Committee of the Society for Cardiac Angiography and Interventions was created as a resource for physicians and administrators to provide comprehensive independent outside review services for cardiac catheterization laboratories. Since 1989, when the committee began its work, surveys of 23 catheterization laboratories have been completed. Our review of this experience identified several recurring problems among the laboratories. The purpose of this paper is to summarize our experience and highlight the lessons we learned in the hope that this information will benefit many other laboratories.

Guidelines for internal peer review in the cardiac catheterization laboratory. Laboratory Performance Standards Committee, Society for Cardiac Angiography and Interventions

The Laboratory Performance Standards Committee of the Society for Cardiac Angiography and Interventions has proposed guidelines for establishing an internal peer review program in the cardiac catheterization laboratory. The first step is to establish a committee and a data base. This data base should include quality indicators that reflect: physician qualifications, outcomes of procedures, and processes of care. The outcomes must be risk-adjusted to account for the variable severity of illness. Data should be collected by catheterization laboratory personnel and entered into a laboratory-specific computerized data base. These data must be analyzed and organized into profiles that reflect the quality of care. Based on this information, the Committee would institute the following interventions to improve physician performance: education, clinical practice standardization, feedback and benchmarking, professional interaction, incentives, decision-support systems, and administrative interventions. The legal aspects of peer review are reviewed briefly.

Separation of a flexible nose cone tip during directional atherectomy

An 82-yr-old white female underwent directional coronary atherectomy of a high-grade proximal left anterior artery stenosis. The nose cone tip of a Simpson Atherocath SCA-EX separated during loading of the device onto a 360-cm exchange wire. This was recognized prior to insertion through a rotating hemostatic valve and exchanged for another device. Catheterization laboratory policy regarding defective devices is briefly discussed.