Perfusion quality improvement and the reduction of clinical variability

Abstract

The purpose of this study was to describe the development and utilization of a perfusion quality improvement program to reduce perfusion-to-perfusion variability in a large multi-center perfusion practice. Phase I of the study included the establishment of a perfusion database using standard spreadsheet format to serve multiple administrative functions including patient and procedure sequencing, predictive algorithms for yearly caseload, summary statistics, and inter-perfusionist comparison. The database used 236 separate variables, including demographic and clinical procedure-related categories. Forty of these variables are modifiable by perfusion interaction as established via protocol and algorithm. Phase II of the study used a perfusion electronic data recording system to automatically obtain patient data from physiologic monitors and the heart-lung machine. Data were transferred to a central database for perfusionist comparison. Data analysis used logical functions and macros programming, and statistical analysis used both parametric and non-parametric models within the program. Each quarter all variables underwent analysis with summary data established for the most recent 225 patients undergoing CPB. Twenty-five cases from each perfusionist (n = 9) were compared with the aggregate data of the entire staff, with reference to previous quarter's summary statistics. The results were discussed in monthly staff meetings and methods for improving compliance were discussed. Individual variation (p < .01) varied in 17 of 40 variables (26.0 +/- 8.6), with quarterly improvement (27.4 +/- 2.3 vs. 24.2 +/- 2.1 vs. 17.0 +/- 2.1) demonstrated in seven of nine individuals. In Phase II, performance was analyzed using the same variables as in Phase I but it also included the electronically recorded data from which 27 core measures were derived. All results were discussed with the staff at monthly departmental quality improvement meetings. The perfusion quality improvement program has evolved from a simple descriptive listing of cases to a quantitative instrument used to reduce variability amongst perfusionists and assure compliance with policies and standards of care.

Figure 1.

Graphic depiction of several parameters contained in quality improvement quarterly report. Negative (?) marks indicate that the perfusionist quarterly data was statistically less than the 225 aggregate data, while positive (+) marks indicate statistically higher results.

Figure 2.

Graphic depiction of single parameter (hematocrit) across quarters and amongst perfusion staff. Negative (−) marks indicate that the perfusionist quarterly data was statistically less than the 225 aggregate data, while positive (+) marks indicate statistically higher results. CPB, cardiopulmonary bypass.

Figure 3.

Percent of time that mean arterial pressure during cardiopulmonary bypass was less than 50 mmHg. The mean (X) indicates results for most recent 225 procedures and letters designate individual perfusionists. CPB, cardiopulmonary bypass; MAP, mean arterial pressure.

Figure 4.

Percent of time that patient temperature during cardiopulmonary bypass was greater than 37°C. The mean (X) indicates results for most recent 225 procedures and letters designate individual perfusionists.

Figure 5.

Percent of time that vacuum assist venous drainage pressure during cardiopulmonary bypass was less than −40 mmHg. The mean (X) indicates results for most recent 225 procedures and letters designate individual perfusionists. VAVD, vacuum assist venous drainage.

Figure 6.

Percent of time that base excess during cardiopulmonary bypass was less than −2 mmol. The mean (X) indicates results for most recent 225 procedures and letters designate individual perfusionists.

Figure 7.

The near infrared spectroscopy mean values during cardiopulmonary bypass. The mean (X) indicates results for most recent 225 procedures and letters designate individual perfusionists. CPB, cardiopulmonary bypass; NIRS, near infrared spectroscopy.

Figure 8.

Percent of time that regional oxygen saturation during cardiopulmonary bypass was less than 40%. The mean (X) indicates results for most recent 225 procedures and letters designate individual perfusionists. CPB, cardiopulmonary bypass; rSO2, regional oxygen saturation.