The Perfusion Downunder Collaboration: Leveraging Our Data Rob Baker* & Richard Newland On behalf of the Perfusion Downunder Collaboration *Director Cardiac Surgery Research and Perfusion Flinders Medical Centre and Flinders University, Bedford Park, South Australia. Perfusion Downunder Collaboration

COI’s / Disclosures Travel and Research support in the last 12 months –Medtronic –Cellplex Pty Ltd –Terumo Corporation

Perfusion Downunder Collaboration A collaborative network of perfusion and interested researchers, who share the commitment to cooperation and collaboration in the pursuit of excellence in perfusion.

Who is the PDUC?

PDUC Mission Statement To foster and grow high quality research in the perfusion sciences by the establishment and maintenance of a prospective data set on cardiac surgical procedures performed in centres throughout Australia and New Zealand.

Perfusion Downunder Collaboration Understand and quantify our practice Quality improvement Research

HLM software (DMS or JOCAP) PDU Database PDU Transfer Database De-identified Central PDU Database PDU Collaborative Database

Current: Recruitment & Data

Dataset (n=7769) Total records imported (April 2011) Adult isolated CABG/ Valve/ Valve + CABG (n=7364) (n=5465) Jan Feb after censor date 111 missing date of surgery 111 missing age 22 age <18

Dataset Demography –Age, Sex, Weight etc Clinical –Urgency, Clinical history etc Perfusion and quality indicators –Bypass time, management, monitoring etc –Electronic data variables (continuous and calculated) Procedure –Number of grafts, valve replacement etc Outcomes –Length of stay, complications etc

Risk factors and Demographics PDUC ASCTS * PDUC ASCTS PDUC ASCTS * PDUC PDUC Total Number of patients Risk Factors%%%% Current Smoker Diabetes Hypertension Cerebrovascular disease Family history of heart disease Hypercholesterolaemia Previous cardiac intervention Congestive heart failure MI before surgery^ Male7475** Age > Euroscore * Based on the ASCTS Cardiac surgery in Victorian public hospitals 2009–10 public report (data reported from Victorian hospitals only). **approximate ^ MI – myocardial infarction, <21 days (ASCTS) or <90days (PDUC)

Risk Factors: Core Procedures

Euroscore: Core Procedures

Postoperative outcomes PDUC PDUC PDUC PDUC PDUC Total %%% Stroke New renal failure Myocardial infarction Reoperation Ventilation > 24 hrs day mortality

We are interested in what is not in other databases (ie Perfusion variables) and relating practices to outcomes:

Components of the Circuit Venous Reservoir Type Pump Type

Biopassive circuit coating Coated circuit use Circuit coating:type Oxygenator coating

Monitoring Blood gas monitoring Cerebral oximetry BIS monitoring

Clinical incidents Accidents reported to PIRS: 56.5% Near misses reported to PIRS: 37% Incidents Near misses PIRS reports

23 (Cummulative %) Exposure to RBC transfusion

Blood management utilisation OverallBy site

ICU blood loss (n=2890, 384 cases missing data)(introduced nov n=2259, 393 cases missing data) 1 st 4 hoursTotal

Continuous and Electronic data Quality indicators –haemoglobin <70 g/dl –blood glucose > 10 mmol –arterial temperature >37C for >2 min –arterial pressure 5 minutes –cardiac index 5 minutes –venous saturation 5 minutes –pCO 2 45 mmHg –pO 2 <100 mmHg Multi-insitutional Level

Art P 5 min

CI 5 min

Defining benchmarking? “Concept of using a structured method of quality measurement and improvement” “Process of measuring performance using one or more specific indicators to compare activity with others”

Methods - Benchmarks Quality Indicators –Chosen Evidence / guidelines Consensus –arterial outlet temperature > 37 o C –blood glucose 10 mmol/l –pCO 2 45 mmHg Achievable Benchmarks of Care –Weissman et al 1999 J Eval Clin Pract 5;

Avoidance of Hyperthermia Limiting arterial line temperature to 37C might be useful for avoiding cerebral hyperthermia. (Class 1a, Level B) “Coupled temperature” ports for all oxygenators should be checked for accuracy and calibrated.

but

pH Management The clinical team should manage adult patients undergoing moderate hypothermic CPB with alphastat pH management. (Class I, Level A)

Calculate adjusted performance fraction (APF) APF = (x + 1)/(d + 2) Rank centres in order of performance for a specific quality indicator Create subset comprising top 10% best-performing centres, add centres until a subset represents at least 10% of the entire dataset is established Calculate benchmark based on subset as follows: Total number of patients in subset receiving recommended intervention Total number of patients in subset Weissman et al 1999 J Eval Clin Pract 5; Calculating benchmarks with paired-mean method

20.3% Arterial pCO 2 45 mmHg

Arterial outlet temperature > 37 o C 6.2% Percentage of Patients

Factors

Arterial outlet temperature > 37 o C

Cummulative site performance

Next steps - making the transition from measurement to improvement Identified areas of practice to benchmark based on established guidelines Quantified our practice as a baseline for improvement Identified modifiable factors as a focus for QI initiatives Define / Measure / Analyse / Improve / Control

Next steps - making the transition from measurement to improvement Identified areas of practice to benchmark based on established guidelines Quantified our practice as a baseline for improvement Identified modifiable factors as a focus for QI initiatives Define / Measure / Analyse Share information on current practices

Next steps - making the transition from measurement to improvement Disseminate information to teams Develop improvement initiatives Audit practice (using PDUCD) Improve / Control Audit and compare group practice data Feedback data for periodic discussion Local PDUC

Thankyou