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Background: Institutions or clinicians (units) are often compared according to a performance indicator such as in-hospital mortality. Several approaches have been proposed for the detection of outlying units, whose performance deviates from the overall performance. Methods: We provide an overview of three approaches commonly used to monitor institutional performances for outlier detection. These are the common-mean model, the 'Normal-Poisson' random effects model and the 'Logistic' random effects model. For the latter we also propose a visualisation technique. The common-mean model assumes that the underlying true performance of all units is equal and that any observed variation between units is due to chance. Even after applying case-mix adjustment, this assumption is often violated due to overdispersion and a post-hoc correction may need to be applied. The random effects models relax this assumption and explicitly allow the true performance to differ between units, thus offering a more flexible approach. We discuss the strengths and weaknesses of each approach and illustrate their application using audit data from England and Wales on Adult Cardiac Surgery (ACS) and Percutaneous Coronary Intervention (PCI). Results: In general, the overdispersion-corrected common-mean model and the random effects approaches produced similar p-values for the detection of outliers. For the ACS dataset (41 hospitals) three outliers were identified in total but only one was identified by all methods above. For the PCI dataset (88 hospitals), seven outliers were identified in total but only two were identified by all methods. The common-mean model uncorrected for overdispersion produced several more outliers. The reason for observing similar p-values for all three approaches could be attributed to the fact that the between-hospital variance was relatively small in both datasets, resulting only in a mild violation of the common-mean assumption; in this situation, the overdispersion correction worked well. Conclusion: If the common-mean assumption is likely to hold, all three methods are appropriate to use for outlier detection and their results should be similar. Random effect methods may be the preferred approach when the common-mean assumption is likely to be violated. [ABSTRACT FROM AUTHOR]

Background: Interview and questionnaire studies have identified barriers and challenges to preventing surgical site infections (SSIs) by focusing on compliance with recommendations and care bundles using interviews, questionnaires and expert panels. This study proposes a more comprehensive investigation by using observations of clinical practice plus interviews which will enable a wider focus., Aim: To comprehensively identify the factors which affect SSI prevention using cardiac surgery as an exemplar., Methods: The study consisted of 130 h of observed clinical practice followed by individual semi-structured interviews with 16 surgeons, anaesthetists, theatre staff, and nurses at four cardiac centres in England. Data were analysed thematically., Findings: The factors were complex and existed at the level of the intervention, the individual, the team, the organization, and even the wider society. Factors included: the attributes of the intervention; the relationship between evidence, personal beliefs, and perceived risk; power and hierarchy; leadership and culture; resources; infrastructure; supplies; organization and planning; patient engagement and power; hospital administration; workforce shortages; COVID-19 pandemic; 'Brexit'; and the war in Ukraine., Conclusion: This is one of the first studies to provide a comprehensive overview of the factors affecting SSI prevention. The factors are complex and need to be fully understood when trying to reduce SSIs. A strong evidence base was insufficient to ensure implementation of an intervention., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Public reporting of clinical performance is increasingly used in many countries to improve quality and enhance accountability of the health system. The assumption is that greater transparency will stimulate improvements by clinicians in response to peer pressure, patient choice or competition. The international diffusion of public reporting might suggest greater similarity between health systems. Alternatively, national and local contexts (including health system imperatives, professional power and organisational culture) might continue to shape its form and impact, implying continued divergence. The paper considers public reporting in the USA and England through the lens of Scott's 'pillars' institutional framework. The USA was arguably the first country to adopt public reporting systematically in the late 1980s. England is a more recent adopter; it is now being widely adopted through the National Health Service (NHS). Drawing on qualitative data from California and England, this paper compares the behavioural and policy responses to public reporting by health system stakeholders at micro, meso and macro levels and through the intersection of ideas, interests, institutions and individuals through. The interplay between the regulative, normative and cultural-cognitive pillars helps explain the observed patterns of on-going divergence. [ABSTRACT FROM AUTHOR]

NHS England recently mandated that the National Early Warning Score of vital signs be used in all acute hospital trusts in the UK despite limited validation in the postoperative setting. We undertook a multicentre UK study of 13,631 patients discharged from intensive care after risk-stratified cardiac surgery in four centres, all of which used VitalPACTM to electronically collect postoperative National Early Warning Score vital signs. We analysed 540,127 sets of vital signs to generate a logistic score, the discrimination of which we compared with the national additive score for the composite outcome of: in-hospital death; cardiac arrest; or unplanned intensive care admission. There were 578 patients (4.2%) with an outcome that followed 4300 sets of observations (0.8%) in the preceding 24 h: 499 out of 578 (86%) patients had unplanned re-admissions to intensive care. Discrimination by the logistic score was significantly better than the additive score. Respective areas (95%CI) under the receiver-operating characteristic curve with 24-h and 6-h vital signs were: 0.779 (0.771-0.786) vs. 0.754 (0.746-0.761), p < 0.001; and 0.841 (0.829-0.853) vs. 0.813 (0.800-0.825), p < 0.001, respectively. Our proposed logistic Early Warning Score was better than the current National Early Warning Score at discriminating patients who had an event after cardiac surgery from those who did not. [ABSTRACT FROM AUTHOR]

Professional autonomy has come under greater scrutiny due to managerialism, consumerism, information and communication technologies (ICT), and the changing composition of professions themselves. This scrutiny is often portrayed as a tension between professional and managerial logics. Recently, medical autonomy has increasingly been shaped in terms of transparency, where publication of clinical performance (via ICT) might be a more pervasive form of surveillance. Such transparency may have the potential for a more explicit managerial logic but is contested by clinicians. This paper applies notions of surveillance to public reporting of cardiac surgery, involving the online publication of mortality rates of named surgeons. It draws on qualitative data from a case‐study of cardiac surgeons in one hospital, incorporating interviews with health care managers and national policymakers in England. We examine how managerial logics are mediated by professional autonomy, generating patterns of enrolment, resistance and reactivity to public reporting. The managerial 'gaze' of public reporting is becoming widespread but the surgical specialty is accommodating it, leading to a re‐assertion of knowledge, based on professional definitions. The paper assesses whether this form of surveillance is challenging to or being assimilated by the medical profession, thereby recasting the profession itself. [ABSTRACT FROM AUTHOR]

Objective: To describe the long-term outcomes, treatment pathways and risk factors for patients diagnosed with hypoplastic left heart syndrome (HLHS) in England and Wales.Methods: The UK's national audit database captures every procedure undertaken for congenital heart disease and updated life status for resident patients in England and Wales. Patients with HLHS born between 2000 and 2015 were identified using codes from the International Paediatric and Congenital Cardiac Code.Results: There were 976 patients with HLHS. Of these, 9.6% had a prepathway intervention, 89.5% underwent a traditional pathway of staged palliation and 6.4% of infants underwent a hybrid pathway. Patients undergoing prepathway procedures or the hybrid pathway were more complex, exhibiting higher rates of prematurity and acquired comorbidity. Prepathway intervention was associated with the highest in-hospital mortality (34.0%).44.6% of patients had an off-pathway procedure after their primary procedure, most frequently stenting or dilation of residual or recoarctation and most commonly occurring between stage 1 and stage 2.The survival rate at 1 year and 5 years was 60.7% (95% CI 57.5 to 63.7) and 56.3% (95% CI 53.0 to 59.5), respectively. Patients with an antenatal diagnosis (multivariable HR (MHR) 1.63 (95% CI 1.12 to 2.38)), low weight (<2.5 kg) (MHR 1.49 (95% CI 1.05 to 2.11)) or the presence of an acquired comorbidity (MHR 2.04 (95% CI 1.30 to 3.19)) were less likely to survive.Conclusion: Treatment pathways among patients with HLHS are complex and variable. It is essential that the long-term outcomes of conditions like HLHS that require serial interventions are studied to provide a fuller picture and to inform quality assurance and improvement. [ABSTRACT FROM AUTHOR]

Background: In 2016, the Royal Brompton Hospital site introduced frequent/repeated swabbing of the chest wound site from 2 days after surgery to screen for alert organisms. Following this, the number of surgical site infections (SSIs) increased. Methods: The authors used prospective SSI data and audited the characteristics of patients who developed SSIs. They also reviewed other factors that might have an impact on SSIs to identify the possible cause. Results: No single surgical team, theatre/environment or product was associated with the outbreak. Audit data demonstrated an almost four-fold increase in superficial SSIs that coincided with the introduction of the intense swabbing regimen (means: 0.7% prior to and 2.6% after the introduction of screening). Conclusion: Early and frequent or repeated swabbing of a healthy new surgical wound may disrupt the epithelisation/healing process and increase the risk of infection by opportunistic pathogens. Further investigation and analysis is needed. [ABSTRACT FROM AUTHOR]

Background: CHD was the most prevalent congenital anomaly (60.9 per 10,000, 95% CI 59.0-62.8) in England in 2018, with 1767 babies born with severe cardiac defects. The 30-day survival rates for complex procedures continue to improve; however despite care advances, the early post-operative period and first year of life remain a critical time for these infants. The Congenital Heart Assessment Tool was developed to support parental decision-making, standardise care provision, improve communication, and the safety and quality of care., Aim: To further evaluate the Congenital Heart Assessment Tool., Design: A four centre collaborative mixed-methods quality improvement project funded by The Health Foundation, involving eight phases conducted during 2016-2018. Phases six to eight (clinical simulation exercise, parent workshop, and updated tool) are reported in this paper., Results: Four themes emerged from the clinical simulation exercise (phase six) including: improving documentation; preparation of parents; preparation of health care professionals; and communication. One main theme emerged from the parent workshop (phase seven): "what parents know versus what professionals know [about CHD]"., Conclusion: These phases further validated the effectiveness of the CHATm in terms of triggering amber and red indicators and demonstrated parents' ability to identify deterioration in their infant's clinical condition. Recommendations arising from the quality improvement project enabled the project team to create an updated version of the Congenital Heart Assessment Tool, CHAT2.

Background: Surgery for severe mitral regurgitation is indicated if symptoms or left ventricular dilation or dysfunction occur. However, prognosis is already reduced by this stage, and earlier surgery on asymptomatic patients has been advocated if valve repair is likely, but identifying suitable patients for early surgery is difficult. Quantifying the regurgitation may help, but evidence for its link with outcome is limited. Cardiovascular magnetic resonance (CMR) can accurately quantify mitral regurgitation, and we examined whether this was associated with the future need for surgery. Methods and Results: One hundred nine asymptomatic patients with echocardiographic moderate or severe mitral regurgitation had baseline CMR scans and were followed up for up to 8 years (mean, 2.5±1.9 years). CMR quantification accurately identified patients who progressed to symptoms or other indications for surgery: 91% of subjects with regurgitant volume ≤55 mL survived to 5 years without surgery compared with only 21% with regurgitant volume >55 mL (P<0.0001). A similar separation was observed for regurgitant fraction ≤40% and >40%. CMR-derived end-diastolic volume index showed a weaker association with outcome (proportions surviving without surgery at 5 years, 90% for left ventricular end-diastolic volume index <100 mL/m(2) versus 48% for ≥100 mL/m(2)) and added little to the discriminatory power of regurgitant fraction/volume alone. Conclusions: CMR quantification of mitral regurgitation was associated with the development of symptoms or other indications for surgery and showed better discriminatory ability than the reference-standard CMR-derived ventricular volumes. CMR may be able to identify appropriate patients for early surgery, with the potential to change clinical practice, although the clinical benefits of early surgery require confirmation in a clinical trial. [ABSTRACT FROM AUTHOR]

Background: Minimal-access aortic valve replacement (MAAVR) may reduce post-operative blood loss and transfusion requirements, decrease post-operative pain, shorten length stay and enhance cosmesis. This may be particularly advantageous in overweight/obese patients, who are at increased risk of post-operative complications. Obese patients are however often denied MAAVR due to the perceived technical procedural difficulty. This retrospective analysis sought to determine the effect of BMI on post-operative outcomes in patients undergoing MAAVR.Methods: Ninety isolated elective MAAVR procedures performed between May 2006-October 2013 were included. Intra- and post-operative data were prospectively collected. Ordinary least squares univariate linear regression analysis was performed to determine the effect of BMI as a continuous variable on post-operative outcomes. One-way ANOVA and Chi-squared testing was used to assess differences in outcomes between patients with BMI <25 (n = 36) and BMI ≥25 (n = 54) as appropriate.Results: There was no peri-operative mortality, myocardial infarction or stroke. Univariate regression demonstrated longer cross-clamp times (p = 0.0218) and a trend towards increased bypass times (p = 0.0615) in patients with higher BMI. BMI ≥25 was associated with an increased incidence of hospital-acquired pneumonia (p = 0.020) and new-onset atrial fibrillation (p = 0.036) compared to BMI <25. However, raised BMI did not extend ICU (p = 0.3310) or overall hospital stay (p = 0.2614). Similar rates of sternal wound complications, inotrope requirements and renal dysfunction were observed in both normal- and overweight/obese-BMI groups. Furthermore, increasing BMI correlated with reduced mechanical ventilation time (p = 0.039) and early post-operative blood loss (p = 0.004).Conclusions: Our results demonstrate that within the range of this study, MAAVR is a safe, reproducible and effective procedure, affording equivalent clinical outcomes in both overweight/obese and normal-weight patients considered for an isolated first-time AVR, with low post-operative morbidity and mortality. MAAVR should therefore be considered as an alternative surgical strategy to reduce obesity-related complications in patients requiring aortic valve replacement. [ABSTRACT FROM AUTHOR]

Background: Tricuspid valve (TV) infective endocarditis (IE) is a known complication of intravenous drug use (IVDU). This study assessed long-term outcomes of surgically and medically treated cases of TV IE.Methods: This was a retrospective cohort study of all cases of native TV IE treated in London, Ontario between 2008 and 2011. Outcomes for medically and surgically managed cases were assessed at two years. Outcomes related to the timing of surgery were also assessed.Results: Thirty-eight patients were included; seven received valve surgery: five repairs, two replacements. All patients had a history of IVDU. Baseline characteristics were equal in both groups. Death at two years was 43% in the surgical group and 26% in the nonsurgical group (p = 0.522). In those who received surgery within 30 days versus after 30 days from admission, death was 33% and 50%, respectively (p = 1.00). No patients received emergent surgery (within seven days of admission). Twenty-nine percent of the surgical group survived disease free versus 52% of the nonsurgical group. Survival with morbidity was mainly related to ongoing IVDU. The highest risk for mortality in both groups was ongoing IVDU.Conclusions: In IVDU-related TV IE the highest risk for mortality appears to be ongoing IVDU and persistent or recurrent endocarditis. [ABSTRACT FROM AUTHOR]

Objectives Various risk models exist to predict short-term risk-adjusted outcomes after cardiac surgery. Statistical models constructed using clinical registry data usually perform better than those based on administrative datasets. We constructed a procedure-specific risk prediction model based on administrative hospital data for England and we compared its performance with the EuroSCORE (ES) and its variants. Methods The Hospital Episode Statistics (HES) risk prediction model was developed using administrative data linked to national mortality statistics register of patients undergoing CABG (35,115), valve surgery (18,353) and combined CABG and valve surgery (8392) from 2008 to 2011 in England and tested using an independent dataset sampled for the financial years 2011–2013. Specific models were constructed to predict mortality within 1-year post discharge. Comparisons with EuroSCORE models were performed on a local cohort of patients (2580) from 2008 to 2013. Results The discrimination of the HES model demonstrates a good performance for early and up to 1-year following surgery (c-stats: CABG 81.6%, 78.4%; isolated valve 78.6%, 77.8%; CABG & valve 76.4%, 72.0%), respectively. Extended testing in subsequent financial years shows that the models maintained performance outside the development period. Calibration of the HES model demonstrates a small difference (CABG 0.15%; isolated valve 0.39%; CABG & valve 0.63%) between observed and expected mortality rates and delivers a good estimate of risk. Discrimination for the HES model for in-hospital deaths is similar for CABG (logistic ES 79.0%) and combined CABG and valve surgery (logistic ES 71.6%) patients and superior for valve patients (logistic ES 70.9%) compared to the EuroSCORE models. The C-statistics of the EuroSCORE models for longer periods are numerically lower than that of the HES model. Conclusion The national administrative dataset has produced an accurate, stable and clinically useful early and 1-year mortality prediction after cardiac surgery. [ABSTRACT FROM AUTHOR]

* Objective: The use of antibiotic-impregnated sponges (Collatamp) during cardiac surgery is controversial. We analysed the cost-effectiveness of its selective use in patients at high-risk of sternal wound infection (SWI). * Method: Postoperative costs were analysed in two groups of patients undergoing heart surgery between 201 I and 201 3:those with SWI (group I) and in high-risk patients without SWI (group 2).The potential cost of gentamicin-impregnated collagen sponges (GCS) use in high-risk patients was compared with our current practice. * Results: We identified 1,251 patients with at least one recognised risk factor for developing SWI in this period. Of these, 18 developed SWI (incidence 1.4%).The median postoperative cost per patient without SWI was £9,617. The additional cost per patient incurred by SWI was £4,860.75. The annual additional cost for treating patients with SWI was £43,749. With a 50% reduction in SWI, the annual additional cost of treating these patients would be reduced to £21,873. The cost of GCS is £80 per patient. Adding this to £21,873 gives a potential total cost of £71,91 3 in the treated high-risk cohort. * Conclusion: In our practice the annual cost of treating SWI in high-risk patients without use of GCS is lower than the annual cost of using GCS in all high-risk patients (£43,749 versus £71,91 3) if it produces a 50% reduction in SWI. The reduction in the incidence of SWI poses no economic benefit when the cost of the product is factored in. [ABSTRACT FROM AUTHOR]

Objective: In England, every death in childhood is reviewed by a local multidisciplinary Child Death Overview Panel (CDOP) with the intention of understanding causation and implementing interventions to reduce future deaths. This study aimed to establish how well panels work from the perspective of the paediatricians involved and to ascertain whether they deliver good value and identify areas for improvement. Design: A questionnaire was sent to every CDOP paediatrician in the country (n=93). Questions focused on the quality of CDOP case discussions as well as examples of effective and significant recommendations. Responses were analysed using simple quantitative and qualitative methods. Results: 84/93 (90%) of the paediatricians responded. Among the respondents, 60 (71%) believe that investment in CDOPs is offering good value, 73 (87%) feel that case discussionsare rigorous and consistent and over 90% believe that the correct issues are emerging from discussions. However, responders noted many areas for improvement: 40 (48%) suggested devolving the discussion of specialist deaths (eg, neonates) to hospital-based review meetings or holding themed meetings with invited specialists, 11 (13%) suggested filtering out cases where learning is unlikely before full CDOP meetings and 13 (15%) called for national integration and analysis of data. Conclusions: In this time of economic austerity it is vital that the CDOPs add value to the invested resources. Although CDOP paediatricians feel that panels are working well, there is scope for improvement through enhancing relationships with commissioning bodies, aggregate review and analysis of CDOP data at a national level and consideration of specialist and/or network review of certain categories of deaths such as cardiac surgery, oncology and neonates. [ABSTRACT FROM AUTHOR]

The Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) has published named mortality data since 2001. The importance of accurate and robust clinical outcome reporting has been emphasized by a number of high-profile cases in England. In this article, we give a technical review of the United Kingdom National Adult Cardiac Surgery Governance Analysis 2008–11. The statistical and analytical assumptions and methods are discussed in order to add an additional layer of transparency to the clinical governance process and precipitate scrutiny with the aim of optimizing future analyses. [ABSTRACT FROM PUBLISHER]

Parental refusal to consent for medical and surgical consent can present children's nurses with a professional dilemma and can potentially negatively impact the care provided for the both the paediatric patient and their family. With in this article, the legal, ethical and professional aspects associated with this dilemma are presented and discussed from the parental, child and nurse point of view. [ABSTRACT FROM PUBLISHER]

The article discusses a study to evaluate the safety of training and assessment in operating theaters by assessing the performance of specialists and trainees. The findings revealed that no significant differences were observed between the procedural outcomes of trainees and specialists, thereby indicating that trainees are safe to operate under senior supervision. Several procedural outcomes have been found capable of evaluating the performance of clinicians and healthcare systems.

Objective: The Bristol heart inquiry in the United Kingdom (UK) highlighted the lack of standards for evaluating surgical performance and quality. In 2009, the World Health Organisation (WHO) proposed six standardised metrics for surgical surveillance. This is the first study to collect and analyse such metrics from a cohort of National Health Service (NHS) Trusts in England, helping to determine their feasibility and utility in measuring surgical performance, its impact on public health and mortality, and for tracking surgical trends over time. Methods: Freedom of Information Act 2000 (FOI) requests for WHO standardised surgical metrics were made to 36 NHS Trusts in England during July to November 2010. Additional data on Hospital Standardised Mortality Ratio (HSMR), Patient Safety Score and Abdominal Aortic Aneurysm (AAA) volume and mortality was obtained from Dr Foster Health and The Guardian Newspaper. Analysis was performed using mixed-effect logistic regression. Results: 30/36 trusts responded (83%). During 2005-9, 5.4 million operations were performed with a 24.2% increase in annual number of operations. This rising volume within hospitals was associated with lower mortality ratios. A 10% increase in operative volume was associated with a lower day of surgery death rate (DDR OR = 0.94, p = 0.056) and post-operative inpatient 30-day mortality (PDR30 OR = 0.93, p = 0.001). For every 10,000 more operations that an NHS Trust does, a 4% drop in PDR30 mortality was achieved. A 10% increase in the volume of elective AAAs was associated with lower elective AAA (OR = 0.96, p = 0.032) and emergency AAA (OR = 0.95, p = 0.009) PDR30 mortality. Lower DDR mortality was noted for emergency AAA mortality (OR = 0.95, p = 0.025) but not elective AAAs (OR = 0.97, p = 0.116). Conclusion: Standarised surgical metrics can provide policy makers and commissioners with valuable summary data on surgical performance allowing for statistical process control of a complex intervention. This study has shown their collection is feasible albeit using FOI and the first to show a statistically significant volume-outcome relationship for surgery as a whole within hospitals. It adds weight to the argument that patients are safer in larger hospitals or those that become larger by growing their patient base. Together with other measures, such metrics can help build a picture of surgical surveillance in the UK and potentially lead us to safer surgery. [ABSTRACT FROM AUTHOR]

Aim. The aim of this study was to determine whether an individual's country of origin influenced performance of self-care behaviours after heart surgery. Background. Patients are required to perform self-care behaviours following cardiovascular surgery. Usual care encompasses a patient education initiative that addresses self-care behaviour performance. Within Canada, current heart surgery patient education efforts have been designed and evaluated using homogenous samples that self-identify their country of origin as England, Ireland or Scotland. However, approximately 42·6% of Canadian cardiovascular surgical patients self-identify their country of origin as India or China. Thus, current cardiovascular surgery patient education initiatives may not be applicable to all patients undergoing heart surgery, which may result in decreased patient outcomes such as performance of self-care behaviours. Design. This descriptive study. Methods. A convenience sample of 90 patients who underwent heart surgery at one of two university-affiliated teaching hospitals, representing individuals of diverse backgrounds. Point-biserial correlational analysis was conducted to determine the relationship between country of origin and performance of self-care behaviours. Results. Findings indicate individuals who self-identified their country of origin as England or Ireland were associated with a higher score on the number of self-care behaviours performed ( p < 0·05) than individuals who self-identified other countries of origin. Self-care behaviours were taught using patient education materials that were designed based on feedback obtained from individuals whose country of origin was England or Ireland. Conclusion. This study provides preliminary evidence to suggest country of origin influences the amount of self-care behaviours individuals will perform. Relevance to clinical practice. Patient education initiatives should incorporate the values, beliefs, attitudes and customs reflective of an individual's country of origin to enhance the likelihood of producing desired outcomes. [ABSTRACT FROM AUTHOR]

Severe post-operative bleeding can lead to adverse outcomes for cardiac surgery patients and is a relatively common complication of cardiac surgery. One of the most effective drugs to prevent such bleeding, aprotinin, has been withdrawn from the market due to concerns over its safety. Alternative prophylactic drugs which can be given to patients to prevent bleeding can result in significant side effects and are expensive. For this reason it is difficult to make a clinical or economic case for administering these drugs to all cardiac surgery patients, and the prevailing view is that their use should be targeted at patients considered to be at relatively high risk of post-operative bleeding. However, there is currently no objective method for identifying such patients. Over the past 7 years, a team of clinicians and researchers at Papworth Hospital has collected data concerning post-operative blood loss for each cardiac surgery patient, totalling 11,592 consecutive records. They approached a team of operational researchers (MU, ACP, BR) with extensive experience of developing clinical risk models with the aim of devising a risk stratification scheme that could potentially be used to identify a cohort of higher risk patients. Such patients could be treated with the available prophylactic drugs or recruited to studies to evaluate new interventions. This paper is intended to describe the Operational Research process adopted in the development of this scheme. A concise description of the scheme and its clinical interpretation is published elsewhere. [ABSTRACT FROM AUTHOR]

Background Cardiopulmonary bypass during cardiac surgery can result in a shortfall in oxygen delivery relative to demand, marked by a decrease in muscle tissue oxygen saturation as blood flow is redistributed to vital organs. Such "tissue shock" might impair postoperative recovery. Objectives To determine the association of changes in tissue oxygen saturation with postoperative outcome in cardiac surgery patients. Methods In 74 adults undergoing cardiac surgery, tissue oxygen saturation in the thenar eminence was recorded using near-infrared spectroscopy before and during induction of anesthesia, throughout surgery, and in the intensive care unit until extubation or for a maximum monitoring time of 24 hours. The measurements were related to postoperative outcome. Results Mean tissue oxygen saturation increased from 81.7% to 88.5% with induction of anesthesia and decreased to 78.9%and 69.9% during surgery and on arrival in the intensive care unit, respectively. Saturation increased to 77.8% by 6 hours after surgery and remained stable. Mean saturation during the first minutes of anesthesia and 20 minutes in the intensive care unit was lower in patients with a postoperative morbidity than in patients without such morbidity on day 15 (81.1% vs 87.6%; P = .04) and on day 3 (72.9% vs 85.5%; P = .009). No associations with other outcome measures were observed. Conclusions In patients undergoing cardiac surgery, reduced tissue oxygen saturation in the thenar eminence may be associated with poor postoperative outcome. Further studies are needed to confirm these findings and to determine whether measures to improve the balance between oxygen delivery and consumption might improve both tissue oxygen saturation and outcome. [ABSTRACT FROM AUTHOR]

Abstract: Background: Primary cardiac and pericardial tumours are rare with a prevalence of between 0.001% and 0.3%. Thus, general pathologists are not familiar with them. Modern advances in cardiac imaging have increased the number of patients identified with a primary cardiac tumour in its early stage and also improved prognosis. At the Royal Brompton Hospital, London, we did a retrospective study to investigate the pathological features of primary cardiac and pericardial tumours and compared our findings to other cardiac centres. Methods: All pathologic records at the Royal Brompton Hospital between 1990 and 2008 were reviewed to identify patients with a confirmed diagnosis of primary cardiac tumours. A total of 94 patients with a histological diagnosis of primary cardiac and pericardial tumours were identified and formed the study population. Results: The majority (n=67, 71.3%) of cases were benign cardiac tumours. Myxoma was the most common histologic type accounting for 27 cases. Among cases with primary malignant tumours (n=27, 28.7%), unclassified sarcoma (n=11), leiomyosarcoma (n=5), and lymphoma (n=4) were the most common histologic types. Conclusion: This study, primarily from an adult setting (n=78, 83%) demonstrates a large spectrum of cardiac tumours seen in recent cardiologic practice. Myxoma is still the most common tumour but more fibroelastomas are being diagnosed due to increased imaging. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the frequency and nature of complications in patients undergoing diagnostic cardiac catheterisation and to assess time trends in complications since the introduction of a voluntary cooperative audit. Methods: Cardiac centres undertaking diagnostic cardiac catheterisation in England and Wales during the 10 years 1990–9 were invited to join the study. Each participating centre reported numbers of patients catheterised each month and details of complications and deaths as they occurred. Complication rates were calculated for the main diagnostic procedures and for each participating hospital and time trends in complications were examined. Results: 41 cardiac centres contributed. 211 645 diagnostic procedures in adults and 7582 paediatric procedures were registered. The majority (87%) of diagnostic catheter studies in adults were left heart studies with coronary arteriography. The overall complication rate for adult procedures was 7.4/1000, with mortality at 0.7/1000; for paediatric procedures the complication rate was similar but mortality rather higher. Complication rates varied between centres but there was little association with caseload. Time trends across the decade showed both complication and mortality decreasing; from 9.5 to 5.8/1000 and from 1.4 to 0.4/1000, respectively. Conclusion: Complication rates of diagnostic catheterisation are low but neither negligible nor irreducible. While voluntary audit of cardiac catheter complications is useful and inexpensive, there is a clear need to establish a formal reporting system in all cardiac catheter laboratories, with clear definitions of reportable complications. [ABSTRACT FROM AUTHOR]

A monitoring system for cardiac surgery has been in use at Papworth Hospital for 10 years. We wished to determine whether this system would have detected an increase in deaths associated with a single practitioner, whether a poorly performing doctor or a serial killer such as Dr Harold Shipman, whose activites went undetected in the absence of a monitoring system for nearly a quarter of a century. Random extra deaths were artificially introduced into the practice of a surgeon and an anaesthetist in a way that broadly reproduced Shipman's pattern. The standard monitoring system was then used to analyse the hypothetical data thus generated. Using the current standard monitoring, the excess deaths would have been detected in less than 10 months. Suspicions would have been raised even earlier. Robust local quality monitoring of risk-adjusted outcomes is possible and, in our opinion, essential. [ABSTRACT FROM AUTHOR]

Presents the abstracts of anesthesia-related studies presented at the summer meeting of the Association of Cardiothoracic Anaesthetists in Cambridge, England in June 2003 and the autumn meeting in London on November 2003. "Evaluation of a long radial artery catheter for the PiCCO system," by R.M. L'E. Orme and D.W. Pigott; "Dysaesthesia following cardiac surgery," by P. Pechon et al; "Postoperative metabolic acidosis following cardiac surgery," by A. Barakat.

Focuses on recommendations made by a public inquiry at the Bristol Royal Infirmary in England regarding the failures of surgeons involved in heart surgery on children. How to make the recommendations a reality in medical practice; Details of the recommendations; How appropriateness and outcome of care can be improved by engaging patients in treatment and management decisions; Need for feedback from patients in order to improve quality of care.

Examines the response of the Department of Health on the Kennedy Report regarding the Bristol Royal Infirmary pediatric cardiac surgery. Assessment of the significance of the report on midwifery profession; Consideration of the enactment future changes; Highlights of the provisions.

Objectives: To determine whether mortality between 1991 and 1995 in hospitals in England carrying out surgery for congenital heart disease in children was associated with the annual volume of cases and to estimate the extent to which an association could explain the apparent divergent mortality at Bristol Royal Infirmary. Design: Retrospective analysis of data from two sources, a register of returns by surgeons to their professional society and an administrative database. Setting: 12 hospitals in England carrying out surgery for congenital heart disease over the period April 1991 to March 1995. Main outcome measure: 30 day mortality. Results: For open heart operations in children under 1 year old, and in particular for arterial switches and repair of atrioventricular septal defect, there is strong and consistent evidence of an inverse association between mortality and volume of cases (not taking into account any data from Bristol). A hospital carrying out 120 open operations per year in 1991-5 on children aged under 1 year would be expected to have a mortality 25% lower than that in a hospital carrying out 40 operations. If the children in the hospitals had the same mix of operations, this reduction is 34%. Stratifying for types of operation or including the results from Bristol strengthens this association. It was also estimated that less than a fifth of the excess mortality at Bristol Royal Infirmary in open operations in children less than 1 year old was due to the hospital's lower volume of surgery. Conclusions: Using appropriate methods, this study showed that mortality in paediatric cardiac surgery was inversely related to the volume of surgery. Considerable caution is needed in interpreting these results, and it does not necessarily follow that concentrating resources in fewer centres would reduce mortality. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to quantify the distribution of peripheral arterial disease in the diabetic and nondiabetic population attending for angiography and to compare severity and outcome between both groups of patients.Research Design and Methods: Randomly selected lower-extremity angiograms were examined according to the Bollinger system. Patient demographics and medical history were recorded and case notes were examined to determine which patients later underwent a revascularization procedure or amputation and which patients had died.Results: A total of 136 arteriograms obtained between 1992 and 1996 were analyzed. The age (mean +/- SD) of the patients was 64.7 +/- 10.8 years. Diabetic patients (43%) and nondiabetic patients were of similar age (63.9 +/- 10.4 vs. 65.3 +/- 11.1 years, P = 0.43), with a similar history of smoking (81.0 vs. 76.9%, P = 0.26), ischemic heart disease (41.4 vs. 37.2%, P = 0.54), and hypercholesterolemia (24.4 vs. 30.8%, P = 0.48). However, there were a greater proportion of hypertensive patients in the diabetic group (63.8 vs. 39.7%, P = 0.006). Diabetic patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee (P = 0.02). A greater number of amputations occurred in the diabetic group: diabetic patients were five times more likely to have an amputation (41.4 vs. 11.5%, odds ratio [OR] 5.4, P < 0.0001). Mortality was higher in the diabetic group (51.7 vs. 25.6%, OR 3.1, P = 0.002), and diabetic patients who died were younger at presentation than nondiabetic patients (64.7 +/- 11.4 vs. 71.1 +/- 8.7 years, P = 0.04).Conclusions: In patients with peripheral arterial disease, diabetic patients have worse arterial disease and a poorer outcome than nondiabetic patients. [ABSTRACT FROM AUTHOR]

Interpretation: Our results suggest that Bristol was an outlier, and we do not believe that statistical variation, systematic bias in data collection, case-mix, or data quality can explain a divergence in performance of this size. [ABSTRACT FROM AUTHOR]

Examines gender differences in access to cardiac surgery in a nationally representative sample in England around 1993 and 1994. Disease and intervention rates in the study population; Socioeconomic status factor in health care access; Post-operative complication rate among women; Risk of mortality and non-fatal complications after myocardial infarction.

Following a recent enquiry into surgery at a paediatric cardiac centre in England, there will be substantial changes in the way that the success and failure of surgical procedures will be monitored and investigated. Post-mortem examinations on patients dying after cardiac surgery are likely to be performed and reported in more detail. This review describes the protocol that we have developed and summarizes recent clinical and pathological studies that have increased our understanding of postoperative pathophysiology. Close attention should be paid to the history, particularly the operation note. Cardiac failure is the commonest cause of death. We believe this is a clinicopathological diagnosis and provide definitions of preoperative and perioperative cardiac failure. Haemorrhage, stroke, pulmonary emboli and infection are other important causes of death. Methods of dissection are suggested for bypass grafts and valve replacements. Two recent studies show that the post-mortem examination provides answers to most clinical questions and reveals an unexpected cause of death in 10–15% of patients. There are limitations however: an incomplete or indeterminate cause of death is found in 14–25% of patients, most commonly sudden clinically unexplained death or clinically unexplained cardiac failure soon after surgery. [ABSTRACT FROM AUTHOR]

Recent tragic events at the Bristol Royal Infirmary represent a disaster for a number of different actors. First, and greatest, is the disaster for the bereaved families. Secondly, the unusually high mortality and morbidity rates exposed at the hospital trait suggest both clinical and managerial failures on behalf of practitioners and administrators. Thirdly, that the 'scandal' took almost a decade to uncover, and relied largely on the efforts of one individual, questions the institutions of medical self-regulation, and provides a graphic illustration of the culture of patronage embedded in British medicine. This article attempts to unpack some of the issues raised by the 'Bristol case'. After tracing some background, and examining the system of medical accountability and the nature of medical culture. I will ask how can we explain and attribute responsibility for such events? Adopting ideas from the study of disasters and errors permits a greater understanding. In particular, it is claimed that focusing the lens exclusively on the acts of the individuals in question hinders appreciation of the broader reality. For true learning and prevention, a larger picture must be taken, encompassing organizational and cultural aspects often 'hidden' on the quest to name and blame. [ABSTRACT FROM AUTHOR]

Focuses on the cardiac surgery in Wessex, England. Prevalence of operations for valve disease; Percentage of mortality for aortic valve replacement; Rate of percentage for mitral valve replacement.

The aim of this study was to discover what information and support patients feel they need in the 6-week rehabilitation period following discharge after cardiac surgery. It was undertaken at the request of the hospital multidisciplinary cardiac rehabilitation team to enable them to plan a package of information to meet those needs. It was a local study aiming to gain insight into the patients’ own views by asking them to keep a diary over the 6-week period and then take part in an unstructured interview when they returned for their 6-week out- patient appointment. The analysis of the respondents’ comments gave an insight into their whole experience of the first 6 weeks following discharge. The themes which emerged were wide-ranging and were grouped under the headings of the early discharge needs of pain relief and sleep promotion, psychological needs, practical needs and community support. To take the study forward, several recommendations were made to improve the rehabilitation experience. These included additions to the literature and patient education sessions, and changes to ensure a smoother transition into the community. The findings also suggest the need for improvements in and further research into the whole area of the psychological preparation for discharge after cardiac surgery. [ABSTRACT FROM AUTHOR]

Examines cardiac surgery in Wessex, England. Revision on the open-heart procedures carried out in the country; Use of conventional normothermic perfusion in adults; Rate of mortality in cardiac surgery.

At a recent in-house meeting at the European Association for Cardiothoracic Surgery (EACTS) headquarters in Windsor, the Chairs of the four domains were asked by the President to present their perception of the next 5 years in their respective domains. This review represents a distillation of our discussions on adult cardiac surgery. Advances in technology and imaging are having a radical effect on the working lives of surgeons. In clinical practice, the growth of heart teams and the breaking down of artificial barriers between specialities are altering the way we practice for the better. We see the development of hybrid approaches to many areas such as coronary artery surgery and operations on the thoracic aorta. These changes require careful analysis to ensure that they produce better outcomes that are also cost-effective. All health-care systems are at breaking point, and it is our responsibility to harness new technology to benefit our patients. This is all part of placing the patient at the centre of our activities. Hence, we see the involvement of patients in the design and analysis of clinical trials, which also require great mutual trust and cooperation between surgeons in different countries. Because of the dramatic changes in the pattern of working, we have had to alter our patterns of training and education, and we will continue to make significant innovations in the future. These are exciting challenges that will keep us all busy for the next 5 years at least. [ABSTRACT FROM AUTHOR]

Objective To describe trends in mortality of open cardiac surgery in children in Bristol and England since 1991. Design Retrospective analysis of hospital episode statistics data. Setting All open cardiac surgery of children in England. Population Patients younger than 16 undergoing open cardiac surgical procedures in England between April 1991 and March 2002. Three time periods were defined: epoch 3 (April 1991 to March 1995), epoch 5 (April 1996 to March 1999), epoch 6 (April 1999 to March 2002). Main outcome measure Mortality in hospital within 30 days of a cardiac procedure. Results We identified 5221 open operations between April 1996 and March 2002 in children under 1 year and 6385 in children aged 1-15 years. Mortality for all centres combined fell from 12% in epoch 3 to 4% in epoch 6. Mortality in children under 1 year at Bristol fell from 29% (95% confidence interval 21% to 37%) in epoch 3 to 3% (1% to 6%) in epoch 6, below the national average. The reduction in mortality did not seem to be due to fewer high risk procedures or an increase in the numbers of low risk cases. Oxford had a significantly higher mortality than the national average in all three epochs (11% (5% to 18%) in epoch 6), which was not affected by adjusting for procedure or the inclusion of cases with missing outcomes. Conclusions At Bristol, mortality for open operations in children aged under 1 year has fallen markedly, to below the national average. Nationwide mortality has also fallen. Improved quality of care may account for the drop in mortality, through new technologies or improved perioperative and postoperative care, or both. [ABSTRACT FROM AUTHOR]

Examines the quality of life of patients after cardiac surgery in Southampton, England. Information on the postoperative careers of patients; Benefit of cardiac surgery on the individual, family and the community; Return to work pattern for men of employment.

Purpose: To investigate ethnic differences in mortality for infants with congenital heart defects (CHDs) undergoing cardiac surgery or interventional catheterisation., Design: Observational study of survival to age 1 year using linked records from routine national paediatric cardiac surgery and intensive care audits. Mortality risk was investigated using multivariable Poisson models with multiple imputation. Predictors included sex, ethnicity, preterm birth, deprivation, comorbidities, prenatal diagnosis, age and weight at surgery, preprocedure deterioration and cardiac diagnosis., Setting: All paediatric cardiac surgery centres in England and Wales., Patients: 5350 infants with CHDs born from 2006 to 2009., Main Outcome Measure: Survival at age 1 year., Results: Mortality was 83.9 (95% CI 76.3 to 92.1) per 1000 infants, with variation by ethnic group. Compared with those of white ethnicity, infants in British Asian (Indian, Pakistani and Bangladeshi) and 'all other' (Chinese, mixed and other) categories experienced significantly higher mortality by age 1 year (relative risk [RR] 1.52[95% CI 1.19 to 1.95]; 1.62[95% CI 1.20 to 2.20], respectively), specifically during index hospital admission (RR 1.55 [95% CI 1.07 to 2.26]; 1.64 [95% CI 1.05 to 2.57], respectively). Further predictors of mortality included non-cardiac comorbidities, prenatal diagnosis, older age at surgery, preprocedure deterioration and cardiac diagnosis. British Asian infants had higher mortality risk during elective hospital readmission (RR 1.86 [95% CI 1.02 to 3.39])., Conclusions: Infants of British Asian and 'all other' non-white ethnicity experienced higher postoperative mortality risk, which was only partly explained by socioeconomic deprivation and access to care. Further investigation of case-mix and timing of risk may provide important insights into potential mechanisms underlying ethnic disparities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Administrative databases with dedicated coding systems in healthcare systems where providers are funded based on services recorded have been shown to be useful for clinical research, although their reliability is still questioned. We devised a custom classification of procedures and algorithms based on OPCS, enabling us to identify open heart surgeries from the English administrative database, Hospital Episode Statistics, with the objective of comparing the incidence of cardiac procedures in administrative and clinical databases., Design: A comparative study of the incidence of cardiac procedures in administrative and clinical databases., Setting: Data from all National Health Service Trusts in England, performing cardiac surgery., Participants: Patients classified as having cardiac surgery across England between 2004 and 2015, using a combination of procedure codes, age >18 and consultant specialty, where the classification was validated against internal and external benchmarks., Results: We identified a total of 296 426 cardiac surgery procedures, of which majority of the procedures were coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral repair and aortic surgery. The matching at local level was 100% for CABG and transplant, >90% for aortic valve and major aortic procedures and >80% for mitral. At national level, results were similar for CABG (IQR 98.6%-104%), AVR (IQR 105%-118%) and mitral valve replacement (IQR 86.2%-111%)., Conclusions: We set up a process which can identify cardiac surgeries in England from administrative data. This will lead to the development of a risk model to predict early and late postoperative mortality, useful for risk stratification, risk prediction, benchmarking and real-time monitoring. Once appropriately adjusted, the system can be applied to other specialties, proving especially useful in those areas where clinical databases are not fully established., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The article focuses on a year-long investigation of the cardiac unit of Leeds General Infirmary which concluded that care at the hospital is safe. According to the National Health Service (NHS) England, they found no evidence of excessive mortality in their review of the cases of 35 children who died between 2009 and 2013. Families complained of inadequate counseling and support after diagnosis as well as little compassion and understanding from the medical staff.

Aim: To explore the acceptability and feasibility of a parental early warning tool, called the Congenital Heart Assessment Tool (CHAT), for parents going home with their infant between first and second stage of surgery for complex congenital heart disease., Background: Home monitoring programmes were developed to aid early recognition of deterioration in fragile infants between first and second surgical stage. However, this necessitates good discharge preparation to enable parents to develop appropriate knowledge and understanding of signs of deterioration to look for and who to contact., Design: This was a longitudinal qualitative feasibility study, within a constructivist paradigm. Parents were taught how to use the CHAT before taking their infant home and asked to participate in semistructured interviews at four time points: before discharge (T0), 2 weeks after discharge (T1), 8 weeks after discharge (T2) and after stage 2 surgery (T3). Interviews were transcribed verbatim and thematically analysed., Setting: One tertiary children's cardiac centre in the UK., Subjects: Twelve parents of eight infants who were discharged following first stage cardiac surgery for complex congenital heart disease, between August 2013 and February 2015., Results: Four main themes emerged: (1) parental preparation and vigilance, (2) usability, (3) mastery, and (4) reassurance and support., Conclusions: The study highlighted the benefit of appropriately preparing parents before discharge, using the CHAT, to enable identification of normal infant behaviour and to detect signs of clinical deterioration. The study also demonstrated the importance of providing parents with information about when and who to call for management advice and support., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The article discusses an analysis by research director Anna Quigley, which revealed that sites in Birmingham, Bristol, Liverpool, two in London (Evelina Children's and Great Ormond Street hospitals), Newcastle and Southampton are ten congenital heart surgery services for children that will stay open. Each surgical service will be part of regional children's cardiology networks covering England and Wales with 156 quality standards, and minimum nurse staffing levels in each network..

The article focuses on reorganisation of children's heart services in England. Children's heart surgery and interventional cardiac catheterisation need to be conducted in fewer larger units. Care to be taken by nurses and doctors, who are trained to look after them in surroundings built for children.