Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Mejia, Omar Asdrúbal Vilca; Mendonça, Frederico Carlos Cordeiro de; Sampaio, Lucimar Aparecida Barrense Nogueira; Galas, Filomena Regina Barbosa Gomes; Pontes, Mauricio Franklin; Caneo, Luiz Fernando; Dallan, Luís Roberto Palma; Lisboa, Luiz Augusto Ferreira; Ferreira, João Fernando Monteiro; Dallan, Luís Alberto de Oliveira; Jatene, Fabio Biscegli

doi:10.1016/j.clinsp.2022.100048

Omar Asdrúbal Vilca Mejia ^**Corresponding author. E-mail address: omar.mejia@incor.usp.br (O.A.V. Mejia)

Quality and Safety Surgical Unit, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-1635-4984

Frederico Carlos Cordeiro de Mendonça

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-8899-1763

Lucimar Aparecida Barrense Nogueira Sampaio

Nursing Unit of the Surgical Center, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-8765-8010

Filomena Regina Barbosa Gomes Galas

Anesthesiology Unit, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0003-0803-403X

Mauricio Franklin Pontes

InnovaSpace UK, Space & Extreme Environment Research Center, Universidade Federal de Ciências da Saúde de Porto Alegre, RS, Brazil

http://orcid.org/0000-0001-6490-8868

Luiz Fernando Caneo

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0001-5545-8172

Luís Roberto Palma Dallan

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0001-8137-5434

Luiz Augusto Ferreira Lisboa

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-2137-0604

João Fernando Monteiro Ferreira

Patient Safety Subcommittee, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0001-9184-7140

Luís Alberto de Oliveira Dallan

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-8655-8966

Fabio Biscegli Jatene

Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0001-6175-5595

*Corresponding author. E-mail address: omar.mejia@incor.usp.br (O.A.V. Mejia)

Author's contribution

OAVM and FBJ conceived, designed, and directed the project. OAVM, FCCM, and MP were involved in planning and supervising the work. FCCM, LABNS, FRBGG, LFC, and JFMF Collected the data. LRPD and LAFL performed the analysis, drafted the manuscript, and designed the figures. OAVM aided in interpreting the results and wrote the manuscript. All authors discussed the results and revised the final content of the manuscript.

Conflicts of interest

The authors declare no conflicts of interest.

	2013		2014		2015		2016		2017		2018		2019
Variables	n	%	N	%	n	%	n	%	n	%	n	%	n	%
Procedure ^a a IQR, Interquartile Range 25% and 75%.
CABG	584	51.1%	614	51.0%	622	52.4%	549	51.7%	523	52.2%	554	51.6%	700	47.6%
CABG + valve surgery	87	7.61%	89	7.04%	61	5.13%	40	3.77%	67	6.69%	46	4.28%	91	6.19%
Mitral valve surgery	212	18.5%	234	19.4%	255	21.5%	225	21.2%	187	18.7%	198	18.4%	374	25.5%
Aortic valve surgery	211	18.5%	215	17.9%	187	15.7%	193	18.2%	166	16.6%	211	19.6%	215	14.6%
Mitral + aortic valve surgery	49	4.29%	51	4.24%	63	5.03%	54	5.09%	58	5.79%	65	6.05%	89	6.06%
Procedure status
Elective	1015	88.8%	1057	87.9%	1046	88.0%	787	74.2%	734	73.3%	778	72.4%	1125	76.6%
Urgency	128	11.2%	146	12.1%	142	11.9%	274	25.8%	267	26.7%	296	27.6%	344	23.4%
Age, median (IQR) ^a a IQR, Interquartile Range 25% and 75%.	63	(54–70)	63	(54–70)	62	(54–69)	61	(52–68)	62	(54–69)	62	(53–69)	61	(53–68)
Gender
Male	704	61.6%	762	63.3%	726	61.1%	670	63.1%	616	61.5%	648	60.3%	883	60.1%
Female	438	38.3%	441	36.7%	462	38.9%	391	36.8%	385	38.5%	426	39.6%	585	39.8%
Systemic arterial hypertension	389	34.0%	460	38.2%	487	41.0%	381	35.9%	377	37.7%	357	33.2%	526	35.8%
Insulin-dependent diabetes	26	2.27%	16	1.33%	19	1.06%	17	1.06%	19	1.09%	19	1.77%	32	2.18%
Non-insulin dependent diabetics	133	11.6%	116	9.64%	109	9.18%	102	9.61%	127	12.7%	106	9.87%	153	10.4%
Acute renal failure	11	0.96%	11	0.91%	14	1.18%	26	2.45%	25	2.05%	23	2.14%	27	1.84%
Chronic renal failure	24	2.1%	16	1.33%	13	1.09%	19	1.79%	14	1.04%	17	1.58%	29	1.97%
Atrial fibrillation	60	5.25%	61	5.07%	52	4.38%	36	3.39%	32	3.02%	32	2.98%	53	3.61%
Obesity (IMC >40)	29	2.54%	28	2.33%	26	2.19%	20	1.89%	20	1.99%	24	2.23%	34	2.31%
LVEF, median (IQR) ^a a IQR, Interquartile Range 25% and 75%.	60	(50–64)	61	(55–64)	61	(55–64)	61	(55–64)	61	(55–64)	61	(55–65)	60	(55–64)
EuroSCORE, mean, ± standard deviation	1.98	±1.13	1.51	±0.53	2.53	±2.92	2.72	±4.58	2.52	±4.22	2.51	±4.23	2.48	±4.31
New York Heart Association NYHA
I	8	0.69%	7	0.58%	9	0.76%	6	0.57%	6	0.06%	6	0.56%	8	0.54%
II	1126	98.5%	1189	98.8%	1169	98.4%	1033	97.4%	972	97.1%	1054	98.1%	1436	97.7%
III	6	0.52%	7	0.58%	8	0.67%	19	1.79%	20	2.00%	12	1.12%	19	1.29%
IV	3	0.26%	0	0%	2	0.17%	3	0.28%	3	0.03%	2	0.19%	6	0.41%
ASA score ^b b American Society of Anesthesiologists.§Defined as the inability of the heart to provide the necessary blood flow for the vital organs (cardiac failure without ventricular failure, ventricular failure with or without abnormal ventricular systolic function, prolonged tachycardias or tachyarrhythmias in normal hearts).
I	1	0.09%	1	0.08%	2	0.17%	0	0%	2	0.02%	0	0%	0	0%
II	42	3.67%	41	3.41%	29	2.44%	24	2.26%	17	1.07%	51	4.75%	49	3.34%
III	681	59.6%	613	51.0%	718	60.4%	654	61.6%	594	59.3%	691	64.3%	923	62.8%
IV	416	36.4%	544	45.2%	435	36.6%	383	36.1%	386	38.6%	328	30.5%	497	33.8%
v	3	0.26%	4	0.33%	4	0.34%	0	0%	2	0.02%	4	0.37%	0	0%
anemia	53	4.64%	46	3.82%	44	3.07%	45	4.24%	27	2.69%	32	2.98%	77	5.24%
Previous acute myocardial infarction	74	6.47%	89	7.04%	97	8.16%	112	10.6%	105	10.5%	99	9.22%	139	9.46%
Angina	97	8.49%	86	7.15%	77	6.48%	72	6.79%	66	6.59%	64	5.96%	116	7.9%
Chronic obstructive pulmonary disease	19	1.66%	17	1.41%	15	1.26%	16	1.51%	17	1.07%	17	1.58%	37	2.52%
Asthma/ bronchitis	9	0.79%	14	1.16%	6	0.51%	6	0.57%	3	0.3%	1	0.09%	15	1.02%
Stroke	18	1.57%	13	1.08%	15	1.26%	9	0.85%	10	1%	13	1.21%	25	1.07%
Dilated Cardiomyopathy	15	1.31%	8	0.67%	11	0.93%	11	1.04%	7	0.07%	13	1.21%	19	1.29%
Cardiogenic Shock	9	0.79%	8	0.67%	7	0.59%	15	1.41%	18	1.8%	5	0.47%	19	1.29%
Peripheral arterial disease	16	1.04%	20	1.66%	14	1.18%	5	0.47%	8	0.08%	7	0.65%	12	0.82%
Valvar endocarditis	31	2.71%	23	1.91%	31	2.61%	24	2.26%	20	2%	18	1.68%	35	2.38%
Cardiac insufficiency^c	67	5.86%	69	5.74%	84	7.07%	67	6.31%	48	4.8%	50	4.66%	67	4.56%

	2013		2014		2015		2016		2017		2018		2019
Variables	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Intra-aortic balloon	124	10.8%	156	13.0%	113	9.51%	101	9.52%	73	7.29%	55	5.12%	143	9.73%
Hemotransfusion	154	13.5%	134	11.1%	161	13.5%	126	11.9%	191	19.1%	307	28.6%	371	25.3%
Length of stay in the preoperative phase (days), median (IQR)^a a IQR, Interquartile Range 25% and 75%.	5.10	(1.10–10.5)	3.00	(1.00–7.40)	3.60	(0.90–7.40)	2.80	(0.90–6.90)	2.10	(0.80–6.50)	1.70	(0.80–5.80)	1.10	(0.70–40.7)
Operating room time (hours), median (IQR)^a a IQR, Interquartile Range 25% and 75%.	6.83	(6.00–7.75)	6.83	(6.08–7.67)	6.62	(6.17–7.83)	7.00	(6.33–7.95)	7.25	(6.42–8.25)	7.12	(6.25–8.17)	6.83	(6.08–7.67)
Length of stay in the postoperative phase (days), median (IQR)^a a IQR, Interquartile Range 25% and 75%.	9.25	(7.10–15.8)	9.10	(7.00–14.8)	9.00	(7.00–14.0)	8.10	(6.80–12.5)	8.80	(6.90–14.8)	8.00	(6.70–13.8)	8.90	(6.90–14.5)
Length of hospital stay (days) median (IQR)^a a IQR, Interquartile Range 25% and 75%.	17.0	(11.1–27.6)	15.0	(10.0–22.9)	14.5	(9.40–21.9)	13.7	(9.00–20.4)	13.4	(9.10–21.7)	12.7	(8.60–19.9)	12.4	(8.80–18.9)
30-day mortality	94	8.22%	82	6.82%	89	7.49%	69	6.5%	57	5.69%	50	4.66%	46	3.13%

Questionnaire	Answer^a a Score ranges from 1 (completely disagree) to 5 (completely agree). (mean ± standard deviation)
I believe that the InCor-Checklist will make the surgical team better able to perform safe surgeries	4.86 ± 0.4
I believe that the InCor-Checklist will be easy to use	4.01 ± 0.9
I would use the InCor-Checklist if I was part of the surgical team	4.98 ± 0.1
If I had an operation, I would like the surgical team to use the checklist	4.94 ± 0.2

Year	Number of surgeries	Mortality	InCor-Checklist use	Checklist completeness (5 phases)
2013	1143	8.22%	0%	–
2014	1203	6.82%	0%	–
2015	1188	7.49%	58%	3.3
2016	1061	6.5%	75%	3.2
2017	1001	5.69%	72%	3.1
2018	1074	4.66%	94%	3.6
2019	1469	3.13%	100%	3.9

[1] *Corresponding author. E-mail address: omar.mejia@incor.usp.br (O.A.V. Mejia)

Brasil

Brasil

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Abstract

Objectives

Methods

Results

Conclusion

HIGHLIGHTS