Quality Assurance Performance Improvement

Heart Institute at UPMC Children’s Hospital of Pittsburgh

As part of the Heart Institute, the Division of Pediatric Cardiology has a robust quality assurance/performance improvement (QAPI) process - a multi-disciplinary strategy in conjunction with cardiothoracic surgery, cardiac critical care medicine, cardiac anesthesiology, through a monthly review process with quality reports from each division and sections of pediatric cardiology (cath lab, echocardiography, fetal/perinatal, inpatient services).

Examples of recent quality/safety projects include:

1. Overall Heart Institute QAPI
   Track important global metrics in length of stay, ventilator days, CICU days, line infections rates, surgical mortality, surgical complication rates. These not only serve as important ways to improve quality and safety, they are also tracked nationally by organizations such as U.S.News & World report “Best Hospitals”.
2. Inpatient Service
   1. Ongoing monitoring and RN education in all areas of the hospital for proper EKG lead placement to address limb lead reversal errors.
   2. Inpatient/Outpatient Service: Introduction of the anticoagulation patient guide and the OP RN education being provided to prepare families for managing Coumadin therapy at home.
3. Echo Lab
   1. Hosts a monthly QAPI conference that reports to the Heart Institute QAPI committee, reviewing diagnostic errors and QAPI projects.
   2. To address wound infection - The use of the Hydroscan barrier for transthoracic ECHO for patients within the first 48 hours post op or with an open chest - Policy change approved.
   3. Each sonographer complete QAPI projects revolving around accuracy, measurement consistency, inter- and intra-observer variability.
4. Cardiology Educational Program
   Each cardiology fellow is mandated to do a QAPI project as part of their ACGME training, which is included as part of their fellowship portfolio – teaching a culture of quality to our trainees.
5. Cath Lab
   1. Hosts a monthly QAPI conference that reports to the Heart Institute QAPI committee.
   2. Participation in the Congenital Cardiac Catheterization Outcomes Project-Quality Improvement (C3PO-QI) National Registry with UPMC QI committee approval for this retrospective data collection and evaluation of cardiac cath patients.
   3. Participation in IMPACT (another national cath Quality registry).
6. EP
   Improving cardioversion process is under development.
7. CICU
   1. Hosts a monthly QAPI conference that reports to the Heart Institute QAPI committee.
   2. Leadership working on a sedation policy to adequately sedate all patients including the adult congenital patients.
   3. Feeding protocol for pre-op and high risk neonates with congenital heart disease final draft complete and ready to go to committee.
8. Cardiac Perfusion
   An ECMO database has been implemented and approved for a UPMC QI project, to facilitate tracking adverse event rates, length of therapy and safety protocols for ventricular assist devices.

This comprehensive multidisciplinary process has culminated in the improved outcomes, exemplified by the recent Society for Thoracic Surgery (STS) report for Congenital Heart Surgery was 110 (out of 120) pediatric cardiac programs in the United States. The programs are divided into 3 categories: low, medium and high volumes (Children’s Hospital of Pittsburgh of UPMC is a high volume program).

This report encompasses the last 4 years of data (July 2008 to June 2012). The national average mortality is 3.3% and Children's Hospital's mortality overall 4 years = 1.1%.

The Heart Institute at Children’s Hospital has the lowest overall 4 year mortality among all high and medium volume programs in the nation. Furthermore, as QAPI process has been implemented and become an integral part of clinical practice, we have further reduced our mortality to an incredible 0.6% this past year. In effect, QAPI is part of the Heart Institute culture of achieving excellence in a cost-effective manner.