Formulation of Quality Improvement Methodology for Risk Mitigation in Congenital Cardiac Catheterization

Area of Science:

• Cardiology
• Pediatrics
• Quality Improvement Science

Background:

• The C3PO collaborative has a proven track record in quality improvement (QI).
• Congenital cardiac catheterization carries risks of adverse events (AEs).
• A multi-center approach is needed to standardize and improve safety protocols.

Purpose of the Study:

• To develop and implement a multi-center quality improvement (QI) initiative aimed at reducing adverse events (AEs) in congenital cardiac catheterization.
• To identify key drivers and develop actionable strategies for AE prevention.
• To create tools, such as a risk calculator, to support pre-procedure communication and risk assessment.

Main Methods:

• A 32-person interdisciplinary working group analyzed 2014-2017 data from 10 sites (14,717 cases).
• Root cause analysis informed a key driver diagram focusing on risk assessment, preventable events, and procedure length.
• An online risk calculator was developed using 2014-2019 data to aid pre-procedure planning.

Main Results:

• Between 2014-2017, high-severity (level 3/4/5) AEs occurred in 5.0% of cases, and level 4/5 AEs in 1.5%.
• Key drivers identified were Pre-Procedure Risk Assessment, Possibly Preventable Events, and Procedure Length Optimization.
• Change strategies were developed around five communication timepoints, integrated with a risk calculator and scheduling tools.

Conclusions:

• The developed protocol enhances catheterization team efficiency in responding to AEs.
• Improved resource planning and risk assessment aim to prevent the escalation of adverse events.
• The protocol offers reproducible interventions adaptable to various clinical settings for improved patient safety.