Developing Congenital Cardiac CT Services in Low-Resource Settings: A Quality Improvement Approach

Cardiac computed tomography (CCT) is increasingly used to evaluate congenital heart disease (CHD), but remains underutilized in low and middle-income countries (LMICs) due to training and system level barriers. Structured quality improvement (QI) strategies for safe implementation are limited. This initiative aimed to implement a high-quality congenital CCT service in a resource-limited public hospital through structured QI methods, multidisciplinary collaboration across cardiology, anesthesia, radiology, and surgery, and innovative training approaches including virtual mentorship without requiring new capital equipment. This QI initiative was conducted at a public tertiary hospital in Pakistan from January 2023 to June 2024. Interventions included protocol development, vendor-supported training, remote mentorship, and structured diagnostic review. Metrics such as radiation dose, tube voltage optimization, diagnostic error rate (DER), and sedation-related adverse events (SER) were monitored using run charts and paired t tests. Diagnostic discrepancies were classified using a structured taxonomy. A total of 118 congenital CCT scans were performed. Median dose length product declined from 915 to 62 mGy*cm (p < 0.001). Tube voltage optimization improved from 0% to 100% (p < 0.001). DER decreased from 9 to 0% and SER declined from 6 to 0%. Improvements were sustained in 152 post intervention scans. Indication appropriateness remained at 98% with no further DER and SER. Congenital CCT services can be safely implemented in low-resource settings using structured QI methods, mentorship, and multidisciplinary collaboration. This model may be applicable across similar healthcare environments.