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Using tracking data to find complications that physicians miss: the case of renal failure in cardiac surgery
1Clinical Data Services, Health Data Research, Inc, Portland, OR 97221, USA. uspl@worldnet.att.net
Insights
A fast-track protocol in cardiac surgery was linked to increased renal failure in high-risk patients. Adjusting the protocol for these patients reduced renal failure incidence while maintaining shorter intensive care unit (ICU) stays for others.
Area of Science:
- Cardiovascular Surgery
- Nephrology
- Health Informatics
Background:
- Health Data Research, Inc. (HDR) manages clinical registries, including the Merged Cardiac Registry.
- Quarterly reports revealed inconsistent and out-of-range data, prompting further investigation.
- An increase in moderate and severe renal failure was observed in 3 of 30 contributing centers between 1992-1996.
Purpose of the Study:
- To investigate the causes of increased renal failure incidence in cardiac surgery patients.
- To identify risk factors and protocols associated with renal failure.
- To optimize patient care protocols for improved outcomes.
Main Methods:
- Analysis of detailed clinical databases from contributing centers.
- Development of a risk model to identify high-risk patients for renal failure.
- Utilizing run chart analysis to detect trends and protocol impacts.
Main Results:
- A fast-track protocol was identified as a potential cause for increased renal failure.
- The risk model identified 20% of patients as high-risk for renal failure.
- Protocol modifications for high-risk patients in mid-1995 led to a decrease in renal failure rates below baseline.
Conclusions:
- Protocol adjustments for high-risk patients effectively reduced renal failure incidence.
- The study successfully balanced the need to mitigate renal failure risk with the benefits of rapid extubation and shorter ICU stays for other patients.
Background:
Health Data Research, Inc (HDR) develops, manages, and maintains clinical registries from physicians and hospitals, including the Merged Cardiac Registry. Quarterly reports indicate data that are inconsistent, out of range, or outside the norms found in other medical centers.
Case Study:
In reports on cardiac surgery patients, HDR noted that for the 1992-1996 period, 3 of the 30 contributing centers experienced a significant increase in the incidence of moderate and severe renal failure. One of these three contributors gave HDR access to its detailed clinical database, and HDR ruled out most of the suspected causes for this increase in renal failure. A risk model for renal failure identified 20% of the patients to be at high risk. HDR then isolated a fast-track protocol as the culprit. One of the 30 contributing centers found that the protocol was associated with significant decreases in the intensive care unit (ICU) and hospital lengths of stay. However, as the severity of renal failure increased, charges, average length of stay, transfusions, and ICU times increased. At one of the three sites, after protocol changes were instituted in mid-1995 for the high-risk patients, the rate of renal failure reverted to below baseline levels.
Summary And Conclusions:
Analysis of run charts led to protocol changes for patients at high risk of renal failure, while retaining the positive outcomes associated with rapid extubation and shorter ICU stays for the remaining 80% of the patients.