Hospital Referral Guidelines

Michigan Health and Safety Coalition Hospital Referral Guideline for Open Heart Surgery*

• This volume-based guideline applies to all "open-heart" procedures performed by a hospital. (See Appendix A for a list of codes.)

• In collaboration with the Michigan Society of Thoracic and Cardiovascular Surgeons, all Michigan surgeons and hospitals performing open-heart surgery should collect clinical variables for the Society of Thoracic Surgery (STS) database to be analyzed by the Duke Clinical Research Institute (DCRI) and should participate in audits of data quality and accuracy as required.

• By May 2002, all Michigan cardiac surgeons performing open-heart surgery should work with the Michigan Society of Cardiovascular and Thoracic Surgeons Quality Committee to actively participate in designing and implementing a process improvement strategy that uses data derived from the Michigan Society of Thoracic and Cardiovascular Surgeons database. Active participation includes:

1. attending regularly scheduled meetings and developing processes by which data will be collected and data quality will be ensured;
2. reviewing, analyzing, using and refining the Michigan STS data;
3. identifying risk-adjusted morbidity and mortality indicators that reflect differences in quality of care (consider measures such as re-operation for post-operative bleeding, deep sternal infection, permanent stroke, prolonged ventilation, post-operative renal failure, and ratios of observed to expected mortality);
4. sharing information across surgical programs and learning from successful programs perhaps using the Northern NE Cardiovascular model of site visits and reverse-site visits to identify best practices;
5. developing, implementing, evaluating, and periodically updating measurable evidence-based quality of care indicators, hospital and physician-specific standards and guidelines, best practices and clinical protocols;
6. evaluating hospital and physician-specific performance relative to agreed upon standards and guidelines;
7. educating physicians and hospitals about quality of care indicators, standards, guidelines, protocols and best practices as well as their hospital-specific patient outcomes;
8. sharing data and disseminating hospital and physician-specific performance information with physicians;
9. identifying innovative models to cover the costs of data collection, analysis and use; and
10. creating a forum for discussion with purchasers and payors regarding data sharing.

• Pending a review and analysis of Michigan risk-adjusted mortality and morbidity data, only hospitals with annual volumes of at least 200 should perform open-heart procedures.

• Hospitals should require that their medical staff implement appropriateness criteria and use the criteria to conduct clinical case review of open-heart procedures.

Future direction of Coalition work related to the Open-Heart Surgery Guideline

Preliminary data from the Michigan STS database is expected to be available in 1Q2002. At that time, the STS data, along with national and other regional or state-level data should be analyzed and the volume threshold should be refined as appropriate.

* This is meant to be a guideline and not a standard of care; this guideline represents the best of an evidence-based review at this time; the guideline is based on the principles of CQI and is not intended to be used in a punitive manner; this guideline needs to be taken as a whole, and not have selected parts be used without considering the entire content of the guideline.