THE PRE/PERI/POST-OPERATIVE PROVINCIAL PACEMAKER PROJECT (P6) - A QUALITY IMPROVEMENT INITIATIVE TO DRIVE HIGH QUALITY PACEMAKER CARE IN BRITISH COLUMBIA

Abstract

Pacemakers (PM) are life-saving devices used to enhance care for patients with symptomatic bradycardia. Preliminary reports suggest regional variability throughout British Columbia (BC) with respect to implant rates, device types used, and the quality of care delivered. Cardiac Services BC (CSBC), in partnership with physician leaders, have embarked on a 3-year initiative to establish a coordinated service network to improve PM care throughout the province. Initial work included current state mapping of PM care using a patient pathway framework and an inaugural provincial meeting to discuss clinical outcomes following pacemaker implants. For each site, the following was compiled: process maps describing the flow of cardiac information, review of protocols and patient materials and identification of the skills, roles and comfort of intraoperative team members. The CSBC information system, Discharge Abstract Database, and BC Vital Statistics were used to analyze the outcomes of all BC residents aged >18 years who underwent a PM procedure between 2008 and 2014. Quality indicators evaluated at the provincial, site and operator level included: 30-day, 1-year and 2-year repeat procedure rate, 30-day all-cause hospital readmission, 30-day and 1-year mortality, and 30-day device-related complications. Variability existed among the 13 active PM centres with respect to referral management, intraoperative team, use of protocols and checklists, OR availability and procedure scheduling, and patient discharge education. 27,556 PM procedures were included in the outcomes analysis. The 30-day repeat procedure rate in BC was 2.5%, (sites range from 0.7% to 6.6%) and increased to 4.6% for BC at 1-year (range 1.8% to 10.4%). Kaplan-Meier analyses (4-year follow-up) revealed that the majority of repeat procedures occurred within the first 60-days of the procedure. After-hour procedures (18.2% of BC procedures) were associated with a 30% increased risk of requiring a repeat procedure. Overall, 74% of 30-day repeat procedures followed an initial implant and 86% of these were due to the lead. The 30-day BC complication rate was 6.0% (range 3.4% – 14.2%) and the 30-day BC mortality rate was 1.3% (0.7-2.1%). Variability is expected in a decentralized system with care models that serve different geographical regions. Our findings reveal the need for a provincial quality improvement initiative whose key targets are to include: device selection alignment with current guidelines, lead selection and implant technique, ongoing physician and staff training and collaboration, support for scheduling and operational logistics, patient education, and standardized data collection including patient reported complications.