The C3PO collaborative, with a history of successful quality improvement (QI) initiatives, leveraged registry participants to develop a multi-center QI initiative to reduce adverse events (AEs) in congenital cardiac catheterization. A 32-person, interdisciplinary working group analyzed audited data for all congenital cardiac catheterization cases from 2014-2017. The primary outcome was the occurrence of any high-severity (level 3/4/5) AE. Cases were organized from shortest to longest duration, and level 3/4/5 and 4/5 AE rates were summarized for each procedure duration decile. Observations from the root cause analysis were used to inform the creation of a key driver diagram and determine change strategies and implementation tools. To facilitate pre-procedure communication and risk assessment, an online risk calculator was developed using 2014-2019 data. Between 2014-2017, 14,717 cases were entered from 10 sites. Level 3/4/5 AEs occurred in 732 (5.0%) cases, while 4/5 AEs occurred in 224 (1.5%) cases. The key driver diagram defined three drivers: (1) Pre-Procedure Risk Assessment, (2) Possibly Preventable Events, and (3) Procedure Length Optimization. Actionable change strategies organized around five communication timepoints were developed in interdisciplinary discussions. Pre-case risk calculator outputs were available as a case summary print out and incorporated into a calendar for weekly schedule planning. Pre-intervention (2019) and preliminary intervention period data (2020-2021) are presented here. Through improved resource planning, the protocol equips catheterization teams to respond efficiently to AEs and possibly prevent escalation into dangerous events. This protocol provides reproducible interventions that can be adapted to local practice.
Keywords: Adverse events; Congenital cardiac catheterization; Quality improvement; Risk mitigation.
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