FIASCO - Never Events in Cardiac Surgery

The main reason why cardiac surgeons were the first to publish meaningful surgical outcomes is the ability for them to risk stratify each individual patient about to undergo heart surgery.  In other words, it is possible to state the risk of that particular patient dying or even more usefully to state what the predicted death rate for a group of patients is. This can than be compared to the actual death or mortality rate. Using this data, it is possible therefore to correct for the fact that certain surgeons operate on higher risk patients than others. In In this novel study entitled FIASCO, Nashef et al from Papworth Hospital examined the deaths of patients who had very low risk scores - i.e. they were not expected to die. As expected the mortality rate was very low and the individual circumstances surrounding each death were different from those discovered when a similar analysis was made several years ago - evidence that the team was learning.
This exercise is immensely useful to me in my cardiac surgical practice. In my opinion every death should reviewed at an M&M (Morbidity and Mortality) meeting. But what this study has added is that every death of a 'low risk' patient (and low risk is easily defined in cardiac surgery) should be classed as a never event and investigated fully with all the resources an institute has at its disposal. 

Prince Philip and the #NHS

Prince Philip was admitted to Papworth hospital on Xmas Eve having suffered an episode of chest pain. He went on to receive a coronary stent within hours of admission. It is likely therefore that he suffered a ST elevation myocardial infarct (STEMI) or heart attack. It has been suggested in the blogosphere that he received a standard of treatment most plebs would not have received. A STEMI is diagnosed with an on site ECG that is performed by the paramedics.  Until a few years ago, the gold standard of treatment for patients suffering a STEMI was to give an intravenous injection of a clot buster or thrombolysis within 3-4 hours of onset of chest pain. This would dissolve the clot blocking the coronary artery at the site of a narrowing and a full blown potentially fatal heart attack averted. A few years ago, evidence start to emerge that if patients were taken within 3-4 hours straight to the cardiac catheterisation lab, a coronary angiogram performed and the offending blockage in the coronary artery removed mechanically and a coronary stent used to reopen the narrowing, the results were even better than thrombolysis. Getting the cath (catheterisation) lab (not present in all hospitals) and all the staff (who are not resident) ready within 60 minutes of a call several times a night is logistically challenging. I personally thought that it could never happen on a large scale . The above graph from Anglia Strategic Health Authority shows that the percentage of STEMIs or heart attacks treated with Primary Percutaneous Intervention  or PPCI (which is what the procedure is called) has gone from 0% to just under 100% in 2 years These figures are quite extraordinary & have been reproduced around the country (and can be found here). They do represent a triumph for the NATIONAL health service and show that Prince Philip received treatment 90+% would have received. 

Flying Pigs in my lifetime?

This piece on BBC news today about an article in the Lancet brought back vivid memories.
During my cardiothoracic surgical training in the early 1990s, I spent three years at Papworth Hospital in Cambridge.  Eighteen months of these three years were spent as Senior Transplant Fellow.