Faisal Latif MD, FSCAI, and Suresh Mulukutla MD, FSCAI

As interventional cardiologists, we are constantly striving to achieve the best procedural outcomes for our patients. However, on occasion, the outcome is not what is desired and adverse events unfortunately do occur. As stewards of quality, SCAI emphasizes continuous quality improvement (CQI) across all cardiac catheterization laboratories (CCLs). To this end, SCAI published a position statement a few years ago.¹ A key element of CQI is random case review for all operators. It is important, as an interventionalist, to be familiar with the components of random case reviews, which essentially are commensurate with prevailing American College of Cardiology (ACC)/American Heart Association (AHA)/SCAI guidelines and appropriate use criteria (AUC). In this Tip of the Month, we discuss tips that will be helpful for interventional cardiologists and CCL directors/managers alike in developing a process for random case reviews. It is important for these case reviews to be equitable, random, and nonpunitive.

Click here to download a Random Case Review Template

Below is a suggested format for random case reviews:

A. Case Selection:

1. A randomizing tool should be established by a statistician to select cases for review.
2. A minimum but an equivalent number of cases should be reviewed for each operator at quarterly intervals (six to 10 cases/operator/year is a reasonable number), depending on caseload.
3. Elective as well as emergent cases should be included.
4. Each case should ideally be reviewed by at least two reviewers.
5. It is preferred that the data, including cath films, are provided to reviewers anonymously (patient and operator identifiers removed).
6. All operators whose cases are reviewed should also have the opportunity to serve as reviewers. There should be general agreement that this process, while onerous, is an essential component of CCL CQI.

 B. Components of Review:

1. Appropriateness of diagnostic coronary angiography and percutaneous coronary intervention (PCI) (per AUC criteria):
   1. Classifications include appropriate, may be appropriate, or rarely appropriate.
   2. Lesion severity: PCI in intermediate stenosis is only justifiable if instantaneous wave-free ratio (iFR)/fractional flow reserve (FFR) is significant or there is corresponding ischemia on the stress test.
2. Quality of angiogram:
   1. Adequate views and vessel opacification
   2. Reviewer’s assessment of lesion severity
3. Procedural complications:
   1. The complication was related to the operator's technique and was something that most operators could have avoided.
   2. The complication was related to patient factors but was something that most operators could have avoided.
   3. The complication was related to patient factors and not avoidable.
4. Was the management of procedural complications adequate?
   1. Yes, the complication was appropriately recognized and treated.
   2. No, the treatment was delayed or inadequate and could have resulted in patient harm.
   3. No, the complication was inadequately treated and resulted in patient harm.
5. Assessment of procedural success:
   1. Was the technical and procedural outcome suboptimal and/or unsuccessful?
   2. Were there any technical factors that contributed to a suboptimal result (anticoagulation and antiplatelet therapy, guide/guidewire choice, lesion preparation, stent length, and size)?
   3. If there was a complication, was it managed appropriately?
   4. Was the response from other services (if needed) adequate (anesthesia, cardiac surgery)?
6. Contrast amount and radiation dose:
   1. Was the contrast volume and patient radiation exposure in air kerma (AK) excessive for the type of PCI performed?
   2. Were there any measures to lower contrast and radiation exposure that could have been applied?
   3. Was there adequate documentation and follow-up for excessive contrast and/or radiation implemented by the operator?
7. Procedural documentation/cath report quality:
   1. Indication, equipment used, contrast amount, radiation dose, and recommendations for further care
   2. Were complications (if any) and their management adequately explained in the report?
   3. Was the cath report completed in a timely fashion?

C. Providing Feedback:

1. Each interventional cardiologist is provided written feedback of the random case reviews by the cath lab director or chief of cardiology (per institutional discretion).
2. The reviewer’s name should never be revealed.

Herein we have provided a suggested format for the random case review process and emphasized its importance in the current era of quality over quantity! Based on these suggestions, each CCL should devise its own format and policy best suited to its needs. It should be noted that random case reviews do not supplant the need for monthly or quarterly morbidity and mortality (M&M) conferences, where all major complications are discussed and their management is adjudged optimal or suboptimal.

Reference:

1. Klein LW, Uretsky BF, Chambers C, Et Al. Quality assessment and improvement in interventional cardiology: a position statement of the Society of Cardiovascular Angiography and Interventions, part I: standards for quality assessment and improvement in interventional cardiology. Catheter Cardiovasc Interv. 2011 Jun 1;77(7):927-35.