Quality Improvement Projects

Adult Congenital Heart Disease Transition Working Group

Led by Felice Heller, the NECCA ACHD/Transition working group that came out of the 2012 annual meeting in Saybrook, CT developed a survey to perform a regional ‘Needs Assessment’.

  • ACHD Needs Assessment Survey

  • In order to tabulate results in a timely fashion and start to work on solutions, the deadline for completion is fittingly Valentine’s Day (Congenital Heart Disease Awareness Day), which is Friday, February 14, 2014. To make the results meaningful, we need to hear from all providers, not just those who take care of adult patients. If you have any questions, please do not hesitate to contact Felice at Fheller@connecticutchildrens.org

    NECCA Quality Improvement Steetring Committee Minutes

    December 21, 2013
    · The chest pain SCAMP will enter senior status where deviations from the guideline will be monitored rather than data actively collected and analyzed. The initial name is “SCAMPs Lite”, though many are lobbying for an alternative. A draft of the form for abbreviated data collection is attached and will be updated based on discussion. The go live date for use will be February 1st. We will discuss further on our January call.

    · The Syncope SCAMP SDF updates are attached and are ready for use. Some formatting changes specific to NECCA will be available shortly. The gender and age in days elements need to be added. Notably they increase the efficiency of the documentation process, allowing for rapid completion for Typical Syncope and translation of testing data to the SDF-2 follow up form when results are more logically available for those with more complex presentation

    · The Long QT forms with minor modification will go before committee at BCH. Now is the last chance to send comments before the pilot starts. Many opportunities for further comments based on the pilot will be available. All felt the forms though extensive were clear, intuitive and flowed well.

    November 21, 2013

    Present: Gerald Angoff; Michael Epstein; Ashley Renaud; Salgado, Teddy; Nancy Drucker; David Fulton; Mark Alexander; Naomi S. Gauthier; Hank Leopold; Niels Giddins; Lucy Arnold; Lisa Hom

    Chest Pain SCAMP ‘Lite’
    • Questions about chest pain data recently sent adding cardiac diagnosed cases
    • Proposal for graduated or senior status for the SCAMP
    • Form distributed
    • Questions: agree with status change? Agree with NECCA transition to the new form and process? Thoughts on the form
    • Idea of continuing to monitor the integrity of the developed/validated SCAMP guideline for changes in practice, shifts in following the guidelines
    • Set a date for transition? Some data from DC Children’s will still be coming in for their site validation
    • Final changes in the form
    • Implement through NECCA starting February 1st

    Syncope SCAMP data submission and analysis status
    • New SDF’s distributed
    • Approved by the SCAMP committee; concern for the IT work
    • Will switch with final distribution
    • Need age and gender
    • Final form adjustments
    • Switch to the updated forms when distributed

    Long QT SDF development status
    • Latest version of SDF sent out
    • Solicit comments from NECCA
    • To be submitted to BCH committee absent further comments or resultant changes
    • Issue of long QT found on cardiology evaluation for example when referred for another complaint
    • One abnormal QT EKG interpreted by cardiology will be enough to enter the SCAMP
    • Discussion over language, word choice
    • One page form on standardization of exercise test protocol to be part of documentation
    • Pilot will start on BCH committee approval
    • Start pilot after ETT protocol form developed and BCH committee approval

    September 26, 2013

    Present: Gerald H. Angoff; Michael Epstein; Kathy Rotondo; Ashley Renaud; Yvonne Paris; Salgado, Teddy; Nancy Drucker; Steven N. Weindling; David Fulton; Mark Alexander; Ashraf Harahsheh; Tsirka, Anna; Naomi S. Gauthier; Lucy Arnold; Olga Salazar

    Borderline QT SCAMP
    • Mike: draft best developed further perhaps face to face at NECCA meeting
    • Mark: significant questions that can be addressed at this point
    • Flow chart attractive for simplicity
    • Techniques for measurement: automated vs. cardiologists measurements to be tracked
    • Measurement technique: to standardize or leave to individual cardiologist
    • Which lead, number of beats to average in SA
    • Holter’s: difficult to specify because of the delay in results and finishing of the form
    • Collect data on Holter’s and echo’s without specifying as a guideline element?
    • Holter’s helpful with Schwartz score elements: NSVT, T alternans
    • Exercise test will also delay completion but needed
    • Exercise test: specify a number for post exercise measurement – 480 msec
    • Standing upright pre ETT QTc a new element to consider – add to #17; may discriminate among QT types
    • Family Hx of long QT: perhaps redundant as Fam Hx an exclusion
    • Elements are recommendations: Holter, ETT etc with question “did you follow”
    • Flow diagram needs more clarity: EKG timing and designation need more specificity; should add recommended testing
    • Outside EKG scanned and maintained in EMR per site and not submitted as part of SCAMP
    • Consider national death database search for subsequent sudden death?
    • Clear QTc prolongations exit the SCAMP
    • Diagnostic SCAMP; stops at Dx and not include Rx?; include in an SDF2?
    • Need to specify clearly when have exited the SCAMP
    • Pattern like Syncope where the writing committee will engineer drafts for QI committee monthly call review and/or obtain consensus on specific guideline issues
    • Next review at NECCA annual meeting
    • Consider like with Syncope a pilot study as first implementation
    • SDF next draft based on discussion
    • SDF and flow diagram review next at NECCA annual meeting
    • Value of in-person discussions
    • Concept of core writing group and larger QI committee review

    • Process reviewed: Yvonne for Syncope attestation and Gerry for Chest Pain attestation

    Next Meetings
    • At the NECCA annual meeting
    • November 21, 2013 – the third Thursday as Thanksgiving is the 4th

    August 22, 2013

    Present: Gerald H. Angoff; Michael Epstein; Niels Giddins; Kathy Rotondo; Ashley Renaud; Yvonne Paris; Salgado, Teddy; Nancy Drucker; Steven N. Weindling; David Fulton

    Topic Key Points Follow Up
    Review of agenda
    • Documents from Mike Epstein on long QT distributed before the meeting: Plausible Outcomes, Workflow, SCAMP SDF elements, Scoring System

    Borderline Long QT
    • Documents reviewed in sequence
    • Plausible outcomes revision: less tied to genetic testing; well written
    • Possible use of the national death indexes at some point
    • Possible SDF 2 for returning patients
    • SDF form elements: to be put in SDF format
    • For sinus arrhythmia method involved: average vs. sequential
    • Inclusion criteria: would patients enter and exit if two EKG’s not abnormal vs. enter only if 2 EKG’s abnormal? Consensus to enter all patients with a referral and then have a branch point if second EKG QTc normal
    • Flow diagram valuable as part of the SDF process
    • Schwartz score: create an input table
    • Electrolyte testing on the form perhaps optional and tracked
    • Genetic testing based on score; options for why and why not done
    • Score of >= 3 genetic testing recommendation; issue of insurance reimbursement • Next steps: incorporate suggestions
    • Pass along to BCH for review and formatting into SDF document and flow sheet
    Syncope SCAMP
    • Analysis of syncope data recently finished
    • Syncope writing group to meet soon for review; changes in SDF anticipated
    • 500+ patients
    • Echo’s not revealing
    • Mostly typical syncope
    • Orthostatic measurements to be revised
    Maintenance of Certification
    • Syncope attestation process from Yvonne soon in place
    • Online courses an effort: need to do only once
    • Participation on calls #4 in a year sufficient
    • Email to go out with process; to be sent to Mary Dunn
    • Register for fall conference: Dave Brown
    Next Meeting September 26th at 5:00 by conference call

    April 25, 2013

    Leader Gerry Angoff
    Attendees: Present: Gerald H. Angoff; Lucy Arnold; Michael Epstein; Niels Giddins; Seth Lapuk; Olga Salazar; David W. Brown; David Fulton; Kathy Rotondo; Hank Leopold; Mark Alexander; Ashley Renaud; David Kane; Lisa Hom; Ashraf Harahsheh; Yvonne Paris

    New QI Project
    • Discussion comprised the majority of the meeting time; limitations of phone call format and absence of Web link for projecting documents
    • Dave Fulton sent out some guidance on how to craft a plausible outcome statement (Plausible Finding); emphasis on making statements specific and data defined, e.g. percentages, time frames, measurable endpoints
    • BAV – Niels et al.
    o List read; direct review by those able to open email listing
    o More descriptive than numeric or data defined
    o In the past, SCAMP e.g. syncope, started with a background review on what is known and unknown
    o List should optimally reflect what is not known or agreed, concentrating on manageable time course for achieving results; focus at least in part on the short term
    o Next steps: add numeric/data aspects to the BAV plausible outcomes statement list and develop a background statement as an overview
    • Long QT – Mike et al
    o Started with discussion during a NECCA annual meeting breakout session on prolonged QT
    o A summary view or perspective implicit from prior discussion
    o Plausible outcomes statements sent out by Mike previously and sent with prior minutes
    o The Circulation paper of Leslie et al (sent with prior minutes) contains a long QT algorithm which the list reflects
    o EKG data, personal history, family history and genetics are major elements
    o Concern that genetics which are expensive is a major end point because of the cost
    o Schwartz criteria/score relevant
    o Issue of EKG’s done for screening in the absence of symptoms; increased likelihood of false positives; e.g. unconfirmed computerized reading
    o Should those with pre-referral abnormal EKG readings be included? Some sites have readings only by pediatric cardiologists, others not
    o Entry criteria key to crafting of SCAMP and plausible outcomes: to what degree should volume captured be limited? Any EKG? Only on referral?
    o Next steps: background paper or statement; proposal for inclusion/entry criteria into the SCAMP
    o Proposal that the EP group gather in person to facilitate efficiency and process • For BAV: Develop background statement; craft outcome statements to include more numeric and measurable criteria
    • For Long QT: Develop background statement; propose entry criteria; consider an in person meeting

    Syncope SCAMP
    • Data collection closed; to be analyzed at the end of April Update next call
    Chest pain SCAMP
    • Over 2,000 patients
    • Analysis deferred due to other ongoing activity; probably late this year

    Next Meeting May 23rd (4th Thursday) vs May 30th (5th Thursday)

    February 28, 2013

    Attendees: Gerald H. Angoff; Steven N. Weindling; Salgado, Teddy; Lucy Arnold; Ashley Renaud; Michael Epstein; Niels Giddins; Seth Lapuk; Olga Salazar

    Review of last conf. call minutes Prior minutes sent out
    Chest Pain SCAMP
    • Not addressed this call
    Syncope SCAMP Pilot Feedback
    • Not addressed this call
    New Project Possibilities
    • Email thread had circulated about possible projects to include current BCH SCAMPs of dilated aorta and aortic stenosis, both complex protocols with AS involving significant hemodynamic change (trivial AS excluded) and the dilated aorta connective disuse disease and BAV
    • Jim Locke email and phone call with Gerry proposing NECCA adopt “SCAMP Lite” (vs. “SCAMP Classic”) approach which consists of using a mature BCH SCAMP as a clinical practice guideline, reporting the variations from the SCAMP as the study outcome
    o Concern that NECCA would not be contributing to the guideline development and outcomes measurement, just the validity of the established SCAMP
    o Ashley’s comment: would not involve data collection, just deviation incidence
    o Consensus that NECCA should be involved in their own project
    • Consensus from email and discussion to study actual disease or pediatric cardiology condition rather than just resource utilization for otherwise unrelated symptoms such as chest pain and syncope and include in the study both current and longitudinal outcomes data
    • Among those on the call, Bicuspid Aortic Valve With and Without Stenosis, With and Without Dilated Aorta most attractive; could include longitudinal data and results from screening of first degree relatives both as an origin of the diagnosis and a consequence of the diagnosis
    • Other potential projects:
    o Premie PDA closure: difficulty in getting buy-in from neonatologists
    o Screening of athletes: controversial in the literature with economic and ethical issues and difficulties in defining the denominator
    o New born saturation mandate: anecdotally, referrals under the protocol rare; UVM is collecting retrospective data on presentation of neonatal CHD and finding few instances where the disease would have been missed based on pulse ox measurement
    o Hypertension: not discussed during the call but referenced in email threads: not everyone sees these folks who often or usually see nephrology
    • Need to involve the larger committee: emails, minutes and focus on the next call
    • Prior survey?: bicuspid AV strategies; Scott Yeager
    • Proceed with polling the committee on BAV with/without AS/Ao root dilatation as
    the next project to include BCH feedback

    Contact Gerrry Angoff or Erin Matthews if you are interested in participating on the next teleconference.