Einleitung Rückblick
20 Jahre Herzchirurgie im Kanton Aargau
Herzchirurgie Hirslanden Klinik Audit Qualitätsproblematik KVG Schluss
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Hirslanden Klinik 1990
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Klinik im Schachen
Herz Zentrum Hirslanden Aarau
Hirslanden Klinik 2000
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
KANTON AARGAU (INVASIVE) KARDIOLOGIE
KANTON AARGAU
60 %
KSA NF
HERZCHIRURGIE
Basel
40 %
HIRSLANDEN
KSB NF
HIRSLANDEN NF
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
12
PROJEKT HERZZENTRUM AARGAU (INVASIVE) KARDIOLOGIE
HERZCHIRURGIE
KSA NF HIRSLANDEN KSB (NF) HIRSLANDEN (NF)
13
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Hirslanden Klinik Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
ECMO 2 Herzchirurgen
3 Interventionelle Kardiologen
2 Kardiotechniker
2 Rhythmologen
Anästhesisten / Intensivisten
Herzchirurgie 2 NichtInterventionelle Kardiologen
OP–Schwestern (TOA)
2 MPA‘s
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Abteilungspersonal (Telemetrie)
Surgery
In coronary artery surgery, the „open method“ is used for vein harvesting, and is performed to an extremely high standard. Endoscopic harvesting has also been used.
laser QT_PowerPoint_Hi.mpg
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Summary and Conclusions To improve sustained angina relief [class I, level A evidence] To reduce MACE and improve exercise performance [class I, level A evidence ] To reduce readmissions and reinterventions [class IIa, level B evidence] 1. In patients with diffuse CAD who cannot be completely revascularized by CABG alone adjunctive TMR + CABG can be recommended: To improve long term angina relief [class IIa, level A evidence ] To reduce 30-day mortality and MACE [class IIa, level A/B evidence] To improve 1-year exercise performance [class IIa, level A evidence ]
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Transmyokardiale Laserrevaskularisation 1
Transmyokardiale Laserrevaskularisation 2
n = 13
(Juli 94 – August 98)
f-up
Ø Alter
63.9 Jahre
AP NYHA 3.8 → 1.4
EF
58%
REDO‘S
10
9 Patienten mit Te-Sestamibi-Szinti
TMLR allein 5 TLMR + AKB
38 Monate
8
Herz Zentrum Hirslanden Aarau
verbessert
6
verschlechtert
1
unverändert
2
Herz Zentrum Hirslanden Aarau
Vergleich ganzes Jahr 2011 Hirslanden Klinik Aarau und Universitätsspital Basel
Standby – KSA 2000 bis 2011 90 80 70
Hirslanden Klinik
Anzahl Fälle
60
BypassOperationen
62
KlappenOperationen
50 40 30 20 10
Anzahl Fälle
BypassOperationen
70
21
KlappenOperationen
73
Spez. Herzoperationen
5
Spez. Herzoperationen
25
Total
88
Total
168
20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11
0
Anzahl
Universitätsspital Basel
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Anzahl Herzoperationen 250
200
The referral rate from Cardiologists at the KSA seems to be inappropriately low. We are not sure why this is, given the quality of service at the clinic.
andere Klappen ACBP
150
100
50
Herz Zentrum Hirslanden Aarau
10 11 20
09
20
07
08
20
20
20
05 06 20
03
02
04
20
20
20
20
99
98
00 01 20
20
19
97
19
19
94
93
95 96 19
19
19
19
19
92
0
Herz Zentrum Hirslanden Aarau
Durchschnittsalter 1992 - 2011 71 69 67 65 63 61 59 57 55
92 93 94 95 96 97 9 8 99 00 01 02 03 04 0 5 06 07 08 09 10 11 19 19 1 9 19 19 1 9 19 19 20 2 0 20 20 20 20 20 20 20 20 20 20 Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Service Review Report May 2010 Confidential Hirslanden Klinik Aarau
Cardiac Surgical Services
Herz Zentrum Hirslanden Aarau
Currently, the cardiac service of the clinic does not seem to have sufficient public visibility, despite the cardiac surgeons engaging with local media, and GPs in the past. We randomly interviewed members of the public, and were surprised to find that few were aware either of the clinic or that cardiac surgery is performed there. We are not certain that patients with general insurance actually know they can have heart surgery in Hirslanden without having to pay more. Herz Zentrum Hirslanden Aarau
General Conclusions
Risk Assessment
Overall, we assessed the cardiac surgical provision as being excellent.
The figures for the last 3 years show a mean additive euroscore of 6.7 and logistic euro score in the region of 8-11. The figures seem consistent over several years. The mean ejection fraction was about 56%.
All aspects of the review show at least a substantial contribution to the attainment of the stated aims. - There is much evidence of patient care and attention to detail - There is excellent team work, collaboration and relationships - There are excellent clinical guidelines, and protocol documents in use
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Conclusions Clinical effectiveness
The use of well constructed clinical policies, flow sheets, algorithms, guidelines and checklists is evident for all parts of the patient’s journey from the requirements of the referral process to that of patient discharge and rehabilitation.
In general, there is impressive attention to detail; for example, in theatre: the maintenance of temperature, infection control and patient safety. The team works extremely comfortably and well together. The HR department is compliant in all the key areas currently. The HR goals are in line with the organization and seem to be consistent with meeting the challenges ahead. It is clear that new techniques are tried and assessed by cardiac services, in a desire to stay current and to improve the quality of patient care. White coats, and long sleeves are an infection risk
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Case-Load H+ und Mortalität (NEJM 2010)
für Pneumonie, Herzinsuffizienz + AMI
Das Qualitätsproblem
Hohes Volumen, niedrigere Mortalität Wenn Volumen weiter ↑, Effekt ↓ Schwelle, wenn ↑ → Mortalität ↑ Wenn > 100 / a → Kurve →
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
New England Journal 2003 20 Aortic-valve replacement
15 10
Carotid endarterectomy
9.1 7.8
Coronary-artery bypass grafting
0
1.8
1.3
6.2
4.6 3.9
1.1
40
42
162
17.5
Zwischen 1.6 und 3.8 %
Esophagectomy
20
Pancreatic resection 18.8
15
Mortalität Hirslanden Klinik Aarau (1994 – 2011)
6.5
5.4 4.3 4.0
5
Elective repair of an abdominal aortic aneurysm
13.1
9.2 14.7
Resection for lung cancer
8.5
4.6
AKB immer < 2.0 %
Cystektomie
10 6.1 5.6 5.0
5.5
5.3
3.1
5 0
17.0
3.5
6.0
4.0
Herz Zentrum Hirslanden Aarau
British Journal of Surgery 2005
Surgeons who performed fewer than 21 rectal cancer resections had nearly twice the local recurrence rate of high volume surgeons (42 versus 26 per cent). In contrast to the rectal cancer situation, studies of colon cancer have failed to show difference of meaningful clinical relevance.
Herz Zentrum Hirslanden Aarau
Chirurgische Ärztezeitschrift 2011
Die Evidenzlage nach klinischen Studien ist nach Einschätzung aller Experten für die meisten infrage stehenden Eingriffe nicht eindeutig und damit nach Belieben auslegbar
But for colorectal surgery in general, hospital volume appears to be an imperfect surrogate for surgical quality.
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
ZfHThG 2006
Chirurgische Ärztezeitschrift 2011
Stat. Qualitätssicherung durch Einführung von Mindestmengen in der Herzchirurgie Einigkeit besteht auch darüber, dass eine Mindestmengenzahl eine überwiegend politische Entscheidung ist.
Herz Zentrum Hirslanden Aarau
Offensichtlich sind Mindestmengen jedoch nur ein relativ grober Surrogatparameter für die Versorgungsqualität und stellen lediglich ein Hilfsmittel zur Zeitüberbrückung dar, bis bessere Indikatoren für die Qualität der Versorgung vorhanden sind
Herz Zentrum Hirslanden Aarau
KOF untersucht Kostentreiber im Gesundheitswesen
Was bringt das neue KVG?
Herz Zentrum Hirslanden Aarau
Zunahme der Zahl der über 75-Jährigen Allgemeines Lohnwachstum Erwerbsquote der Frauen
Herz Zentrum Hirslanden Aarau
KVG (1) H
- mit ICU - ohne ICU
Gutachten „Trüb“
KVG (2) Kantonsgrenzen gefallen Schweiz: 8 Grossräume
Planung: leistungsorientiert H
- Finanzierung - Investitionskosten
- Mittelland / Aarau Umgehung der Wettbewerbsneutralität Mindestmengen
- Keine Subventionen Gleichbehandlung Listenspitäler Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
Comments
20 Jahre Herzchirurgie im Kanton Aargau QUO VADIS?
Herz Zentrum Hirslanden Aarau
Aargau has a population of 600,000 which would indicate a demand for about 300 coronary artery bypass grafts, 70-80 valve procedures and probably around 10-15 other procedures, so clearly there is potential for the number of operations at Hirslanden clinic to increase.
Herz Zentrum Hirslanden Aarau
Herz Zentrum Hirslanden Aarau
