A Tragic Incident: The Urgent Need for Coronary Bypass Surgery
Recently, a friend told me a disturbing story. Her mother was distraught because her good friend had gone to the local hospital, and it was determined that he needed emergent coronary bypass surgery. The hospital in question, which has had a cardiothoracic surgery program since the mid ’90s, was “unable to do the surgery”, so he had to be transferred to the quaternary care facility of that hospital system, which is 80 miles away. He died before making it to the operating room.
My friend, knowing that I had dedicated the majority of my career to making sure that things like this do not occur, wanted to how this could happen in today’s world. Her mother is now living in a community that is fearful that a vital emergency service has been taken away without their knowledge.
The Decline of Cardiac Surgery Programs and the Rise of CABG
I had a few questions. First, was this hospital no longer performing open heart surgery? The closure of cardiac surgery programs has become commonplace due to the decreasing volume of coronary artery bypass graft (CABG) and valve repair/replacement surgeries.
Between the years of 2001 to 2008, the instance of CABG surgery decreased by a third (Boyles, 2011). By that time, 75% of the patients who had a coronary revascularization were already having it done successfully in a cardiac cath lab, compared to 60% in the decade prior (Boyles, 2011). Since 2011, when the first transcatheter aortic valve device was approved by the FDA, the need for open valve surgeries also decreased (www.sts.org, 2020). The current shortage of cardiac surgeons is also playing its part (AAMC, 2018).
Staffing Crisis: The Impact on Heart Surgery Availability
We did some digging and found out that cardiothoracic surgery was indeed still offered at this hospital. My friend called a friend who is on staff there who reported that surgeries are less frequent (“about 1 or 2 per week”) and that “sometimes the availability of staff plays a role on if the surgery can be performed here on a given day”.
Staffing struggles are everywhere in health care today. But it is sad to speculate that a lack of staff could prohibit the performance of such a vital emergency service. This hospital system advertises cardiac surgery services at 4 hospitals and 4 cardiac surgeons on staff. That ratio could make for a challenging call schedule for 4 surgeons to cover the same number of hospitals, 24/7. Also, the approximate volume of elective cardiac surgeries is dangerously close to the 100 surgery/per year minimum which has been considered the industry standard to maintain competency.
Navigating Complex CABG Challenges
I also questioned if there was something about this particular CABG surgery that had precluded it from being done on-site. We were unable to get an answer to this question. If the standard of care is to offer a service 24/7, then I would assume that it would maintain the expertise to take all comers, just as the cardiac cath lab does with STEMI care.
Regardless of the reason for the transfer, I have to ask myself how comfortable I would feel having as complex a surgery as emergent CABG done in a hospital that is doing minimal elective volume. A team is only as good as its weakest link. You can have a very experienced operator, but if he or she has not worked repeatedly with a particular team, in a particular environment to iron out all processes and make things go like clockwork, the true benefit of the experience level may not make it to the patient.
Could there have been delays in the transfer process itself that contributed to the catastrophic outcome? If all 4 hospitals routinely perform their own cardiac surgeries, the process for transfer between sites may not have been a commonly occurring event. Were there agreements in place with both ground and flight EMS services with critical care transport capabilities to ensure an expedited response?
In the end, even if I knew the true reason for the need for transfer, I could really give no reassurance to my friend’s mother about the availability and or quality of cardiac surgery in her hometown hospital. It was quite possibly an infrastructure failure of the worst kind.
Corazon Accreditation: Securing Quality Cardiac Surgery Services
What I do know, however, is something that can help – the accreditation of cardiac services. Corazon Accreditation is a collaborative process in which we work with hospitals to define and then practice their processes to promote excellence. Transfer agreements with tertiary or quaternary care facilities, as well as with transport services, are encouraged, and transfer drills are routinely facilitated. Minimum staffing levels, both during business hours and on 24/7 on-call schedules are reviewed as per the Society Coronary Angiography and Intervention 2023 recommendations. We partner with the facility to map out patient flows for all scenarios, then facilitate practice drills. Staffing unavailability, changes in evidence-based modes of care, societal recommendations, and patient clinical presentations are all curve balls that we routinely deflect in health care today. Corazon Accreditation, along with the SCAI, partners with facilities to help them evaluate, enhance, and excel as we all adapt to the ever-changing healthcare climate.
Written by Holly James