ABC | Volume 114, Nº4, April 2020

Original Article Mejia et al. Quality, the new era of cardiovascular surgery Arq Bras Cardiol. 2020; 114(4):603-612 The purpose of this study is to assess the evolution of the incidence and and mortality of cardiovascular surgery, as well as the influence of the CQI Program in one of the centers of reference in cardiology in Brazil: the InCor-HCFMUSP. Methods Sample An observational retrospective study from InCor database. We collected information on the surgical volume and mortality outcomes from January 1984 to June 2019. To facilitate this analysis, data were grouped into 5 periods: 1984-1989; 1990‑1999; 2000-2007; 2008-2015 and 2016-2019. Thus, we analysed the surgical volume and mortality rates in general, as well as those related to the groups with the highest surgical volume and mortality rates (Coronary, Valvular, Congenital and Arrhythmias). In addition, the evolution of mortality rates in the last two periods (4th and 5th) for Aortic Valve Surgery, Mitral Valve Surgery, Aortic Valve Surgery + Mitral Valve Surgery, CABG + Valve Surgery (Aortic or Mitral) and Aortic Dissection Surgery was analysed in isolation. Data collection, definition and organization The InCor database (SI3) 7 includes clinical and follow-up data of patients inside and outside the hospital. Filling out this register is compulsory and performed by employees from several healthcare areas. The data are placed online (http://si3/) with a personal password and user. Data completeness and veracity were validated by the Incor Hospital Medical Information Unit, by the Assistance Operations Management and by the Patient Safety and Quality Surgical Unit. Data of the first publication, “Evolution of Cardiovascular Surgery at the Instituto do Coracao: Analysis of 71,305 Surgeries”, were retrieved and analysed together. 8 Surgical mortality was defined as any death occurring within 30 days after the main procedure, in or out of the hospital. Inclusion Criteria All cardiovascular procedures performed at the InCor, between January 1984 and July 2019. Exclusion Criteria For the analysis by procedure type, emergency or rescue procedures were excluded. The CQI Program Envisioning a new era of cardiovascular surgical outcomes, the new InCor management, led by Prof. Fábio Jatene, created, inside the Cardiovascular Surgery Division of Incor, the Patient Safety and Quality Surgical Unit (UCQSP). This unit aims at supporting the construction of a safety culture, by promoting transparency, standardizing training courses, improving staff work and monitoring performance. In order to converge these and other activities, the UCQSP established the CQI Program in Cardiovascular Surgery. 9 To this end, an alignment with the Information Technology Service and the Hospital Medical Information Unit of the InCor was crucial to monitor the program implementation. Thus, the initial set of measures of the CQI Program was: 1) establish annual goals of surgical volume and outcomes; 2) public and monthly presentations of the outcomes; 3) implementation of a surgical Checklist and its propagation to 100% of the surgical procedures; 4) establishment of a clinical/surgical outpatient setting for all groups; 5) monitoring of adherence to the perioperative protocols established; 6) multidisciplinary approaches to all surgeries and/or patients at high risk; 7) assessment of the cause of operativemortality using the POCMA (Phase of Care Mortality Analysis) process; 8) requirement of quality improvement metrics for each area involved in healthcare; 9) development of Researches in Quality and Safety; 10) accurate indication and timing of surgery for urgency/ emergency patients. Statistical analysis Regarding the mortality rates observed, the periods were compared using a two-tailed test for comparison of proportions. In 2019, it was observed that the second and the first semester had the same number of surgeries and average deaths. From1984 to 2007, for the Arrhythmia group, only the annual mean of the number of surgeries perfomed in each period was available. Therefore, we considered that the number of surgeries carried out in each year was equal to the average of the period, in order to estimate the p-value. For the variable number of surgeries, the two-tailedMann-Whitney test was used. The level of significance established was 0.05. The R software (version 3.5.3) was used for the analyses and graphs. The Excel software was used to consolidate the original basis. Ethics and consent term This Project was carried in the UCQSP, with the approval of the hospital management, as a study on quality improvement. It was a database study with no identification of patients. Therefore, the Free and Informed Consent Form was not required. Results A total of 105,599 CVSs were performed, with an annual mean of 2,964 procedures and mortality of 5.63%. In the total volume analysis, there was an increase of 32.5% between the 1st and 2nd periods (p = 0.001) and of 35.3%, between the 2nd and 3rd periods (p = 0.0001). There was a decrease of 22.7% between the 3rd and 4th periods (p = 0.0006) and a slight increase of 6.7% between the 4th and 5th periods (p = 0.3677). In relation to CABG surgery, there was an increase of 18.3% between the 1st and 2nd periods (p = 0.0145), and of 9.2%, between the 2nd and 3rd periods (p = 0.0293). 604