. 2023 May 4;8(5):e012049. doi: 10.1136/bmjgh-2023-012049

Table 3.

Detail of quality audit variables at different congenital cardiac levels

Metric	Definition	Numerator	Denominator	Target	Comments
PCCSL-2
Diagnostic accuracy rate*	The proportion of potentially preventable and clinically important inaccurate diagnoses among congenital heart surgical patients Minor: no change in patient plan Moderate: change in plan but no harm Severe: catastrophic event/death	Number of inaccurate diagnoses	Number of CHD scans done	Minor: <5% Moderate: <2% Severe: 0%	This will be done as previously described taxonomy of diagnostic error in congenital echocardiography.^{35 40}
PCCSL-3 (in addition to above metrics)
ICU and inpatient complications rate	CAUTI, CLABSI, VAP, soft tissue infections			<5/1000 central line days. <5/1000 urinary catheter days. <5 VAP/1000 ventilator-days. 10% soft tissue infections	Programmes can follow standard defintions and methods to calculate CAUTI, CLABSI, VAP and soft tissue infections. Standard report per 1000 line/catheter/ventilator days can be used for tracking these metrics.
	Crude mortality rate	Number of mortalities	Number of patients admitted	<10%	Since programmes are not expected to be on a registry at this level, targets can be set internally with a focus on consistent improvement.
	ICU LOS	Mean/median LOS in ICU	Expected LOS in ICU according to lesion	–
Emergent cardiac catheterisation procedure outcomes	Crude mortality rate in hospital after emergent cardiac catheterisation	Number of mortalities attirbuted to the emergent procedure.	Number of emergent procedures performed in a year	<10%	–
Regular M&M meetings	Number of M&M meetings conducted per year	–	–	>2	–
PCCSL-4 (in addition to above metrics)
Safety and outcomes of cardiac catheterisation procedures	Median radiation based on radiation exposure category Standardised level 3–5 adverse event rates	–	–	–	At this level and above, centres will be expected to be on a QI registry such as IQIC to ensure regular data collection and benchmarking. Cumulative data (median length of ICU or hospital stay, mortality rates, etc) from IQIC reports can be used to create benchmarks.
Safety and outcomes of cardiac surgery procedures	Hospital and ICU LOS Standardised major infection ratio Crude mortality ratio Standardised mortality ratio Major morbidity (tracheostomy, insertion of PPM due to postoperative heart block, diaphragm paralysis, reintubation) rate Standardised major morbidity ratio	–	–	–
Fetal diagnostic error rate*	This measure provides a mechanism for fetal echocardiography laboratories to record and analyse diagnostic discrepancies between fetal and postnatal findings	Number of fetal patients with a moderate or severe discrepancy between prenatal and postnatal diagnosis	Fetuses born during the quarter with prenatal CHD diagnosis needing intervention within first year of life	<5%	Comparison of prenatal imaging findings and reports with postnatal investigations and reports or repeat fetal echocardiogram.
Residual lesion score	To keep a record of residual lesion based on predischarge postoperative echocardiogram	Number of procedures with RLS category 3 or more⁵⁶	Total number of surgeries performed	<10%
MDC	Safety of surgical procedures	Cases discussed in MDC	Total number of surgeries	100%	To ensure that all cases undergo MDC.
PCCSL-5 (in addition to above metrics)
TEE accuracy rate*	Accuracy of pre-operative diagnosis based on TEE	Total number of pre-operative TEEs with one or more major discrepancies identified within 24 hours of surgery	Total number of pre-operative TEEs performed	0%	Postcardiac surgery TEE, retrospective medical record review and operative reports.
TEE adverse events rate*	Rate of adverse events associated with TEE	Number of TEEs with adverse events identified during a TEE assessment	Total number of TEEs performed	<2%
Bounce back rate	Rate of readmissions to ICU	Number of patients shifted back to ICU within 24 hours	Number of patients shifted from ICU to ward	<2%	To ensure nursing staff in step-down units/wards are well trained. Also to avoid early, inappropriate shifting of patient from ICU.
Lifelong follow-up care rate	Adherence to lifelong CHD care guidelines⁶⁰	Number of patients in whom lifelong follow-up guidelines are being followed	Total number of patients with CHD in the programme	>80%

*Metrics adapted from the non-invasive ACPC QNET network.^{51 52}

ACPC QNET, Adult Congenital and Paediatric Cardiology Quality Network; CAUTI, catheter-associated urinary tract infection; CHD, congenital heart disease; CLABSI, central line-associated bloodstream infection; ICU, intensive care unit; IQIC, International Quality Improvement Collaborative; LOS, length of stay; MDC, multidisciplinary conference; M&M, morbidity and mortality; PCCSL, paediatric and congenital cardiac service levels; PPM, permanent pcemaker; QI, quality improvement; TEE, trans-oesophageal echocardiography; VAP, ventilator-associated pneumonia.