Simple techniques like hand hygiene, surgical safety check-lists, and empowering nurses to confidently communicate patient concerns can drastically improve outcomes for infants and children undergoing heart surgery in India, according to world’s top pediatric cardiologists assembled at the Amrita Hospital in Kochi.​

Simple, low-cost quality improvement techniques like preventing hospital-acquired infections through hand hygiene, empowerment of nurses to better communication patient concerns, effective communication, surgical safety check-lists to improve teamwork, and conducting mortality meetings can do much more to improve outcomes of child heart surgery than expensive new technology and equipment in developing countries like India. This was the view of top pediatric cardiologists from countries like India, US, Pakistan, Malaysia and Vietnam attending a two-day session of The International Quality Improvement Collaborative (IQIC) on Congenital Heart Surgery at Amrita Institute of Medical Sciences from June 24 – 25, 2016.

Dr. Krishna Kumar, Head, Department of Pediatric Cardiology, Amrita Hospital, Kochi, said, “Simple, low-cost quality improvement measures can make a big difference in outcome of heart surgery in infants and children. Two examples of these include establishment of a robust infection control and prevention program in the ICU and implementation of a surgical safety checklist. A number of mental barriers may have to be initially overcome to successfully engage all stakeholders. However, once outcome, improvements become apparent, it becomes progressively easy to implement such quality improvement systems in hospitals.”

The surgeons at the session noted that India has the largest burden of child heart disease in the world, with over 200,000 children being born every year with Congenital Heart Defects (CHD). In Kerala, CHD is a leading cause of infant mortality. A large proportion of CHDs are correctable through a single surgery or, sometimes, a catheter-based procedure. For this reason, access to a pediatric cardiac facility that provides affordable care is critical. Between 3-10% of infant mortality in many parts of India may be accounted for by CHD, most of which can be prevented through timely intervention. However, only about 10% of the affected infants with serious heart disease receive timely intervention in India. In all probability, the remaining 90% children do not survive.

“Economic challenges are the most significant barrier in children receiving timely care for their heart conditions. Their parents are typically young and have just begun earning. Their financial reserves are often limited. Most medical insurance providers have listed birth defects of the heart as an exception to the list of conditions covered. Heart operations and catheter procedures are expensive. As a result, the economic impact on families who pay from out of their pockets is often devastating. Under these circumstances, it is particularly tragic if a child succumbs to a preventable complication such as a post-operative infection or medication error,” Dr. Krishna Kumar shared.

The International Quality Improvement Collaborative (IQIC) seeks to eliminate such preventable errors in the care of children undergoing surgery for heart defects.  While it is true that heart surgery for children requires high-end medical technology and expertise, a number of simple quality measures that can significantly improve outcomes can be introduced at a low cost. For example, a study at Amrita Hospital showed that for every rupee invested on prevention of hospital-acquired infections, the return on investment was Rs 220.

“Since its establishment in 2008, the International Quality Improvement Collaborative (IQIC) has demonstrated consistent improvements in the results of heart surgery in children in low and middle-income countries. This has been accomplished entirely through systematic implementations of low-cost measures such as robust infection control practices, nurse empowerment and strengthening team-based practices. None of these measures requires investments in high-end technology. At the Amrita Institute of Medical Sciences, adoption of such simple quality improvement measures has enabled us to produce surgical results that are at par with the best international standards. This accomplishment won for us the British Medical Journal Healthcare Award in 2014 in the category of quality improvement,” Dr. Krishna Kumar further added

Dr. Kathy Jenkins, Head, Pediatric Cardiology, Boston Children's Hospital, and Professor of Pediatrics, Harvard Medical School, said "The International Quality Improvement Collaborative project helps doctors and nurses work together so that babies and children with heart disease can live and thrive."

There are many reasons for high mortality of children in India with CHD, the most important being lack of awareness among doctors. Most pediatricians receive little or no training in pediatric cardiology, simply because there are very few pediatric cardiac programs in the country. Only a small proportion of children with CHD are diagnosed in a timely fashion. After diagnosis, there is considerable delay in referral to a pediatric cardiac program because the critical need for early referral is not widely appreciated. There are major logistic hurdles. Vast regions of India have no pediatric cardiac surgical facility at all. Despite subsidies from hospitals, voluntary organizations and the Government, pediatric cardiac care is still too expensive for the average Indian family. In such a scenario, simple quality improvement initiatives that can be introduced at low cost with little resources to drastically improve outcomes in child heart surgery become even more important.

The event was sponsored by Children’s HeartLink, an American NGO which works in partnership with pediatric cardiac programs to promote sustainable cardiac care for children with heart disease.


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