Real-time monitoring of coronary care mortality: a comparison and combination of two monitoring tools.
BACKGROUND
Quality control in clinical care is becoming increasingly more prevalent, resulting in a need for tools that can be readily used by clinical teams for monitoring their own performance. The aim of this study was to devise a practical and effective scheme for monitoring coronary care mortality in real-time.


METHODS
We obtained data for 2153 consecutive patients admitted after acute myocardial infarction between 1st September and 30th November 1995 to one of 20 acute hospitals in West Yorkshire participating in the NHS R and D funded EMMACE-1 study. We developed control charts for each centre to monitor 30-day mortality. These control charts used two complementary tools: the Risk-Adjusted Cumulative Sum chart (CUSUM) and a new 'Rocket Tail' chart based upon the Variable Life-Adjusted Display (VLAD). We also combined information from each of these to devise a further chart.


RESULTS
Control charts are shown for two centres in order to illustrate the important features of the different but complimentary monitoring tools. The Risk-Adjusted CUSUM is shown to be useful for detecting isolated runs of unsatisfactory outcome results but is not 'intuitive', and does not give any indication of the preceding history of outcomes. The Rocket Tail chart is shown to give a good summary of outcome history and also how overall performance compares with what would be expected for the case-mix. A chart that combines both approaches appeals to the advantages of each.


CONCLUSIONS
We propose a visual approach to health-care monitoring that beneficially combines and extends the different information of the previously used CUSUM and VLAD charts.
Sherlaw-Johnson
Chris
C
Clinical Operational Research Unit, University College London, Department of Mathematics, UK. c.sherlaw-johnson@ucl.ac.uk
Morton
Anthony
A
Robinson
Michael B
MB
Hall
Alistair
A
D003625:Data Collection / Q000379:methods*; D017052:Hospital Mortality; D006779:Hospitals, Public / Q000592:standards*; D006801:Humans; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D020379:Risk Adjustment; D006113:United Kingdom / Q000453:epidemiology