title: Process review of a departmental change from conventional coronary artery bypass grafting to totally arterial coronary artery bypass and its effects on the incidence and severity of postoperative stroke.
abstract: BACKGROUND
  We evaluated the process of changing from conventional coronary artery bypass grafting (CABG) to totally arterial off-pump coronary artery bypass (TOPCAB) at a single heart center in Germany.
  
  
  METHODS
  We (1) used multivariate statistical methods to assess real-time monitoring of OPCAB effects, (2) conducted a case review to assess preventable deaths and identify areas of improvement, (3) conducted a team survey, and (4) evaluated benchmarking results.
  
  
  RESULTS
  All surgeons and assistants (n = 18) at this center were involved and were guided by the department head and one of the consultants, who was trained in this procedure in 2004 at the Leuven OPCAB school. The frequency of OPCAB operations increased abruptly in 2005 from 5% to 43% and then increased gradually to 67% (n = 546) by 2008 (total, 1781 OPCAB cases and 1563 on-pump cases). The in-hospital and 30-day mortality rates for OPCAB surgeries (n = 10 [0.6%] and 21 [1.2%], respectively) were lower than for on-pump surgeries (n = 27 [1.7%] and 26 [1.7%], respectively). Stroke rates were also lower for OPCAB surgeries (7 cases [0.4%] versus 15 cases [1%]). The lower risk of stroke in the OPCAB group was significant (P < .05) after risk adjustment. Monitoring curves and case reviews demonstrated a preventable death percentage of at least 30%. The attitude of the team was mostly positive because of the promising results (eg, fewer strokes, increasing TOPCAB popularity, and a top national rank).
  
  
  CONCLUSIONS
  The change from conventional CABG to TOPCAB was effective in decreasing the incidence and severity of stroke, in developing a team routine and a positive team attitude, and in producing excellent benchmarking results. The presence of a training and communication deficiency at the beginning of the study suggested an area for further improvement. After 6 years TOPCAB had largely replaced conventional CABG.
authors.affiliation: Department of Cardio-Thoracic Surgery, University Clinic Düsseldorf, Moorenstrasse 5, Düsseldorf, Germany. alexander.albert@med.uni-duesseldorf.de
authors.forename: Alexander
authors.initials: A
authors.lastname: Albert
authors.forename: Paul
authors.initials: P
authors.lastname: Sergeant
authors.forename: Ines
authors.initials: I
authors.lastname: Florath
authors.forename: Mohammed
authors.initials: M
authors.lastname: Ismael
authors.forename: Ulrich
authors.initials: U
authors.lastname: Rosendahl
authors.forename: Jürgen
authors.initials: J
authors.lastname: Ennker
mesh_terms: D000368:Aged; D002300:Cardiac Care Facilities / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000379:methods / Q000706:statistics & numerical data; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D005858:Germany / Q000453:epidemiology; D006305:Health Status Indicators; D006801:Humans; D015994:Incidence; D008297:Male; D015999:Multivariate Analysis; D009936:Organizational Innovation; D057216:Propensity Score; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000453:epidemiology / Q000209:etiology* / Q000451:nursing / Q000517:prevention & control