Clinical outcomes

To help us provide the best possible care, we monitor the quality of our services and clinical outcomes.

Measuring clinical outcomes

Clinical outcomes are broadly agreed measurable changes in health or quality of life following treatment. These are measured to show the quality and effectiveness of the care and treatment patients receive at our hospitals. 

Different clinical outcomes can be measured in different ways, depending on the service and the patient’s condition.

The adult cardiac service at Royal Brompton has six consultants as well as a team of junior doctors and clinical nurse specialists (CNS). The multi-disciplinary team also includes anaesthetists, physiotherapists, pharmacists and dietitians.

Adult cardiac surgery includes operations such as: 

  • Coronary artery bypass grafts (CABG) – where a piece of vein from a patient's arm, leg or chest is used to bypass a blocked vessel in the heart. 
  • Valve repair or replacement – where a leaky or stiff valve in the heart is repaired or replaced making it work more effectively.
  • Aorta procedures – where damage to the aorta is repaired or replaced.

CABG or valve operations may be performed on their own (isolated) or together (combined).

Adult cardiac surgery clinical outcomes

The revascularisation service

The Society of Cardiothoracic Surgery (SCTS) annual report 2010-11 said ‘There is increasing evidence suggesting that in-hospital mortality rates are better if patients have coronary artery surgery performed without using a cardiopulmonary bypass machine; so called off-pump surgery.’ 

Percentage of RBH first-time isolated CABG patients that have off-pump surgery from 01/04/2009 to 31/03/2014

Percentage of RBH first-time isolated CABG patients that have off-pump surgery from 01/04/2009 to 31/03/2014

The mitral service

The SCTS annual report 2010-11 said ‘It is generally accepted that degenerative mitral valve (MV) disease is best treated by mitral valve repair, rather than mitral valve replacement. A previous analysis showed that in the UK 66.6 per cent of cases were treated by repair – compared with the rate at Royal Brompton, which is around the national target of 80 per cent.

Percentage of RBH patients that were treated by MV repair and replacement from 01/04/2009 to 31/03/2014

Percentage of RBH patients that were treated by MV repair and replacement from 01/04/2009 to 31/03/2014

The aortic service

In recent years, transcatheter aortic valve implantation (TAVI) has been considered as an alternative treatment for aortic valve (AV) disease. This is true for people who may have been considered too high risk for conventional cardiac surgery. For some patients, a surgical aortic valve replacement (AVT) remains the best option. 

Percentage of RBH elective and urgent AV patients that were treated by TAVI and surgical AVR from 01/04/2009 to 31/03/2014

Percentage of RBH elective and urgent AV patients that were treated by TAVI and surgical AVR from 01/04/2009 to 31/03/2014

Comparing ourselves to other centres

The Trust submits data to the National Audit Projects, which collects data from all eligible hospital trusts in the UK. 

The data for adult cardiac surgery is submitted to The Society of Cardiothoracic Surgeons (SCTS), which compares all centres that perform adult cardiac surgery. 

Read more about the type of data collected and how it is managed on the SCTS website 

Read more about Royal Brompton's results on the SCTS website

Percutaneous coronary intervention (PCI) is used to treat patients with narrowed or blocked arteries that supply the heart muscle with blood. During the procedure, a small balloon is inserted into the narrowed artery and temporarily inflated, re-opening the artery. In the majority of cases a small expandable metal tube (stent) is implanted to hold the artery open.

Patients are admitted for PCI with differing levels of urgency.

  • Elective means booked in advance – not involving a medical emergency.
  • ACS (UA/nSTEMI) means an urgent admission is necessary but immediate intervention may not be needed.
  • Primary means an emergency admission and immediate treatment are needed. 
Percentage of Harefield patients having percutaneous coronary intervention (PCI) by urgency

Percentage of Harefield patients having percutaneous coronary intervention (PCI) by urgency

Activity and mortality rates

Harefield is a heart attack centre (HAC) with an excess of 1,000 primary activations (patients thought to be having a heart attack) per year.

Inpatient mortality at Harefield following all PCI

Inpatient mortality at Harefield following all PCI

It is important to note that, as a HAC, a large proportion of the PCI activity at Harefield is for high-risk, primary (emergency) patients.

Harefield operates a large primary service, which has grown over the years, where patients having a myocardial infarction (heart attack) are brought directly to Harefield. A proportion of these primary activations will go on to have a primary percutaneous coronary intervention (PPCI), also referred to as primary angioplasty.

Number of primary activations at Harefield and percentage of patients having primary PCI

Number of primary activations at Harefield and percentage of patients having primary PCI

PPCI patients are emergency admissions and are at much higher risk of mortality. 

Inpatient mortality at Harefield following all Primary PCI

Inpatient mortality at Harefield following all Primary PCI

A large proportion of patients received through the primary service are very high risk and elderly patients.

PPCI patients are a high-risk cohort and are associated with a higher mortality. "Call-to-balloon" (CTB) times for primary activations should aim to be under 150 minutes (regardless of transfer from a district general hospital (DGH) or direct admission to Harefield). With every 30-minute delay, it is quoted that there is a 7.5 per cent increase in risk of death. 

The CTB is the time the patient makes the first emergency call (primary cycle is activated) to the time the first interventional device (stent / balloon) is placed in position. 

National standards quote that 75 per cent of primary calls should make the 150-minute call-to-balloon time.

Percentage of primary PCIs at Harefield with a CTB time within 150 minutes

Percentage of primary PCIs at Harefield with a CTB time within 150 minutes

Percutaneous coronary intervention (PCI) is used to treat patients with narrowed or blocked arteries that supply the heart muscle with blood. During the procedure a small balloon is inserted into the narrowed artery and temporarily inflated, re-opening the artery. In the majority of cases a small expandable metal tube (stent) is implanted to hold the artery open.

Patients are admitted for PCI with differing levels of urgency.

  • Elective means booked in advance – not involving a medical emergency.
  • ACS (UA/nSTEMI) means an urgent admission is necessary but immediate intervention may not be needed.
  • Primary means an emergency admission and immediate treatment are needed. 
Percentage of PCIs performed at Royal Brompton by urgency

Percentage of PCIs performed at Royal Brompton by urgency

Usage of stents

In the majority of PCI procedures, a stent is implanted to hold the narrowed artery open. This is in line with guidance from the National Institute for Health and Care Excellence (NICE), which recommends that “a stent should normally be used during balloon angioplasty in a person who has angina or has had a heart attack”.

National rate data is from the National Audit of Percutaneous Coronary Intervention – developed and led by the British Cardiovascular Intervention Society (BCIS).

Percentage of PCI at Royal Brompton where one or more stents were implanted

Percentage of PCI at Royal Brompton where one or more stents were implanted

Usage of drug-eluting stents

Some stents are coated in medication, which is slowly absorbed into the surrounding tissue, further reducing the likelihood of the artery becoming narrow again. These are called drug-eluting stents.

Percentage of PCI at RBH where one or more drug-eluting stents were implanted

Percentage of PCI at RBH where one or more drug-eluting stents were implanted

Activity and mortality rates

There is evidence to suggest that outcomes (namely deaths and post-procedural complications) are improved for patients being treated at PCI centres performing at least 400 procedures each year.

Royal Brompton Hospital is classified as a high-volume centre, performing well in excess of this figure each year.

PCI activity and mortality at RBH, with national and RBH rates of mortality

PCI activity and mortality at RBH, with national and RBH rates of mortality

The Trust is one of the UK paediatric tertiary referral centres for the diagnosis and treatment of congenital heart disease.

The paediatric congenital heart disease unit, one of the largest in the country, accepts national and international referrals. We offer a highly-specialised service encompassing cardiac surgery and cardiac interventions, supported by a wide range of paediatricspecialised services.

A patient with congenital heart disease needs lifelong follow-up appointments. In some cases, multiple operations and/or interventions are necessary. We offer seamless transition from child to adult congenital heart disease services. 

Read more about our adult congenital heart disease services.

Monitoring activity

To monitor the paediatric congenital heart disease activity, we follow the National Congenital Heart Disease Audit (NCHDA) classification by type of procedure and age at operation.

Activity Financial Year 2016-17

Surgical procedure data 2016-17

All ages

Neonate

(1-30 days)

Infant

(31-365 days)

Child

(1-16 years)

Adult

(16+ years)

Bypass

397

37

96

143

121

Non-Bypass

78

28

27

19

4

Total

475

65

123

162

125

 

Catheter procedure data

All ages

Neonate

(1-30 days)

Infant

(31-365 days)

Child

(1-16 years)

Adult

(16+ years)

Catheter intervention

444

41

105

165

133

 

 

 

 

Electrophysiology

EPS/ablations

131

0

0

53

78

Pacemaker procedures

100

 0

0

17

83

 

ICD implants/procedures

18

0

0

4

14

 

Total

693

41

105

239

308

 

Also see previous year’s activity and how we compare to other units in the country.

 


Paediatric congenital heart disease clinical outcomes

30-day survival rate - short-term outcomes 

Our short-term outcomes in paediatric cardiac surgery are being monitored using variable life-adjusted display (VLAD) plots (Crowe et al, JTCVS, 2012).

The VLAD plots allow us to benchmark against expected outcomes based on the partial risk adjustment in surgery (PRAiS v3.0) national model developed by University College London, which is in use in all paediatric cardiac surgery units in the UK.

The following VLAD plot shows our 30-day outcomes for all paediatric cardiac surgery (0-16 years) for the financial year 2016 to 2017.

Survival rate using PRAiS v3.0
   
RBH actual 30-day survival rate 99.1%
The expected survival rate using PRAiS V3.0 98.4%
Ratio of survival rate to expected survival rate 1.008

The unit runs annual PRAiS analysis at the end of every month and the trends / results are presented and open for discussion in our monthly scheduled clinical governance half days.

Find more information on understanding children’s heart surgery outcomes