The effect of a surgical safety checklist on complication rates associated with permanent transvenous pacemaker implantation in dogs☆
Introduction
Permanent artificial pacemaker (PAP) implantation is the standard of care for treatment of certain bradyarrhythmias in dogs, including high-grade atrioventricular block (HG-AVB) [1], medically refractory sick sinus syndrome (SSS) [2], and persistent atrial standstill [3]. Transvenous pacemaker implantation, performed using a jugular venotomy with the pacing lead placed into the right ventricle under fluoroscopic guidance, is considered the preferred method of pacemaker placement in dogs [4], [5], [6], [7], [8].
Although PAP implantation is generally successful and significantly improves survival in dogs with life-threatening bradyarrhythmias [1], this procedure is associated with a relatively high rate of major complications. Published complication rates ranged from 55 to 71% in the 1980s [9], [10], decreasing to 13–33% in the 2000s [4], [5], [6], [7], [8]. Reports since 2015 suggest major complication rates of approximately 15% for dogs with both HG-AVB [11], [12] and SSS [2], while the most recent large-scale multi-institutional retrospective study of 595 dogs with various bradyarrhythmias found a major complication rate of 21.8%.e Higher complication rates have been reported in dogs with pre-existing structural heart disease [6], postoperative infections [13], previously used pulse generators [6], inexperienced operators [4], and procedures performed after normal business hours [11]. In comparison, large-scale retrospective studies in humans report major complication rates of 2.3–11.2% [14], [15], [16], [17].
A growing body of evidence in human medicine suggests that surgical safety checklists (SSCs) are a useful tool to improve communication among surgical team members and reduce incidence of surgical complications. Based on guidelines published by the World Health Organization (WHO) in 2008, SSCs have been created and implemented in hospitals worldwide [18], [19]. Use of SSCs has been associated with significant decreases in rates of death and inpatient complications [20], particularly in developing nations [21]. Clinicians using SSCs overwhelmingly (93.4%) report that they would want SSCs used by the medical team if they were undergoing surgery themselves [22]. However, a large-scale studies across multiple health-care providers found no improvements in mortality or complication rates after implementing an SSC [23], and reviews of the checklist literature have found limited benefits and a risk of bias in studies of SSC efficacy [24]. In summary, SSCs are a promising method of improving health-care outcomes, but positive outcomes are not a given.
Use of SSCs is also an emerging trend in veterinary medicine. Checklists have been used during routine wellness visits to improve completeness of client communication regarding veterinary preventive care [25], [26]. Surgical safety checklists in veterinary practice have been mentioned in editorials [27] and letters to the editor [28], and a private referral center in the United Kingdom has described anecdotal positive outcomes with SSC use, including improved teamwork and communication [29]. Recently, a veterinary teaching hospital in Sweden reported that SSCs reduced incidence of complications in small animals undergoing a variety of elective surgeries [30]. In 520 dogs and cats undergoing ovariohysterectomy, mass removal, or orthopedic surgery, use of SSCs led to a reduction in the overall complication rate from 17.3% to 6.8% and particularly decreased incidence of surgical site infections and wound healing complications [30]. These positive outcomes support a role for SSCs in veterinary medicine. To date, no veterinary studies have evaluated the use or efficacy of SSCs in cardiac interventions, particularly in urgent or emergent procedures such as PAP implantation.
The cardiology service at North Carolina State University (NCSU) recently collaborated with a human factors psychologist (ACM) to develop an SSC for use during cardiac catheterization procedures [31]. The purpose of this study was to assess the impact of checklist implementation on complication rates during transvenous PAP implantation. We hypothesized that the rate of major complications would be lower for cases where SSCs were used compared with cases without SSCs.
Section snippets
Data collection
A retrospective medical record review of all dogs that underwent permanent transvenous pacemaker implantation at the NCSU Veterinary Teaching Hospital between January 1, 2002 and January 1, 2018 was performed. Medical records were reviewed, and the following information was extracted for each patient: signalment; body weight; electrocardiographic diagnosis (HG-AVB, SSS, or persistent atrial standstill); presence of congestive heart failure (CHF) at diagnosis (defined in the following section);
Demographic, clinical, and procedural findings
One hundred ninety-nine dogs were included (Table 1). Average age at pacemaker implantation was 10.0 ± 3.2 years. Commonly represented breeds included Labrador retrievers (n = 22), cocker spaniels (n = 14), beagles (n = 12), miniature schnauzers (n = 12), German shepherd dogs (n = 10), Chow Chows (n = 10), boxers (n = 8), West Highland white terriers (n = 7), and Boston terriers (n = 6). Indications for PAP implantation were HG-AVB (n = 169), SSS (n = 26), and persistent atrial standstill
Discussion
Results of this study supported our hypothesis that implementation of an SSC for transvenous PAP implantation in dogs was associated with a decrease in the major complication rate (from 15.6% to 2.2%). Furthermore, checklist use was correlated with improved compliance with perioperative antibiotic protocols (administering the first dose of antibiotics within 5 min of incision and repeat dosing of antibiotics every 90 min throughout the procedure). These findings suggest that use of SSCs
Conclusions
This study found that use of an SSC was associated with decreased major complications and increased compliance with antibiotic protocols during transvenous PAP implantation in a veterinary teaching hospital. Results of this study support the use of an SSC in veterinary cardiology procedures.
Conflict of interest statement
The authors declare no conflicts of interest.
Acknowledgments
This study was supported in part by a grant from the American College of Veterinary Internal Medicine Specialty of Cardiology. The authors thank Allison Klein for assistance with data collection.
References (38)
- et al.
Outcome and survival in canine sick sinus syndrome and sinus node dysfunction: 93 cases (2002-2014)
J Vet Cardiol
(2016) - et al.
Survival time with pacemaker implantation for dogs diagnosed with persistent atrial standstill
J Vet Cardiol
(2017) - et al.
Long-term outcome of physiologic VDD pacing versus non-physiologic VVI pacing in dogs with high-grade atrioventricular block
J Vet Cardiol
(2015) - et al.
Comparison of lead dislodgment and pocket infection rates after pacemaker implantation in the operating room versus the catheterization laboratory
Am Heart J
(1988) - et al.
Surgical safety checklists: do they improve outcomes?
Br J Anaesth
(2012) - et al.
Thirty-day outcomes support implementation of a surgical safety checklist
J Am Coll Surg
(2012) - et al.
The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis
Br J Anaesth
(2018) - et al.
Signalment, clinical signs, and prognostic indicators associated with high-grade second-or third-degree atrioventricular block in dogs: 124 cases (January 1, 1997–December 31, 1997)
J Am Vet Med Assoc
(2006) - et al.
Practices and outcome of artificial cardiac pacing in 154 dogs
J Vet Intern Med
(2001) - et al.
Applications, complications, and outcomes of transvenous pacemaker implantation in 105 dogs (1997-2002)
J Vet Intern Med
(2006)
Results of pacemaker implantation in 104 dogs
J Small Anim Pract
Permanent transvenous pacemaker implantation in forty dogs
J Vet Intern Med
The implantation of a permanent transvenous endocardial pacemaker in 42 dogs: a retrospective study
Med Sci Mon Int Med J Exp Clin Res
Pacemaker implantation in the dog: survey and literature review
J Am Anim Hosp Assoc
Complications associated with permanent pacemaker implantation in the dog
J Am Vet Med Assoc
Complication rates associated with transvenous pacemaker implantation in dogs with high-grade atrioventricular block performed during versus after normal business hours
J Vet Intern Med
Cardiovascular device infections in dogs: report of 8 cases and review of the literature
J Vet Intern Med
Complications related to permanent pacemaker therapy
Pacing Clin Electrophysiol
Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity
Hear J
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