The effect of a surgical safety checklist on complication rates associated with permanent transvenous pacemaker implantation in dogs

https://doi.org/10.1016/j.jvc.2018.11.001Get rights and content

Abstract

Introduction

To determine whether use of a surgical safety checklist (SSC) would reduce the rate of major complications after permanent transvenous pacemaker implantation in dogs.

Animals

The study included one hundred ninety-nine dogs undergoing pacemaker implantation for bradyarrhythmias at an academic teaching hospital.

Methods

A service-specific SSC was developed and implemented for cardiac catheterization procedures in 2015. Medical records were reviewed to extract relevant clinical and procedural data for cases with (SSC [+]) and without (SSC [−]) a checklist. Owners or referring veterinarians were contacted for outcome and survival data.

Results

Major complications occurred in 25/199 (12.6%) dogs. Incidence of major complications was significantly lower in SSC [+] dogs compared with SSC [−] dogs (1/45 procedures vs 24/144 procedures; p = 0.019). Dogs with SSCs were more likely to receive antibiotics within 5 min of the first incision (p = 0.0082) and to receive antibiotics every 90 min throughout the procedure as prescribed (p = 0.001) compared with dogs without SSCs. Incidence of cardiac death was lower in SSC [+] dogs compared with SSC [−] dogs (p = 0.0012), but checklist use was not associated with increased survival time (all-cause or cardiac). On average, 91% of checklist components were completed for each SSC; minor changes in record-keeping protocols could increase compliance.

Conclusions

Use of an SSC was associated with a decrease in the major complication rate and an increase in compliance with antibiotic protocols during pacemaker implantation. Results of this study support the use of an SSC in veterinary cardiology procedures.

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)

  • M.S. Johnson et al.

    Results of pacemaker implantation in 104 dogs

    J Small Anim Pract

    (2007)
  • D. Sisson et al.

    Permanent transvenous pacemaker implantation in forty dogs

    J Vet Intern Med

    (1991)
  • O. Domenech et al.

    The implantation of a permanent transvenous endocardial pacemaker in 42 dogs: a retrospective study

    Med Sci Mon Int Med J Exp Clin Res

    (2005)
  • C.W. Lombard et al.

    Pacemaker implantation in the dog: survey and literature review

    J Am Anim Hosp Assoc

    (1981)
  • J.D. Bonagura et al.

    Complications associated with permanent pacemaker implantation in the dog

    J Am Vet Med Assoc

    (1983)
  • J.L. Ward et al.

    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

    (2015)
  • D.M. Fine et al.

    Cardiovascular device infections in dogs: report of 8 cases and review of the literature

    J Vet Intern Med

    (2007)
  • M.S. Kiviniemi et al.

    Complications related to permanent pacemaker therapy

    Pacing Clin Electrophysiol

    (1999)
  • F. Eberhardt et al.

    Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity

    Hear J

    (2005)
  • Cited by (11)

    • The perioperative management of small animals with previously implanted pacemakers undergoing anaesthesia

      2022, Veterinary Anaesthesia and Analgesia
      Citation Excerpt :

      A suggested perioperative checklist for animals with a pacemaker undergoing general anaesthesia is shown in Table 2 (Prutkin & Poole 2016; ASA 2020). The history, reason for general anaesthesia, physical examination, baseline haematology and biochemistry and a surface ECG should be performed in patients with a pacemaker (Prutkin & Poole 2016; Ward et al. 2019; ASA 2020). Complete information about the animal’s pacemaker should be available prior to anaesthesia (Table 2) (Prutkin & Poole 2016; Chakravarthy et al. 2017; ASA 2020).

    • Optimizing single-chamber pacing in dogs Part 1: Rate determinations, rate interventions and hysteresis

      2021, Veterinary Journal
      Citation Excerpt :

      In dogs with sick sinus syndrome long-term monitoring may be particularly important to identify the development of binodal conduction disease (atrioventricular nodal block; Kristensen et al., 2001), noise reversion particularly with coexisting tachyarrhythmias (sinus tachycardia or atrial tachycardia), excessive VA conduction resulting in retrograde P waves with or without echo ventricular complexes, increased percent of pacing, or excessive pacing at hysteresis rate secondary to intrinsic echo or ventriculophasic beats. Creating a checklist not only for the surgical procedure, which has been shown to improve outcome (Ward et al., 2019), but making a checklist for pacemaker programming during and after implantation is just as vital to assess programming goals and evaluate success or problems. A schedule of follow-up pacemaker interrogations should be outlined and specific plans for how the pacing rate profile will be evaluated should be included.

    View all citing articles on Scopus

    A unique aspect of the Journal of Veterinary Cardiology is the emphasis of additional web-based materials permitting the detailing of procedures and diagnostics. These materials can be viewed (by those readers with subscription access) by going to http://www.sciencedirect.com/science/journal/17602734. The issue to be viewed is clicked and the available PDF and image downloading is available via the Summary Plus link. The supplementary material for a given article appears at the end of the page. To view the material is to go to http://www.doi.org and enter the doi number unique to this paper which is indicated at the end of the manuscript.

    View full text