Optimal Resources for Cardiac Surgery-Revisited
S
even years ago the Regional Medical Program Service of the HEW Health Service and Mental Health Administration, with the active cooperation of the American Heart Association and the American College of Cardiology, established the Inter-Society Commission for Heart Disease Resources, under the chairmanship of Irving S. Wright, M.D., with Donald T. Frederickson, M.D., as project director. Its purpose was to develop guidelines for the evaluation and development of medical facilities and services for the prevention, diagnosis, and treatment of cardiovascular disease. Within the Commission a Surgery Study Group, chaired by Dr. J. Gordon Scannell, was impaneled to describe in useful terms the clinical and physical environment needed for the effective performance of cardiac surgery. In 1971 a report prepared by the Surgery Study Group describing such an environment was published simultaneously in Circulation [2] and The Annals of Thoracic Surgery [l]. The report attempted to establish optimal rather than minimal guidelines for the performance of cardiac surgery. It was widely disseminated, and it generated a considerable amount of comment. The guidelines for optimal care were interpreted by several agencies as absolute standards, a purpose for which they were not intended. In addition, other sets of guidelines appeared, differing somewhat from the report of the study group [7]. Nonetheless, the report filled a real void by providing information that had not previously been available from a single source. It also recognized that tremendous changes were occurring in the field of coronary artery surgery at the time the original report was published. To meet this problem, another study group addressed itself to optimal conditions for coronary artery surgery and published a separate report [31. Material on pediatric cardiac surgery appeared in a separate issue of Circulation [41. Perhaps the most controversial part of the report was the recommendation that a minimum of four to six operations employing extracorporeal circulation were necessary per week to maintain a cardiac surgical “center” at the proper level of effectiveness. At the time the report was issued, many cardiac surgical units were not performing open-heart operations with that frequency. Now a revision of the original report is being published simultaneously in Circulation and The AmericanJournal of Cardiology [S]. It combines and updates the original reports on cardiac and coronary artery surgery and includes a revised section on pediatric cardiac surgery. This revision is believed necessary because the complexion of cardiac surgery has changed; questions have been raised by planning agencies that were not answered originally; and clarification of some points has become necessary as the guidelines, inevitably, have become standards. It is hoped that reaffirming still applicable portions of the report and clarifying questionable areas will make it a more useful aid in planning, evaluating, and operating cardiac centers. Liaisons were established with major surgcal organizaVOL. 20, NO. 5, NOVEMBER, 1975
593
Editorial
tions to obtain wider input from thoracic surgeons, and their representatives participated actively in this revision. The revised report reaffirms the need for adequate case loads to stimulate and maintain the quality of support necessary for safe and effective cardiac surgery. The original report stated that a case load of 200 open-heart operations per year was an optimal objective, but it recognized that under certain circumstancesthere might be exceptions to this figure. The revised report spells out these exceptions in greater detail, emphasizing the contributions of related cardiovascular problems and research to the maintenance of an effective cardiac program. The report warns against poorly planned and poorly conceived programs with inadequate case loads and material resources. It supports the concept of regionalization as a solution to the problem presented by the creation of such units. The field of cardiac surgery has expanded, particularly the area of coronary artery surgery, and excellent programs have been developed in community and other nonteaching hospitals. The original report emphasized the need for adequate physician coverage and contended that this need could best be met with resident staffs because cardiac programs first began in teaching hospitals. The revised report recognizes that approved training programs in the cardiological specialties are not essential to the conduct of an excellent cardiac surgical service. It does emphasize that the absence of resident coverage implies a special responsibility to assure that there is adequate in-hospital professional staff coverage at all times. On the other hand, it points out that cardiac residency programs should not be set up as a means of ensuring adequate professional support under the camouflage of education. To do so would not only exploit the services of the residents so appointed, but would also produce a number of marginally qualified specialists without regard to overall need. The report correctly recognizes the increased role of the nurse in both education and intensive care of cardiac patients. The importance of the clinical nurse specialist is emphasized. There is an extensive discussion of the necessary collaborating and supporting services for cardiac surgery and a careful description of the physical facilities necessary in the operating room and intensive care unit. These revised and updated guidelines are a valuable source of information for everyone planning or participating in a cardiac surgery program. They should be required reading. HERBERT SLOAN,M.D. Section of Thoracic Surgery, Department of Surgery University of Michigan Medical Center Ann Arbor, Mich. 481 04 References 1. Optimal resources for cardiac surgery: Report of the Inter-Society Commission for Heart Disease Resources. Ann Thoruc Surg 12:213, 1971.
594
T H E ANNALS OF THORACIC SURGERY
E ditoricc I 2. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Optimal resources for cardiac surgery. Circulation 44:A-221, 1971. 3. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Optimal resources for coronary artery surgery. Circulation 46:A-325, 1972. 4. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Resources for the optimal acute care of patients with congenital heart disease. Circulation 43:A-123, 1971. Revised May 1972. 5. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Optimal resources for cardiac surgery: Guidelines for program planning and evaluation. Circulation (in press, November 1975); Am J Cardiol (in press, November 1975). 6. Scannell, J. G. Report of the Surgery Study Group of the I.C.H.D. A n n Thorac Surg 12:325, 1971. 7. Subcommittee on Hospital Program Review, Cardiovascular Committee, American College of Surgeons. Guidelines for minimum standards in cardiovascular surgery. Bull A m Coll Surg 57:69, 1972.
VOL. 20, NO. 5 , NOVEMBER, 1975
595
S
even years ago the Regional Medical Program Service of the HEW Health Service and Mental Health Administration, with the active cooperation of the American Heart Association and the American College of Cardiology, established the Inter-Society Commission for Heart Disease Resources, under the chairmanship of Irving S. Wright, M.D., with Donald T. Frederickson, M.D., as project director. Its purpose was to develop guidelines for the evaluation and development of medical facilities and services for the prevention, diagnosis, and treatment of cardiovascular disease. Within the Commission a Surgery Study Group, chaired by Dr. J. Gordon Scannell, was impaneled to describe in useful terms the clinical and physical environment needed for the effective performance of cardiac surgery. In 1971 a report prepared by the Surgery Study Group describing such an environment was published simultaneously in Circulation [2] and The Annals of Thoracic Surgery [l]. The report attempted to establish optimal rather than minimal guidelines for the performance of cardiac surgery. It was widely disseminated, and it generated a considerable amount of comment. The guidelines for optimal care were interpreted by several agencies as absolute standards, a purpose for which they were not intended. In addition, other sets of guidelines appeared, differing somewhat from the report of the study group [7]. Nonetheless, the report filled a real void by providing information that had not previously been available from a single source. It also recognized that tremendous changes were occurring in the field of coronary artery surgery at the time the original report was published. To meet this problem, another study group addressed itself to optimal conditions for coronary artery surgery and published a separate report [31. Material on pediatric cardiac surgery appeared in a separate issue of Circulation [41. Perhaps the most controversial part of the report was the recommendation that a minimum of four to six operations employing extracorporeal circulation were necessary per week to maintain a cardiac surgical “center” at the proper level of effectiveness. At the time the report was issued, many cardiac surgical units were not performing open-heart operations with that frequency. Now a revision of the original report is being published simultaneously in Circulation and The AmericanJournal of Cardiology [S]. It combines and updates the original reports on cardiac and coronary artery surgery and includes a revised section on pediatric cardiac surgery. This revision is believed necessary because the complexion of cardiac surgery has changed; questions have been raised by planning agencies that were not answered originally; and clarification of some points has become necessary as the guidelines, inevitably, have become standards. It is hoped that reaffirming still applicable portions of the report and clarifying questionable areas will make it a more useful aid in planning, evaluating, and operating cardiac centers. Liaisons were established with major surgcal organizaVOL. 20, NO. 5, NOVEMBER, 1975
593
Editorial
tions to obtain wider input from thoracic surgeons, and their representatives participated actively in this revision. The revised report reaffirms the need for adequate case loads to stimulate and maintain the quality of support necessary for safe and effective cardiac surgery. The original report stated that a case load of 200 open-heart operations per year was an optimal objective, but it recognized that under certain circumstancesthere might be exceptions to this figure. The revised report spells out these exceptions in greater detail, emphasizing the contributions of related cardiovascular problems and research to the maintenance of an effective cardiac program. The report warns against poorly planned and poorly conceived programs with inadequate case loads and material resources. It supports the concept of regionalization as a solution to the problem presented by the creation of such units. The field of cardiac surgery has expanded, particularly the area of coronary artery surgery, and excellent programs have been developed in community and other nonteaching hospitals. The original report emphasized the need for adequate physician coverage and contended that this need could best be met with resident staffs because cardiac programs first began in teaching hospitals. The revised report recognizes that approved training programs in the cardiological specialties are not essential to the conduct of an excellent cardiac surgical service. It does emphasize that the absence of resident coverage implies a special responsibility to assure that there is adequate in-hospital professional staff coverage at all times. On the other hand, it points out that cardiac residency programs should not be set up as a means of ensuring adequate professional support under the camouflage of education. To do so would not only exploit the services of the residents so appointed, but would also produce a number of marginally qualified specialists without regard to overall need. The report correctly recognizes the increased role of the nurse in both education and intensive care of cardiac patients. The importance of the clinical nurse specialist is emphasized. There is an extensive discussion of the necessary collaborating and supporting services for cardiac surgery and a careful description of the physical facilities necessary in the operating room and intensive care unit. These revised and updated guidelines are a valuable source of information for everyone planning or participating in a cardiac surgery program. They should be required reading. HERBERT SLOAN,M.D. Section of Thoracic Surgery, Department of Surgery University of Michigan Medical Center Ann Arbor, Mich. 481 04 References 1. Optimal resources for cardiac surgery: Report of the Inter-Society Commission for Heart Disease Resources. Ann Thoruc Surg 12:213, 1971.
594
T H E ANNALS OF THORACIC SURGERY
E ditoricc I 2. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Optimal resources for cardiac surgery. Circulation 44:A-221, 1971. 3. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Optimal resources for coronary artery surgery. Circulation 46:A-325, 1972. 4. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Resources for the optimal acute care of patients with congenital heart disease. Circulation 43:A-123, 1971. Revised May 1972. 5. Report of the Inter-Society Commission for Heart Disease Resources (Surgery Study Group): Optimal resources for cardiac surgery: Guidelines for program planning and evaluation. Circulation (in press, November 1975); Am J Cardiol (in press, November 1975). 6. Scannell, J. G. Report of the Surgery Study Group of the I.C.H.D. A n n Thorac Surg 12:325, 1971. 7. Subcommittee on Hospital Program Review, Cardiovascular Committee, American College of Surgeons. Guidelines for minimum standards in cardiovascular surgery. Bull A m Coll Surg 57:69, 1972.
VOL. 20, NO. 5 , NOVEMBER, 1975
595
