The following statement is an updated version of guidelines that were first published by the American College of Surgeons in 1991. The revised statement was developed by the Advisory Council for Cardiothoracic Surgery and approved by the College's Board of Regents in October 1996.
This report provides guidelines to be used by hospital executives and appropriate medical staff only. It places no value judgment on existing successful programs or on the treatment of individual patients.
While current standards of practice form the basis of this report, it is recognized that large programs in cardiac surgery grow from smaller ones. Hospitals and their staffs should exercise their own discretion in approving programs based on local need and the responsibility for achieving a good standard of practice.
While attention is directed primarily to open-heart surgery, the proposed standards should apply to closed-heart operations as well as to operations on the great vessels within the chest.
In borderline situations, in which the number of open-heart operations does not meet the established guidelines, the American College of Surgeons recommends the use of peer review.
Specification of the qualifications for cardiac surgeons in an established practice is beyond the scope of these guidelines. Surgeons practicing cardiac surgery should be certified or awaiting certification by the American Board of Thoracic Surgery or its Canadian equivalent within five years after completion of an approved residency program in cardiac surgery. It is recommended that hospital committees for staff accreditation exercise their judgments for privileges based on the nature of the cardiothoracic residency or postresidency experiences of the applicant.
A team approach with a minimum of two qualified cardiac surgeons is recommended to provide adequate and continuous perioperative care as well as assistance in the OR. It is recognized that, depending on the particular setting and situation, the assistant on a particular case may vary in experience and qualification.
Hospital Operative Volume—Adult Cardiac Surgery
The 1975 report of the Inter-Society Commission on Heart Disease Resources recommended that cardiac surgical programs in a hospital should perform at least 200 procedures annually. This recommendation was based on the premise of a hospital dedicating 1 operating room to cardiac surgery and functioning at 80 percent capacity (4 cases per week x 52 weeks = 200 per year). While there are no presently available data linking an individual surgeon's patient volume and hospital mortality rate, there are data to suggest that an annual volume of at least 100 to 125 open heart procedures (including coronary artery bypass procedures, valve replacements, and other operations requiring the use of cardiopulmonary bypass) per hospital is necessary from a quality standpoint and that there is a greater variation in adjusted mortality rates for teams doing lower volumes of procedures as compared with those doing a high volume. While 100 to 125 cases per year per hospital appears sufficient from a quality standpoint, it is likely that considerably more, and at least 200 procedures per year as previously recommended, are necessary in order for a program to function efficiently.
Congenital Heart Surgery
Surgery for congenital heart disease, especially in infants, requires a setting that readily meets the complex and special needs of this group of patients. These requirements include a cardiac surgeon experienced in the operative and perioperative management of such patients. There should be a pediatric cardiologist, an anesthesia team, perfusionists, intensive care nurses, and appropriate intensive care facilities for the treatment of infants and children. At a hospital where congenital heart operations are performed, a total of 100 congenital heart operations (both open and closed, not including neonatal ductus ligations) should be done. The occasional management of an infant or child with congenital heart disease by an otherwise busy and well-functioning adult cardiac surgical team is strongly discouraged.
Hospital Facilities and Personnel
It is urged that hospital committees for staff accreditation use peer review to determine that adequate standards of practice are maintained in terms of case frequency and results. A registry for the recording of cardiac surgical results is mandatory.
The complex operating room environment required by cardiac surgery in terms of equipment and instruments requires constant improvement in technique and proper indoctrination of personnel. Such educational programs should be under the direction of a clearly designated individual with particular interest and skill in cardiac surgery. Operating room nurses and technicians specializing in cardiac surgery are important. It should be mandatory that operating room nurses and technicians be assigned to cardiac surgery sufficiently often to develop and maintain the skills required for proficient performance in this area.
Anesthesia for cardiac surgical patients encompasses a variety of special problems. To ensure technical competence, frequent changing of the anesthesiologists assigned to cardiac surgery should be avoided.
The operation of a heart-lung machine should be performed by a specially trained nurse or technician under the supervision of the operating surgeon. A perfusionist certified by the American Board of Cardiovascular Perfusion is recommended. Perfusionists who are not certified should have at least two years of experience under supervision in an active clinical program in open-heart surgery and have a thorough background in operating room sterile techniques, perfusion physiology, the use of monitoring equipment, and a general understanding of commonly performed cardiac surgical procedures. The primary responsibility for determining the capability of the perfusionist remains with the cardiac surgeon.
Cardiac surgeons must be primarily responsible for the postoperative care of their patients, including that provided in the intensive care unit. Portions of that care may be shared with others, such as nurses and other physicians. However, only the cardiac surgeon is fully cognizant of all aspects of a given patient's condition and retains the responsibility for the continuity of care, which includes the preoperative status, the operative management, and the postoperative care.
Intensive care nursing of cardiac surgical patients is recognized as a true specialty involving skills in dealing with cardiac and respiratory emergencies. Assignment to cardiac surgical patients should be sufficiently often to maintain competence in this area of nursing. The surgeon should participate in the supervision of cardiac intensive care unit nurses.
The operating room, intensive care unit, and other facilities must conform to standards mandated by the Joint Commission on Accreditation of Health Care Organizations.
The nature of cardiac surgery makes it mandatory that diagnostic facilities be available to the surgical team. A proper cardiac catheterization laboratory must be available for hemodynamic and cine' angiographic studies. This laboratory should be under the direction of a qualified specialist and be accessible for preoperative elective studies, postoperative elective studies, and emergency procedures on a 24-hour basis.
Standard laboratory studies should be available on a 24-hour basis, including blood-gas analysis.
A blood bank facility with full resources under the direction of qualified specialists in this field is mandatory.
An intensive care facility must be available for all patients following cardiac surgery, and in some instances, for patients who are severely ill, preoperatively. This should be a limited-access area that is off limits to nonparticipating personnel and should have facilities for the adequate isolation of septic patients.
Proper patient follow-up is an integral part of surgical treatment. An effective follow-up system for patients having open-heart surgery is the responsibility of the surgical team. The team should be able to demonstrate that it has an adequate follow-up system and that patients are seen as often as necessary during the immediate postdischarge period and, subsequently, are followed up at appropriate intervals.
- Crawford FA, Anderson RP, Clark RE, et al, for the Ad Hoc Committee on Cardiac Surgery Credentialing of The Society of Thoracic Surgeons: Volume requirements for cardiac surgery credentialing: A critical examination. Ann Thorac Surg, 61:12-16, 1996.
- Clark RE, and the Ad Hoc Committee on Cardiac Surgery Credentialing of the Society of Thoracic Surgeons: Outcome as a function of annual coronary artery bypass graft volume. Ann Thorac Surg, 61-20-26, 1996.
- Hannan EL. Siu AL, Kumar D, et al: The decline in coronary artery bypass graft surgery mortality in New York State. The role of surgeon volume. JAMA, 273:209- 13, 1995.
- Shroyer ALW, Marshall G, Warner BA, et al: No continuous relationship between Veterans Affairs hospital coronary artery bypass grafting surgical volume and operative mortality. Ann Thorac Surg, 61:17-20, 1996.
- Luft HS, Romano PS. Chance, continuity, and change in hospital mortality rates: coronary artery bypass graft patients in California patients, 1983 to 1989. JAMA, 270:331-337, 1993.
Bulletin of the American College of Surgeons
Vol. 82, No. 2, February 1997