Quality and Safety Initiatives in a Pediatric and Congenital Heart Surgery Program in a Low- and Middle-Income Country: The Impact of International Collaboration

ABSTRACT

Introduction:  This study assessed the impact of a quality and safety (Q&S) improvement program on outcomes in pediatric and congenital heart surgery (PCHS) through an international non-governmental collaboration in a low-and-middle-income country (LMIC).

Methods:  Surgical data from two distinct periods, PRE (January 2016 - December 2019) and POST (January 2020 - May 2024) Q&S implementation, were analyzed. Outcomes included 30-day mortality, urgency status, patient age, and procedure complexity using the Risk Adjustment for Congenital Heart Surgery (RACHS) 1 classification.

Results:  A total of 4,297 surgeries were performed: 2,429 in the PRE and 1,868 in the POST era. Overall, 30-day mortality decreased significantly from 7.5% to 5.1% (P = 0.002), reaching 3.1% in 2024. Urgent surgeries increased from 28% to 44% (P < 0.0001), while mortality in elective and urgent cases dropped from 3.9% to 1.7% (P = 0.0007) and from 16.5% to 9.6% (P < 0.0001), respectively. A shift toward more neonatal and infant cases was observed, with significant reductions in mortality in both groups (P = 0.01). Case mix complexity also increased (RACHS categories 3-6), yet mortality declined across all RACHS strata.

Conclusion:  The introduction of Q&S initiatives led to marked improvements in PCHS outcomes, even amid growing case complexity and acuity. These findings highlight the value of structured protocols and sustained Q&S efforts and underscore the transformative role of international partnerships in strengthening surgical care in LMICs.

Keywords:
Risk Adjustment; Developing Countries; Congenital Heart Defects; Diagnosis-Related Groups; Infant; Newborn Infant.