CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
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9.9%. Infection and bleeding were the most frequent post-operative
complications (14.8%). ‘Virtual ward rounds’ took place daily and
there was an average three to five extra consultations per week, most
related to clinical instability, drug management or echo revision. On
a qualitative review, ICU teams reported a feeling of security from
the new system, although some still regard telephone calls as simpler
and more efficient than Internet connections.
Conclusion:
Our results do not focus on surgical numbers, as this
experience, despite being aligned with current literature, is still incip-
ient. The emphasis is on the model provided by the ‘virtual ICU’,
which adds experience and diffuses knowledge between centres, thus
providing a safer environment to initiate such complex programmes
in less-developed areas.
1727: PULLING THE PATIENT THROUGH THE SYSTEM:
PROACTIVE CARE AT GREAT ORMOND STREET CHIL-
DREN’S HOSPITAL, LONDON, ENGLAND
Liz Smith, Alessandro Giardini
Great Ormond Street Children’s Hospital NHS Trust, UK
A streamlined patient journey provides a process where clinical staff,
families and children can manage their expectations of the system.
With the present high financial pressures on the National Health
Service, a current review of national children’s surgical heart services
and the opening of a new cardiac unit in 2012, our aim was ‘to reduce
over a six-month period the hospital stay by 5% in children with
congenital heart disease, by removing inefficiencies, and improving
quality of service provision, meanwhile ensuring that each child is
discharged when medically ready’. Quality improvement tools used
were affinity diagrams, interrelationship diagrams and rating final
sub-groups. The final drill down highlighted areas of ‘plan, process,
journey and structure’. The group of champions looked at four keys
areas, patient and family preparation, medication and discharge, inves-
tigations and pre-discharge ECHO. Data were obtained using Tally
sheets and the Great Ormond Street Hospital cardiorespiratory data-
base: length of stay in hours, discharge times, with balancing meas-
ures around patient experience questionnaires and repeat prescrip-
tions. The improvement project is currently on-going using a range
of interventions, with an aim to review data monthly and monitor
outcomes over the next six months as to whether we achieved our aim.
Learning points have however been evident around timing and current
work pressures, culture and structure, and engaging clinically based
individuals to make it a real and tangible experience and outcome.
1744: QUALITY OF CARE THAT CHILDREN WITH HEART
PROBLEMS RECEIVE IN THE SOUTH AFRICAN HEALTH
SYSTEM
Mark Patrick
1,2,3
, Cindy Stephen
1,3
1
Pietermaritzburg Metropolitan Hospital, KwaZulu-Natal, South
Africa
2
University of KwaZulu-Natal, Durban, South Africa
3
Child Healthcare Problem Identification Programme, South Africa
Background:
The quality of care children with heart problems
receive in the broader South African health system is not well
described. The Child Healthcare Problem Identification Programme
(Child PIP) uses mortality audits to assess quality of care. Over 150
South African hospitals have used Child PIP since 2005, recording
over 700 000 admissions and over 29 000 deaths. This paper provides
information on the children dying with heart problems.
Methods:
The study population included children admitted to and
dying in participating South African hospitals. Data were gathered
from 2005 to 2012. The mortality review process established cause
of death and modifiable factors.
Results:
Of the 29 000 deaths, 800 died with a heart problem as the
main cause of death. Most cardiac deaths occurred in infants, 12%
were severely malnourished. HIV status was unknown in one-third.
Over one-third died within 24 hours of admission, 16% of deaths
were considered avoidable. There were 1.7 modifiable factors per
death, 52% of modifiable factors occurred within the health system,
of which 55% were attributed to health workers. For rheumatic heart
disease there were 2.2 per death. A substantial number were attrib-
uted to caregivers’ health-seeking behaviour. A lack of high-care
facilities was most significant for administrators, and inadequate
history, assessment and investigations were the most common for
health workers.
Conclusion:
These findings for children dying with heart problems
suggest areas of concern. Co-morbidities of HIV and malnutrition
may influence decision making about definitive cardiac care. The
high proportion dying within 24 hours of admission and the higher
rate of modifiable factors occurring in children with rheumatic heart
disease call for further investigation and may present opportunities
for improving cardiac care systems. Resource allocation, in particu-
lar critical care, is a problem that needs attention, and improved
awareness of heart-related danger signs in the general population is
necessary.
1791: HOME-BASED PALLIATIVE CARE IN CHILDREN
WITH CARDIAC PROBLEMS
Joanna Dangel
1
, Tomasz Dangel
2
, Małgorzata Murawska
2
1
Perinatal Cardiology Department, Medical University of Warsaw,
Poland
2
Warsaw Hospice for Children, Poland
Introduction:
Warsaw Hospice for Children (WHC) is the first
non-governmental organisation in Poland that provides home-based
palliative care for children with life-limiting conditions and their
families. Children in whom curative treatment was completed could
be admitted to the palliative home-care programme. The aim of this
study was to evaluate patients with cardiac problems who were under
hospice care between 1994 and 2012.
Methods:
During 18 years, 96 children with different cardiac prob-
lems were under WHC care. There were 17 teenagers with Duchenne
muscular dystrophy, 13 children with unoperable heart defects, main-
ly due to pulmonary hypertension or severely hypoplastic pulmonary
arteries, eight children with post-operative complications, four with
Down syndrome and pulmonary hypertension, 54 with lethal chro-
mosomal aberrations, mainly trisomy 13, and 18 with heart defects.
Results:
Until 2000, seven teenagers with heart defects complicated
by pulmonary hypertension, heart failure or hypoplastic pulmonary
arteries were under palliative care. All of them died after 31 days
to seven years in hospice care. Since 1999, perinatal palliative care
has been established, mainly for children with lethal chromosomal
aberrations complicated by congenital heart defects, 37 patients
were admitted to the hospice programme after prenatal diagnosis
and consultation. None of those children was operated on. Period of
palliative home care lasted from three to 1 269 days, mean 161 days.
Just one newborn with hypoplastic left heart syndrome diagnosed
prenatally was in the hospice care for 35 days.
Conclusions:
Palliative care should be considered in all children
with life-limiting conditions. In patients with complicated heart
defects in whom surgical treatment failed, such options should be
discussed with the parents. Palliative care should be the method of
choice for foetuses and neonates with lethal chromosomal disorders
whose parents are against termination of pregnancy.
1826: CARDIAC CARE IN AFRICA: THE NAMIBIAN CHIL-
DREN’S HEART PROJECT
Henning du Toit
1
, Andreas Willberg
1
, Christopher Hugo-Hamman
1,2
1
Windhoek Central Hospital, Ministry of Health and Social Services,
Namibia
2
Christiaan Barnard Memorial Hospital, Cape Town, South Africa
Background:
There is limited access to cardiac care in Africa,
and prior to 2010, there were no cardiac services in Namibia. The
Ministry of Health and Social Services commissioned a heart centre
