Klinikum Passau

Quality results

Treatment sector: Cardiac catheter applications

Information about this treatment area (documentation)

Designation	Perkutane Koronarintervention und Koronarangiographie (LKG)
Shortcut	PCI_LKG
Number of cases	984
Documentation rate	100.6 %

Summary result:

In 6 of 12 quality characteristics, the quality objective was achieved.
No assessment is possible for one quality characteristic

Number of patients treated: 984

Quality objective achieved
Quality objective not achieved

The results in detail

Show national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

So often catheter examinations were well justified because coronary vessels were actually so severely narrowed that treatment was necessary

Hospital: 31,71 %

Target area: at least 40,97 %

Quality objective not achieved

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This is how rarely cardiac catheter examinations were performed, even though there was no pathological narrowing of the coronary arteries

Hospital: 39,78 %

Target area: at most 41,48 %

Quality objective achieved

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This is how often the balloon catheter procedure started within the first hour after admission to hospital

Hospital: 86,27 %

Target area: at least 67,57 %

Quality objective achieved

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So rarely was the time of arrival of patients at the hospital or the start of the balloon catheter procedure not recorded in writing

Hospital: 21,54 %

Target area: at most 5,98 %

Assessment not possible

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Ratio of actual to expected rate of increased radiation exposure during a cardiac catheterisation examination (over 2,800 cGy x cm2)

Hospital: 1,96

Target area: at most 1,65

Quality objective not achieved

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Ratio of actual to expected rate of increased radiation exposure for balloon catheter treatment (over 4,800 cGy x cm2)

Hospital: 2,20

Target area: at most 1,14

Quality objective not achieved

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Ratio of actual to expected rate of increased radiation exposure during a cardiac catheter examination with directly subsequent balloon catheter treatment (over 5,500 cGy x cm2)

Hospital: 1,78

Target area: at most 1,50

Quality objective not achieved

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It is rare that the radiation exposure of patients during a cardiac catheterisation procedure is not recorded in writing.

Hospital: 0,00 %

Target area: at most 0,15 %

Quality objective achieved

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So rarely has the recommended amount of contrast medium been exceeded during cardiac catheter examinations (max. 150 ml)

Hospital: 10,54 %

Target area: at most 6,86 %

Quality objective not achieved

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So rarely has the recommended amount of contrast medium been exceeded in balloon catheter treatments (max. 200 ml)

Hospital: 61,90 %

Target area: at most 21,93 %

Quality objective not achieved

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So rarely has the recommended amount of contrast medium been exceeded (max. 250 ml) during a cardiac catheter examination with directly subsequent balloon catheter treatment.

Hospital: 17,12 %

Target area: at most 16,84 %

Quality objective achieved

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This is how often blood flow improved in patients with sudden severe symptoms and suspected heart attacks

Hospital: 93,00 %

Target area: at least 93,65 %

Quality objective achieved

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So often blood flow improved due to the cardiac catheterisation procedure (all patients)

Hospital: 94,79 %

Target area: at least 93,95 %

Quality objective achieved

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Code ID	56000
Result (%)	31,71
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	287
Events observed	91
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	verschlechtert
National result (%)	64,25
Target range (reference range)	>= 40,97 % (5. Perzentil)
Confidence interval nationwide (%)	64,05 - 64,45
Hospital confidence interval (%)	26,53 - 37,25
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Die Fachkommission sieht Hinweise auf Struktur- und Prozessmängel bei der Indikationsstellung. Die Indikationsstellung liegt im Verantwortungsbereich des Leistungserbringers und muss auch bei auswärts gestellter Indikation von Seiten des Leistungserbringers geprüft und gleichermaßen entsprechend in die QS-Dokumentation eingegeben werden.
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56001
Result (%)	39,78
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	269
Events observed	107
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	27,91
Target range (reference range)	<= 41,48 % (95. Perzentil)
Confidence interval nationwide (%)	27,71 - 28,11
Hospital confidence interval (%)	34,06 - 45,71
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56003
Result (%)	86,27
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	51
Events observed	44
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	76,37
Target range (reference range)	>= 67,57 % (5. Perzentil)
Confidence interval nationwide (%)	75,91 - 76,83
Hospital confidence interval (%)	74,93 - 93,64
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56004
Result (%)	21,54
Evaluation through structured dialogue	An evaluation is not possible because the documentation is incomplete or incorrect. (D80)
Population	65
Events observed	14
Anticipated events	0,00
Result trend compared with the previous reporting year	verschlechtert
Comparison with the previous reporting year	verschlechtert
National result (%)	2,71
Target range (reference range)	<= 5,98 % (95. Perzentil)
Confidence interval nationwide (%)	2,54 - 2,88
Hospital confidence interval (%)	12,91 - 32,63
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Gemäß Stellungnahme liegt in fast allen Fällen ein Dokumentationsfehler vor, die Angaben konnten anhand der Klinikdokumentation nachvollzogen werden.
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56005
Result	1,96
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	863
Events observed	207
Anticipated events	105,37
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	verschlechtert
National result	0,89
Target range (reference range)	<= 1,65 (95. Perzentil)
Confidence interval nationwide	0,88 - 0,90
Hospital confidence interval	1,71 - 2,25
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Die Begründung in der Stellungnahme (ältere Katheteranlage) erscheint der Fachkommission nicht ausreichend stichhaltig. Die Fachkommission sieht Hinweise auf strukturelle Defizite und empfiehlt dringend die Geräteeinstellungen mit der Herstellerfirma zu überprüfen und zu optimieren.
Comments/explanations by the hospital
Specialist note IQTIG Risk adjustment aims to compensate for the different patient structure in different facilities. Ideally, this leads to a fair comparison of the different facilities, since patients have individual risk factors (such as concomitant diseases) that systematically influence the quality outcome, without it being possible to attribute responsibility for e.g. resulting more frequent complications to one facility. With the help of risk adjustment, the quality outcome of, for example, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution with many low-risk cases. More information on risk adjustment can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen. The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered suspicious. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56006
Result	2,20
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	21
Events observed	11
Anticipated events	4,99
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	verschlechtert
National result	0,94
Target range (reference range)	<= 1,14 (95. Perzentil)
Confidence interval nationwide	0,92 - 0,97
Hospital confidence interval	1,17 - 3,81
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Die Begründung in der Stellungnahme (ältere Katheteranlage) erscheint der Fachkommission nicht ausreichend stichhaltig. Die Fachkommission sieht Hinweise auf strukturelle Defizite und empfiehlt dringend die Geräteeinstellungen mit der Herstellerfirma zu überprüfen und zu optimieren.
Comments/explanations by the hospital
Specialist note IQTIG Risk adjustment aims to compensate for the different patient structures in different facilities. Ideally, this leads to a fair comparison of the different facilities, since patients have individual risk factors (such as concomitant diseases) that systematically influence the quality outcome, without one facility being held responsible for, for example, more frequent complications as a result. With the help of risk adjustment, the quality outcome of, for example, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution with many low-risk cases. More information on risk adjustment can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen. The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered suspicious. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56007
Result	1,78
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	444
Events observed	143
Anticipated events	80,37
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	verschlechtert
National result	0,90
Target range (reference range)	<= 1,50 (95. Perzentil)
Confidence interval nationwide	0,89 - 0,91
Hospital confidence interval	1,51 - 2,09
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Die Begründung in der Stellungnahme (ältere Katheteranlage) erscheint der Fachkommission nicht ausreichend stichhaltig. Die Fachkommission sieht Hinweise auf strukturelle Defizite und empfiehlt dringend die Geräteeinstellungen mit der Herstellerfirma zu überprüfen und zu optimieren.
Comments/explanations by the hospital
Specialist note IQTIG Risk adjustment aims to compensate for the different patient structure in different facilities. Ideally, this leads to a fair comparison of the different facilities, since patients have individual risk factors (such as concomitant diseases) that systematically influence the quality outcome, without it being possible to attribute responsibility for e.g. resulting more frequent complications to one facility. With the help of risk adjustment, the quality outcome of, for example, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution with many low-risk cases. More information on risk adjustment can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen. The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered suspicious. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56008
Result (%)	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	1328
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	0,21
Target range (reference range)	<= 0,15 % (90. Perzentil)
Confidence interval nationwide (%)	0,20 - 0,22
Hospital confidence interval (%)	0,00 - 0,19
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56009
Result (%)	10,54
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	863
Events observed	91
Anticipated events	0,00
Result trend compared with the previous reporting year	verschlechtert
Comparison with the previous reporting year	verschlechtert
National result (%)	4,41
Target range (reference range)	<= 6,86 % (95. Perzentil)
Confidence interval nationwide (%)	4,35 - 4,47
Hospital confidence interval (%)	8,63 - 12,73
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Die Fachkommission sieht einen erhöhten Kontrastmittelverbrauch nicht alleine begründet durch die Ausbildung von Kolleg*innen. Die erhöhte Kontrastmittelmenge macht Struktur- und Prozessmängel erkennbar und sollte durch Schulungen vorab ausreichend reduziert werden können.
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56010
Result (%)	61,90
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	21
Events observed	13
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	17,16
Target range (reference range)	<= 21,93 % (95. Perzentil)
Confidence interval nationwide (%)	16,68 - 17,65
Hospital confidence interval (%)	40,71 - 80,06
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	Die Fachkommission sieht einen erhöhten Kontrastmittelverbrauch bei einer Koronarintervention durch die Ausbildung von Kolleg*innen nicht ausreichend begründet. Die erhöhte Kontrastmittelmenge macht Struktur- und Prozessmängel erkennbar und sollte dringend reduziert werden.
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56011
Result (%)	17,12
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	444
Events observed	76
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	9,88
Target range (reference range)	<= 16,84 % (95. Perzentil)
Confidence interval nationwide (%)	9,77 - 10,00
Hospital confidence interval (%)	13,83 - 20,83
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56014
Result (%)	93,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	100
Events observed	93
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	94,29
Target range (reference range)	>= 93,65 % (5. Perzentil)
Confidence interval nationwide (%)	94,05 - 94,52
Hospital confidence interval (%)	86,75 - 96,81
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	56016
Result (%)	94,79
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	365
Events observed	346
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	95,31
Target range (reference range)	>= 93,95 % (5. Perzentil)
Confidence interval nationwide (%)	95,23 - 95,39
Hospital confidence interval (%)	92,15 - 96,73
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.