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Lobdell KW, Perrault LP, Drgastin RH, Brunelli A, Cerfolio RJ, Engelman DT. Drainology: Leveraging research in chest-drain management to enhance recovery after cardiothoracic surgery. JTCVS Tech 2024; 25:226-240. [PMID: 38899104 PMCID: PMC11184673 DOI: 10.1016/j.xjtc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Kevin W. Lobdell
- Sanger Heart & Vascular Institute, Wake Forest University School of Medicine, Advocate Health, Charlotte, NC
| | - Louis P. Perrault
- Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | | | - Alessandro Brunelli
- Department of Thoracic Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | - Daniel T. Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass
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Gal DB, Cleveland JD, Kipps AK. Early Wound and Sternal Management Following Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024; 15:313-318. [PMID: 38263797 DOI: 10.1177/21501351231216448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Early postoperative wound management following congenital heart surgery remains an area without equipoise. Precautionary restrictions can impact quality of life, development, and delay access to other needed care. The influence of different practices on wound healing and complications is unknown. We surveyed Pediatric Acute Care Cardiology Collaborative member centers regarding postoperative wound closure, wound vacuum-assisted closure (VAC) use, sternal precautions, and restrictions in the early postoperative period. We analyzed responses using descriptive statistics. Responses were submitted by 35/46 (76%) centers. Most centers perform primary skin closure with subcutaneous sutures. Wound covers are removed after 48 h at 43% (15/35) of centers and after ≥72 h at 34% (12/35) of centers. For delayed sternal closure, 16 centers close skin with interrupted, externalized sutures, 5 utilize wound VAC-assisted closure, and 12 use variable practices. Generally, 33 centers use wound VACs for wound care. Patient selection for VAC use and length of therapy varies. We found great variability in duration of sternal precautions and in activity, bathing, and submersion restrictions. Finally, 29 centers require a waiting period between cardiothoracic surgery and other surgeries such as tracheostomy or gastrostomy tube placement. Postoperative wound and sternal management lack consistency across North American pediatric heart institutes. Some restrictive practices may prolong length of stay and/or negatively impact quality of life and neurodevelopment. Practices may also impact wound infection rates. Research linking practices with clinical outcomes is needed to better define standards of care and reduce potential negative consequences of overly conservative or aggressive practices.
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Affiliation(s)
- Dana B Gal
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - John D Cleveland
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alaina K Kipps
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
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Tjoeng YL, Werho DK, Algaze C, Nawathe P, Benjamin S, Schumacher KR, Chan T. Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC 4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023. Cardiol Young 2024; 34:563-569. [PMID: 37577942 DOI: 10.1017/s1047951123002950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.
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Affiliation(s)
- Yuen Lie Tjoeng
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - David K Werho
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Claudia Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Pooja Nawathe
- Division of Pediatric Critical Care, Guerin Children's, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Solange Benjamin
- Division of Pediatric Cardiology, Levine Children's Hospital, Charlotte, NC, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C. S. Mott Children's Hospital, University of Michigan. Ann Arbor, MI, USA
| | - Titus Chan
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
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Byrnes J, Bailly D, Werho DK, Rahman F, Esangbedo I, Hamzah M, Banerjee M, Zhang W, Maher KO, Schumacher KR, Deshpande SR. Risk Factors for Extubation Failure After Pediatric Cardiac Surgery and Impact on Outcomes: A Multicenter Analysis. Crit Care Explor 2023; 5:e0966. [PMID: 37753236 PMCID: PMC10519555 DOI: 10.1097/cce.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
IMPORTANCE Extubation failure (EF) after pediatric cardiac surgery is associated with increased morbidity and mortality. OBJECTIVES We sought to describe the risk factors associated with early (< 48 hr) and late (48 hr ≤ 168 hr) EF after pediatric cardiac surgery and the clinical implications of these two types of EF. DESIGN SETTING AND PARTICIPANTS Retrospective cohort study using prospectively collected clinical data for the Pediatric Cardiac Critical Care Consortium (PC4) Registry. Pediatric patients undergoing Society of Thoracic Surgeons benchmark operation or heart transplant between 2013 and 2018 available in the PC4 Registry were included. MAIN OUTCOMES AND MEASURES We analyzed demographics and risk factors associated with EFs (primary outcome) including by type of surgery. We identified potentially modifiable risk factors. Clinical outcomes of mortality and length of stay (LOS) were reported. RESULTS Overall 18,278 extubations were analyzed. Unplanned extubations were excluded from the analysis. The rate of early EF was 5.2% (948) and late EF was 2.5% (461). Cardiopulmonary bypass time, ventilator duration, airway anomaly, genetic abnormalities, pleural effusion, and diaphragm paralysis contributed to both early and late EF. Extubation during day remote from shift change and nasotracheal route of initial intubation was associated with decreased risk of early EF. Extubation in the operating room was associated with an increased risk of early EF but with decreased risk of late EF. Across all operations except arterial switch, EF portrayed an increased burden of LOS and mortality. CONCLUSION AND RELEVANCE Both early and late EF are associated with significant increase in LOS and mortality. Study provides potential benchmarking data by type of surgery. Modifiable risk factors such as route of intubation, time of extubation as well as treatment of potential contributors such as diaphragm paralysis or pleural effusion can serve as focus areas for reducing EFs.
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Affiliation(s)
- Jonathan Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama, Birmingham, AL
| | - David Bailly
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - David K Werho
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, CA
| | - Fazlur Rahman
- School of Public Health, University of Alabama, Birmingham, AL
| | - Ivie Esangbedo
- Division of Critical Care, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Mohammed Hamzah
- Department of Pediatric Critical Care, Cleveland Clinic Children's, Cleveland, OH
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Wenying Zhang
- Congenital Heart Center C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Kevin O Maher
- Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Kurt R Schumacher
- Congenital Heart Center C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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Reich DA, Badru FO, Mustafa MM, Islam S. Massive chest tube output after congenital diaphragmatic hernia repair on extracorporeal membrane oxygenation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2023. [DOI: 10.1016/j.epsc.2022.102493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Lobdell KW, Engelman DT. Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:41-48. [PMID: 36803288 DOI: 10.1177/15569845231153623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
In the field of modern cardiothoracic surgery, chest drainage has become ubiquitous and yet characterized by a wide variation in practice. Meanwhile, the evolution of chest drain technology has created gaps in knowledge that represent opportunities for new research to support the development of best practices in chest drain management. The chest drain is an indispensable tool in the recovery of the cardiac surgery patient. However, decisions about chest drain management-including those about type, material, number, maintenance of patency, and the timing of removal-are largely driven by tradition due to a scarcity of quality evidence. This narrative review surveys the available evidence regarding chest-drain management practices with the objective of highlighting scientific gaps, unmet needs, and opportunities for further research.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
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Bates KE, Madsen NL, Lyren A, Krack P, Anderson JB, Lannon CM, Wooton S. Framework to optimise learning network activities for long-term success. BMJ Qual Saf 2022; 31:800-805. [PMID: 35896418 DOI: 10.1136/bmjqs-2021-014463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/08/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Katherine E Bates
- Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nicolas L Madsen
- Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Anne Lyren
- Pediatrics and Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Paige Krack
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey B Anderson
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, Ohio, USA
| | - Carole M Lannon
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- The American Board of Pediatrics, Chapel Hill, North Carolina, USA
| | - Sharyl Wooton
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Bates KE, Connelly C, Khadr L, Graupe M, Hlavacek AM, Morell E, Pasquali SK, Russell JL, Schachtner SK, Strohacker C, Tanel RE, Ware AL, Wooton S, Madsen NL, Kipps AK. Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project. J Am Heart Assoc 2021; 10:e020730. [PMID: 34713712 PMCID: PMC8751825 DOI: 10.1161/jaha.121.020730] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022]
Abstract
Background Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may impact postoperative length of stay (LOS). We used collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. Methods and Results Nine pediatric heart centers partnered together through 2 learning networks. Patients undergoing 1 of 9 benchmark congenital heart operations were included. Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29). Conclusions We successfully lowered postoperative CT duration and observed an associated reduction in LOS across 9 centers using collaborative learning methodology.
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Affiliation(s)
- Katherine E. Bates
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Chloe Connelly
- Anderson CenterCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Lara Khadr
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Margaret Graupe
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
- Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOH
| | - Anthony M. Hlavacek
- Department of PediatricsChildren’s Heart CenterMedical University of South Carolina Children’s HealthCharlestonSC
| | - Evonne Morell
- Department of PediatricsHeart InstituteUniversity of Pittsburgh Medical Center Children's Hospital of PittsburghPittsburghPA
| | - Sara K. Pasquali
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Jennifer L. Russell
- Department of PediatricsLabatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Susan K. Schachtner
- Cardiac CenterThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
- Department of PediatricsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Courtney Strohacker
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Ronn E. Tanel
- Pediatric Heart CenterUCSF Benioff Children’s HospitalSan FranciscoCA
- Department of PediatricsUCSF School of MedicineSan FranciscoCA
| | - Adam L. Ware
- Department of PediatricsThe Heart CenterPrimary Children’s HospitalSalt Lake CityUT
| | - Sharyl Wooton
- Anderson CenterCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Nicolas L. Madsen
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
- Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOH
| | - Alaina K. Kipps
- Department of PediatricsBetty Irene Moore Children's Heart CenterLucile Packard Children’s Hospital at StanfordStanford School of MedicinePalo AltoCA
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Pasquali SK, Thibault D, Hall M, Chiswell K, Romano JC, Gaynor JW, Shahian DM, Jacobs ML, Gaies MG, O'Brien SM, Norton EC, Hill KD, Cowper PA, Shah SS, Mayer JE, Jacobs JP. Evolving Cost-Quality Relationship in Pediatric Heart Surgery. Ann Thorac Surg 2021; 113:866-873. [PMID: 34116004 DOI: 10.1016/j.athoracsur.2021.05.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/16/2021] [Accepted: 05/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND For the >40,000 US children undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize healthcare value in this population. METHODS Clinical information (Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010-2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, post-operative complications, length of stay (PLOS), and a composite. RESULTS Overall 32 hospitals (n=45,315 patients) were included. Median adjusted cost/case varied across hospitals from $67,700 to $51,200 in the high vs. low cost tertile (ratio 1.32, 95% credible interval 1.29-1.35), and all quality metrics also varied across hospitals. Across cost tertiles there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk STAT 4-5 cases [adjusted median LOS 16.8 vs. 14.9 days in high vs. low cost tertile (ratio 1.13, 1.05-1.24)], and ICU PLOS. CONCLUSIONS Contemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to ICU PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David M Shahian
- Department of Surgery, Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Edward C Norton
- Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey P Jacobs
- Department of Surgery, University of Florida, Gainesville, Florida
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Gaies M, Romano JC, Whiteside W. An Intensivist, a Surgeon, and an Interventionalist Walk Into a Bar…. JACC Cardiovasc Interv 2021; 13:2865-2867. [PMID: 33357523 DOI: 10.1016/j.jcin.2020.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Jennifer C Romano
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Wendy Whiteside
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Harahsheh AS, Kipps AK, Hart SA, Cassidy SC, Clabby ML, Hlavacek AM, Hoerst AK, Graupe MA, Madsen NL, Bakar AM, Del Grippo EL, Patel SS, Bost JE, Tanel RE. High Acuity Therapy Variation Across Pediatric Acute Care Cardiology Units: Results from the Pediatric Acute Care Cardiology Collaborative Hospital Surveys. Pediatr Cardiol 2021; 42:1074-1081. [PMID: 33813599 PMCID: PMC8019478 DOI: 10.1007/s00246-021-02584-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/18/2021] [Indexed: 11/30/2022]
Abstract
We utilized the multicenter Pediatric Acute Care Cardiology Collaborative (PAC3) 2017 and 2019 surveys to describe practice variation in therapy availability and changes over a 2-year period. A high acuity therapies (ATs) score was derived (1 point per positive response) from 44 survey questions and scores were compared to center surgical volume. Of 31 centers that completed the 2017 survey, 26 also completed the 2019 survey. Scores ranged from 11 to 34 in 2017 and 11 to 35 in 2019. AT scores in 2019 were not statistically different from 2017 scores (29/44, IQR 27-32.5 vs. 29.5/44, IQR 27-31, p = 0.9). In 2019, more centers reported initiation of continuous positive airway pressure (CPAP) and Bi-level positive airway pressure (BiPAP) in Acute Care Cardiology Unit (ACCU) (19/26 vs. 4/26, p < 0.001) and permitting continuous CPAP/BiPAP (22/26 vs. 14/26, p = 0.034) compared to 2017. Scores in both survey years were significantly higher in the highest surgical volume group compared to the lowest, 33 ± 1.5 versus 25 ± 8.5, p = 0.046 and 32 ± 1.7 versus 23 ± 5.5, p = 0.009, respectively. Variation in therapy within the ACCUs participating in PAC3 presents an opportunity for shared learning across the collaborative. Experience with PAC3 was associated with increasing available respiratory therapies from 2017 to 2019. Whether AT scores impact the quality and outcomes of pediatric acute cardiac care will be the subject of further investigation using a comprehensive registry launched in early 2019.
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Affiliation(s)
- Ashraf S. Harahsheh
- Division of Cardiology, Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine & Health Sciences, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Alaina K. Kipps
- Division of Cardiology, Department of Pediatrics, Stanford School of Medicine, Palo Alto, CA USA
| | - Stephen A. Hart
- Division of Cardiology, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
| | - Steven C. Cassidy
- Division of Cardiology, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
| | - Martha L. Clabby
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA USA
| | - Anthony M. Hlavacek
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC USA
| | - Amanda K. Hoerst
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Margaret A. Graupe
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Nicolas L. Madsen
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,Division of Pediatric Cardiology, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH USA
| | - Adnan M. Bakar
- Division of Critical Care Medicine, Department of Pediatrics, Cohen Children’s Medical Center, New Hyde Park, NY USA
| | - Erica L. Del Grippo
- Nemours Cardiac Center at A.I. duPont Hospital for Children, Wilmington, DE USA
| | - Sonali S. Patel
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine, Aurora, CO USA
| | - James E. Bost
- Division of Biostatistics and Study Methodology, Children’s National Hospital, George Washington University School of Medicine, Washington, DC USA
| | - Ronn E. Tanel
- Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children’s Hospital, UCSF School of Medicine, San Francisco, CA USA
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Pasquali SK, Thibault D, O'Brien SM, Jacobs JP, Gaynor JW, Romano JC, Gaies M, Hill KD, Jacobs ML, Shahian DM, Backer CL, Mayer JE. National Variation in Congenital Heart Surgery Outcomes. Circulation 2020; 142:1351-1360. [PMID: 33017214 DOI: 10.1161/circulationaha.120.046962] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Optimal strategies to improve national congenital heart surgery outcomes and reduce variability across hospitals remain unclear. Many policy and quality improvement efforts have focused primarily on higher-risk patients and mortality alone. Improving our understanding of both morbidity and mortality and current variation across the spectrum of complexity would better inform future efforts. METHODS Hospitals participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2014-2017) were included. Case mix-adjusted operative mortality, major complications, and postoperative length of stay were evaluated using Bayesian models. Hospital variation was quantified by the interdecile ratio (IDR, upper versus lower 10%) and 95% credible intervals (CrIs). Stratified analyses were performed by risk group (Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT] category) and simulations evaluated the potential impact of reductions in variation. RESULTS A total of 102 hospitals (n=84 407) were included, representing ≈85% of US congenital heart programs. STAT category 1 to 3 (lower risk) operations comprised 74% of cases. All outcomes varied significantly across hospitals: adjusted mortality by 3-fold (upper versus lower decile 5.0% versus 1.6%, IDR 3.1 [95% CrI 2.5-3.7]), mean length of stay by 1.8-fold (19.2 versus 10.5 days, IDR 1.8 [95% CrI 1.8-1.9]), and major complications by >3-fold (23.5% versus 7.0%, IDR 3.4 [95% CrI 3.0-3.8]). The degree of variation was similar or greater for low- versus high-risk cases across outcomes, eg, ≈3-fold mortality variation across hospitals for STAT 1 to 3 (IDR 3.0 [95% CrI 2.1-4.2]) and STAT 4 or 5 (IDR 3.1 [95% CrI 2.4-3.9]) cases. High-volume hospitals had less variability across outcomes and risk categories. Simulations suggested potential reductions in deaths (n=282), major complications (n=1539), and length of stay (101 183 days) over the 4-year study period if all hospitals were to perform at the current median or better, with 37% to 60% of the improvement related to the STAT 1 to 3 (lower risk) group across outcomes. CONCLUSIONS We demonstrate significant hospital variation in morbidity and mortality after congenital heart surgery. Contrary to traditional thinking, a substantial portion of potential improvements that could be realized on a national scale were related to variability among lower-risk cases. These findings suggest modifications to our current approaches to optimize care and outcomes in this population are needed.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor (S.K.P., M.G.)
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.T., S.M.O., K.D.H.)
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.T., S.M.O., K.D.H.)
| | | | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, PA (J.W.G.)
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor (J.C.R.)
| | - Michael Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor (S.K.P., M.G.)
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.T., S.M.O., K.D.H.)
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (M.L.J.)
| | - David M Shahian
- Department of Surgery, Division of Cardiac Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston (D.M.S.)
| | - Carl L Backer
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital, OH (C.L.B.)
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, MA (J.E.M.)
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Arunamata A, Tacy TA, Kache S, Mainwaring RD, Ma M, Maeda K, Punn R. Recent outcomes of the extracardiac Fontan procedure in patients with hypoplastic left heart syndrome. Ann Pediatr Cardiol 2020; 13:186-193. [PMID: 32863652 PMCID: PMC7437630 DOI: 10.4103/apc.apc_5_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/17/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022] Open
Abstract
Objective: To investigate patient-related factors, echocardiographic, and anatomic variables associated with immediate and long-term clinical outcomes after extracardiac Fontan procedure at our institution. Materials and Methods: Retrospective review of preoperative cardiac catheterizations and echocardiograms as well as medical records of all children with hypoplastic left heart syndrome (HLHS) who underwent Fontan between June 2002 and December 2018. Results: Seventy-seven patients with HLHS were included (age 4 years [1.5–11.7]). Seventy patients (91%) received a nonfenestrated Fontan and 57 patients (74%) underwent Fontan without cardiopulmonary bypass (CPB). Presence of a Fontan fenestration (P = 0.69) and use of CPB (P = 0.79) did not differ between those with <2 weeks compared to those with ≥2 weeks of chest tube drainage. There were no differences in either pre- or intra-operative hemodynamics between patients who weighed <15 kg compared to those who weighed ≥15 kg at time of surgery; incidence of death, transplant, and transplant listing were similar between weight groups. Inferior vena cava (IVC) diameter z-score did not differ among patients with and without chylous chest tube drainage (P = 0.78), with and without development of protein losing enteropathy (P = 0.23), or death/heart transplant/transplant listing compared to survivors without transplant (P = 0.26). Conclusion: In HLHS patients undergoing Fontan, preoperative weight and IVC diameter appeared to have no influence on immediate postoperative outcomes. Performing the Fontan off CPB and with a fenestration also conferred no added clinical benefit. These observations should be considered when deciding optimal timing for Fontan completion.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Theresa A Tacy
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Saraswati Kache
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard D Mainwaring
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rajesh Punn
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
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