Measuring quality and outcomes in pediatric cardiac critical care

Assessing enrollment of eligible infants in the national pediatric cardiology quality improvement collaborative (NPC-QIC) through linkage to the pediatric cardiac critical care consortium (PC4) registry

BACKGROUND

The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) lacks a rigorous enrollment audit process, unlike other collaborative networks. Most centers require individual families to consent to participate. It is unknown whether there is variation across centers or biases in enrollment.

METHODS

We used the Pediatric Cardiac Critical Care Consortium (PC4) registry to assess enrollment rates in NPC-QIC for those centers participating in both registries using indirect identifiers (date of birth, date of admission, gender, and center) to match patient records. All infants born 1/1/2018-12/31/2020 and admitted 30 days of life were eligible. In PC4, all infants with a fundamental diagnosis of hypoplastic left heart or variant or who underwent a surgical or hybrid Norwood or variant were eligible. Standard descriptive statistics were used to describe the cohort and center match rates were plotted on a funnel chart.

RESULTS

Of 898 eligible NPC-QIC patients, 841 were linked to 1,114 eligible PC4 patients (match rate 75.5%) in 32 centers. Match rates were lower in patients of Hispanic/Latino ethnicity (66.1%, p = 0.005), and those with any specified chromosomal abnormality (57.4%, p = 0.002), noncardiac abnormality (67.8%, p = 0.005), or any specified syndrome (66.5%, p = 0.001). Match rates were lower for patients who transferred to another hospital or died prior to discharge. Match rates varied from 0 to 100% across centers.

CONCLUSIONS

It is feasible to match patients between the NPC-QIC and PC4 registries. Variation in match rates suggests opportunities for improvement in NPC-QIC patient enrollment.

Medical missions for the provision of paediatric cardiac surgery in low- and middle-income countries

This review will outline the role of visiting cardiac surgical teams in low- and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.

Unscheduled Pediatric Intensive Care Unit Admissions in Patients With Cardiovascular Disease: Clinical Features and Outcomes

BACKGROUND

An unscheduled readmission to the intensive care unit (ICU) is associated with increased morbidity and mortality in children. There is a paucity of data examining the impact of unscheduled admissions on outcomes in children with specific disease processes such as cardiovascular disease. We investigated the impact of scheduled versus unscheduled ICU admission on clinical outcomes and differences in patient characteristics in children with cardiovascular disease.

METHODS

This was a retrospective analysis of contemporaneously collected clinical data using the Virtual PICU Systems database. All consecutive admissions at 102 participating pediatric ICUs in patients with cardiovascular disease were collected from October 2010 to September 2012.

RESULTS

There were 48,653 admissions included in the analysis (44% scheduled and 56% unscheduled). The median patient age was 31 months. Unscheduled admissions were associated with longer ICU length of stay and increased mortality (both P < .001). Adjusting for age, weight, and primary ICU admission diagnosis (cardiovascular vs noncardiovascular), patients with unscheduled admissions had an increased odds of mortality (odds ratio = 4.8, P < .001).

CONCLUSIONS

Unscheduled ICU admissions were associated with worse clinical outcomes including increased mortality. Efforts targeted at reducing unscheduled admissions in at-risk patients are warranted.

Outcomes Analysis and Quality Improvement in Children With Congenital and Acquired Cardiovascular Disease

OBJECTIVES

In this review, the current state of outcomes analysis and quality improvement in children with acquired and congenital cardiovascular disease will be discussed, with an emphasis on defining and measuring outcomes and quality in pediatric cardiac critical care medicine and risk stratification systems.

DATA SOURCE

MEDLINE and PubMed

CONCLUSION

: Measuring quality and outcomes in the pediatric cardiac critical care environment is challenging owing to many inherent obstacles, including a diverse patient mix, difficulty in determining how the care of the ICU team contributes to outcomes, and the lack of an adequate risk-adjustment method for pediatric cardiac critical care patients. Despite these barriers, new solutions are emerging that capitalize on lessons learned from other quality improvement initiatives, providing opportunities to build upon previous successes.

Pediatric Index of Cardiac Surgical Intensive Care Mortality Risk Score for Pediatric Cardiac Critical Care

OBJECTIVE

Comparison of clinical outcomes is imperative in the evaluation of healthcare quality. Risk adjustment for children undergoing cardiac surgery poses unique challenges, due to its distinct nature. We developed a risk-adjustment tool specifically focused on critical care mortality for the pediatric cardiac surgical population: the Pediatric Index of Cardiac Surgical Intensive care Mortality score.

DESIGN

Retrospective analysis of prospectively collected pediatric critical care data.

SETTING

Pediatric critical care units in the United States.

PATIENTS

Pediatric cardiac intensive care surgical patients.

INTERVENTIONS

Prospectively collected data from consecutive patients admitted to ICUs were obtained from The Virtual PICU System (VPS, LLC, Los Angeles, CA), a national pediatric critical care database. Thirty-two candidate physiologic, demographic, and diagnostic variables were analyzed for inclusion in the development of the Pediatric Index of Cardiac Surgical Intensive care Mortality model. Multivariate logistic regression with stepwise selection was used to develop the model.

MEASUREMENTS AND MAIN RESULTS

A total of 16,574 cardiac surgical patients from the 55 PICUs across the United States were included in the analysis. Thirteen variables remained in the final model, including the validated Society of Thoracic Surgeons-European Association of Cardio-Thoracic Surgery Congenital Heart Surgery Mortality (STAT) score and admission time with respect to cardiac surgery, which identifies whether the patient underwent the index surgical procedure before or after admission to the ICU. Pediatric Index of Cardiac Surgical Intensive Care Mortality (PICSIM) performance was compared with the performance of Pediatric Risk of Mortality-3 and Pediatric Index of Mortality-2 risk of mortality scores, as well as the STAT score and STAT categories by calculating the area under the curve of the receiver operating characteristic from a validation dataset: PICSIM (area under the curve = 0.87) performed better than Pediatric Index of Mortality-2 (area under the curve = 0.81), Pediatric Risk of Mortality-3 (area under the curve = 0.82), STAT score (area under the curve = 0.77), STAT category (area under the curve = 0.75), and Risk Adjustment for Congenital Heart Surgery-1 (area under the curve = 0.74).

CONCLUSIONS

This newly developed mortality score, PICSIM, consisting of 13 risk variables encompassing physiology, cardiovascular condition, and time of admission to the ICU showed better discrimination than Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, and STAT score and category for mortality in a multisite cohort of pediatric cardiac surgical patients. The introduction of the variable "admission time with respect to cardiac surgery" allowed prediction of mortality when patients are admitted to the ICU either before or after the index surgical procedure.

The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care

PURPOSE OF REVIEW

Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research.

RECENT FINDINGS

Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD.

SUMMARY

The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.