1
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Shalhoub K, Heydarian HC, Hanke SP, Cnota JF, Stein LH, Tepe B, Hill GD. Achieving an Optimal Outcome After Stage 1 Palliation for Hypoplastic Left Heart Syndrome and Variants: Frequency, Associated Factors, and Subsequent Outcomes. J Am Heart Assoc 2024; 13:e032055. [PMID: 38860404 PMCID: PMC11255728 DOI: 10.1161/jaha.123.032055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/18/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND We sought to measure frequency of achieving an optimal outcome after stage 1 palliation (S1P) for hypoplastic left heart syndrome and variants, determine factors associated with optimal outcomes, and compare outcomes after stage 2 palliation (S2P) using the National Pediatric Cardiology Quality Improvement Collaborative database (2008-2016). METHODS AND RESULTS This is a retrospective cohort study with optimal outcome defined a priori as meeting all of the following: (1) discharge after S1P in <19 days (top quartile), (2) no red flag or major event readmissions before S2P, and (3) performing S2P between 90 and 240 days of age. Optimal outcome was achieved in 256 of 2182 patients (11.7%). Frequency varied among centers from 0% to 25%. Factors independently associated with an optimal outcome after S1P were higher gestational age (odds ratio [OR], 1.1 per week [95% CI, 1.0-1.2]; P=0.02); absence of a genetic syndrome (OR, 2.5 [95% CI, 1.2-5]; P=0.02); not requiring a post-S1P catheterization (OR, 2.7 [95% CI, 1.5-4.8]; P=0.01), intervention (OR, 1.5 [95% CI, 1.1-2]; P=0.006), or a procedure (OR, 4.5 [95% CI, 2.8-7.1]; P<0.001) before discharge; and not having a post-S1P complication (OR, 2.7 [95% CI, 1.9-3.7]; P<0.001). Those with an optimal outcome after S1P had improved S2P outcomes including shorter length of stay, less ventilator days, shorter bypass time, and fewer postoperative complications. CONCLUSIONS Identifying patients at lowest risk for poor outcomes during the home interstage period could shift necessary resources to those at higher risk, alter S2P postoperative expectations, and improve quality of life for families at lower risk.
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Affiliation(s)
- Khayri Shalhoub
- Department of PediatricsBaylor College of MedicineHoustonTXUSA
- Section of Critical Care Medicine & CardiologyTexas Children’s HospitalHoustonTXUSA
| | - Haleh C. Heydarian
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Samuel P. Hanke
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - James F. Cnota
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Laurel H. Stein
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Brooke Tepe
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Garick D. Hill
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
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2
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Ravishankar C. The Second Interstage Period Is Just as "Risky" as the First in HLHS. JACC. ADVANCES 2024; 3:100935. [PMID: 38939632 PMCID: PMC11198592 DOI: 10.1016/j.jacadv.2024.100935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Bates KE, Donohue J, Zhang W, Mikesell K, Anderson JB, Bingler M, Brown DW, Gaies MG, Ghanayem N, Lambert LM, Pasquali SK, Schidlow D, Vergales J, Schumacher KR. 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. Cardiol Young 2024; 34:373-379. [PMID: 37434511 DOI: 10.1017/s1047951123001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
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.
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Affiliation(s)
- Katherine E Bates
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Janet Donohue
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Katherine Mikesell
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Bingler
- Nemours Cardiac Center, Nemours Children's Hospital, Orlando, FL, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Michael G Gaies
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy Ghanayem
- Department of Pediatrics, University of Chicago Comer Children's Hospital and Advocate Children's Hospital, Chicago, IL
| | - Linda M Lambert
- Primary Children's Hospital Heart Center, Salt Lake City, UT, USA
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
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4
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Mavroudis C, Williams WG. The Early History of the Congenital Heart Surgeons' Society. World J Pediatr Congenit Heart Surg 2023; 14:546-551. [PMID: 37737594 DOI: 10.1177/21501351231178729] [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: 09/23/2023]
Abstract
The concept of a new organization for congenital heart surgeons in North America to discuss their difficult cases and offer each other potential solutions began in 1973. This article pays tribute to the founders of the Congenital Heart Surgeons' Society and offers insight into the desire of these surgeons to improve clinical outcomes for children with congenital heart disease.
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Affiliation(s)
- Constantine Mavroudis
- Pediatric Cardiac Surgery, Peyton Manning Children's Hospital, Indianapolis, IN, USA
- Professor Emeritus of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William G Williams
- Surgery Emeritus, University of Toronto School of Medicine, Toronto, Ontario, Canada
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5
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Sunthankar SD, Zhao J, Wei WQ, Hill GD, Parra DA, Kohl K, McCoy A, Jayaram NM, Godown J. Machine Learning to Predict Interstage Mortality Following Single Ventricle Palliation: A NPC-QIC Database Analysis. Pediatr Cardiol 2023; 44:1242-1250. [PMID: 36820914 PMCID: PMC10627450 DOI: 10.1007/s00246-023-03130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
There is high risk of mortality between stage I and stage II palliation of single ventricle heart disease. This study aimed to leverage advanced machine learning algorithms to optimize risk-prediction models and identify features most predictive of interstage mortality. This study utilized retrospective data from the National Pediatric Cardiology Quality Improvement Collaborative and included all patients who underwent stage I palliation and survived to hospital discharge (2008-2019). Multiple machine learning models were evaluated, including logistic regression, random forest, gradient boosting trees, extreme gradient boost trees, and light gradient boosting machines. A total of 3267 patients were included with 208 (6.4%) interstage deaths. Machine learning models were trained on 180 clinical features. Digoxin use at discharge was the most influential factor resulting in a lower risk of interstage mortality (p < 0.0001). Stage I surgery with Blalock-Taussig-Thomas shunt portended higher risk than Sano conduit (7.8% vs 4.4%, p = 0.0002). Non-modifiable risk factors identified with increased risk of interstage mortality included female sex, lower gestational age, and lower birth weight. Post-operative risk factors included the requirement of unplanned catheterization and more severe atrioventricular valve insufficiency at discharge. Light gradient boosting machines demonstrated the best performance with an area under the receiver operative characteristic curve of 0.642. Advanced machine learning algorithms highlight a number of modifiable and non-modifiable risk factors for interstage mortality following stage I palliation. However, model performance remains modest, suggesting the presence of unmeasured confounders that contribute to interstage risk.
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Affiliation(s)
- Sudeep D Sunthankar
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
- Thomas P. Graham Jr Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, 2220 Children's Way, Suite 5230, Nashville, TN, 37232, USA.
| | - Juan Zhao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Garick D Hill
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David A Parra
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Karen Kohl
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Allison McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Natalie M Jayaram
- Division of Pediatric Cardiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Justin Godown
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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6
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Schidlow DN, Gauvreau K, Bucholz EM, Bennett A, Lafranchi T, Pruetz J, Ronai C, Vergales J, Brown DW. Prenatal care coordination, racial and socioeconomic inequities, and pre- and post-operative outcomes in hypoplastic left heart syndrome. J Perinatol 2023; 43:378-384. [PMID: 36539560 DOI: 10.1038/s41372-022-01571-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 11/03/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We sought to identify associations between prenatal care coordination (PNC) and outcomes in hypoplastic left heart syndrome (HLHS). STUDY DESIGN We hypothesized that suboptimal PNC is associated with worse pre-operative status. HLHS patients from 2016 through 2019 were identified using a multicenter registry. Optimal PNC was defined as (1) a completed interdisciplinary conference and (2) closed-loop communication with the obstetric team. Associations between PNC and outcomes were identified. RESULTS Of 1441 patients, 1242 (86%) had prenatal diagnosis. Among those with a prenatal diagnosis, PNC was achieved in only 845 (68%). Suboptimal PNC was associated with adverse events (50% vs 40%, p < 0.001), inotrope need (19% vs 13%, p = 0.007), mechanical ventilation (22% vs 16%, p = 0.016), and parenteral feeding (60% vs 46%, p < 0.001). African-American race and non-commercial insurance were associated with a lower likelihood of optimal PNC (p = 0.006 and p < 0.001, respectively). CONCLUSION Improving PNC and overcoming racial and socioeconomic barriers are important targets to improve HLHS perinatal care.
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Affiliation(s)
- David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Amy Bennett
- Board of Directions, Sisters by Heart, Los Angeles, CA, USA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jay Pruetz
- Division of Cardiology, Children's Hospital Los Angeles, Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Christina Ronai
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jeffrey Vergales
- Department of Pediatrics, Division of Cardiology, University of Virginia, Charlottesville, VA, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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7
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Van den Eynde J, Bartelse S, Rijnberg FM, Kutty S, Jongbloed MRM, de Bruin C, Hazekamp MG, Le Cessie S, Roest AAW. Somatic growth in single ventricle patients: A systematic review and meta-analysis. Acta Paediatr 2023; 112:186-199. [PMID: 36200280 PMCID: PMC10092582 DOI: 10.1111/apa.16562] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/17/2022] [Accepted: 10/05/2022] [Indexed: 01/13/2023]
Abstract
AIM To map somatic growth patterns throughout Fontan palliation and summarise evidence on its key modifiers. METHODS Databases were searched for relevant articles published from January 2000 to December 2021. Height and weight z scores at each time point (birth, Glenn procedure, Fontan procedure and >5 years after Fontan completion) were pooled using a random effects meta-analysis. A random effects meta-regression model was fitted to model the trend in z scores over time. RESULTS Nineteen studies fulfilled eligibility criteria, yielding a total of 2006 participants. The z scores for height and weight were markedly reduced from birth to the interstage period, but recovered by about 50% following the Glenn procedure. At >10 years after the Fontan procedure, the z scores for weight seemed to normalise despite persistent lower height, resulting in increased body mass index. The review revealed a number of modifiers of somatic growth, including aggressive nutritional management, timing of Glenn/Fontan, prompt resolution of complications and obesity prevention programmes in adolescence and adulthood. CONCLUSION This review mapped the somatic growth of single ventricle patients and summarised key modifiers that may be amendable to improvement. These data provide guidance on strategies to further optimise somatic growth in this population and may serve as a benchmark for clinical follow-up.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiovascular Diseases, KU Leuven, Leuven, Belgium.,Helen B. Taussig Heart Center, Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland, USA
| | - Simone Bartelse
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Shelby Kutty
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christiaan de Bruin
- Division of Paediatric Endocrinology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia Le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Biomedical Data sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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8
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Levy VY, Bhombal S, Villafane J, McBride ME, Thiagarajan R, Figueroa M, Hopper A, Johnson JN, Costello JM. Introduction to the Neonatal Cardiac Care Collaborative Supplement. Pediatrics 2022; 150:189879. [PMID: 36317968 DOI: 10.1542/peds.2022-056415b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas.,Neonatal Heart Society.,American Academy of Pediatrics, Section of Cardiology and Cardiothoracic Surgery
| | - Shazia Bhombal
- Department of Pediatrics, Stanford University, Palo Alto, California.,Neonatal Heart Society.,American Academy of Pediatrics, Section of Neonatal and Perinatal Medicine
| | - Juan Villafane
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital, Cincinnati, Ohio.,American Academy of Pediatrics, Section of Cardiology and Cardiothoracic Surgery
| | - Mary E McBride
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Pediatric Cardiac Intensive Care Society
| | - Ravi Thiagarajan
- Department of Pediatrics, Harvard University, Boston Children's, Boston, Massachusetts.,American Heart Association
| | - Mayte Figueroa
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri.,American College of Cardiology
| | - Andrew Hopper
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California.,American Academy of Pediatrics, Section of Neonatal and Perinatal Medicine
| | - Jonathan N Johnson
- Department of Pediatrics, Division of Pediatric Cardiology, Mayo Clinic Children's Center Rochester, Rochester, Minnesota.,American Academy of Pediatrics, Section of Cardiology and Cardiothoracic Surgery
| | - John M Costello
- Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, South Carolina.,American Heart Association
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9
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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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10
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Thienprayoon R, Jones E, Humphrey L, Ragsdale L, Williams C, Klick JC. The Pediatric Palliative Improvement Network: A national Healthcare Learning Collaborative. J Pain Symptom Manage 2022; 63:131-139. [PMID: 34186121 DOI: 10.1016/j.jpainsymman.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT AND OBJECTIVES Although multiple national organizations have created consensus guidelines and metrics for pediatric palliative care (PPC), standardized implementation and measurement has been challenging. In 2016, 6 PPC physician-experts in program development and quality improvement (QI) formed a healthcare learning collaborative network entitled the Pediatric Palliative Improvement Network (PPIN). METHODS The primary drivers identified were 1) Feasibility of a national learning network demonstrated through the completion of one small QI project, 2) Standard education in QI methodology and 3) Salient pediatric palliative care operational, clinical and satisfaction metrics clearly defined. RESULTS PPIN now includes146 members representing 51 organizations. In 2019 the group completed a national collaborative QI project focused on pain assessment at the time of initial consult, demonstrating a national increase in pain assessment from 75.8% to >90% over 12 months. PPIN has hosted two national QI workshops training more than 50 PPC clinicians in QI, with a 2-hour webinar provided in 2020 due to COVID. Monthly calls since 2017 provide QI methods "refreshers", share local works in progress, and provide infrastructure for future collaborative projects. CONCLUSIONS PPIN has become a sustainable organization which improves the quality of PPC through focus on national QI methods training, successful collaborative projects, and the creation of a learning and peer support community with regular calls. With the advent of the Palliative Care Quality Collaborative in 2020, PPIN provides critical educational and organizational infrastructure to inform ongoing quality efforts in PPC, now and in the future.
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Affiliation(s)
- Rachel Thienprayoon
- Division of Palliative Care, Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Emma Jones
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Lisa Humphrey
- Division of Palliative Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Lindsay Ragsdale
- Division of Palliative Care, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky
| | - Conrad Williams
- Palliative Care Program, Department of Pediatrics, Medical University of South Carolina Children's Health System, Charleston, South Carolina
| | - Jeffrey C Klick
- Department of Palliative Care, Children's Healthcare of Atlanta, Atlanta Georgia, USA; Division of Palliative Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
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11
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Orenstein EW, Kandaswamy S, Muthu N, Chaparro JD, Hagedorn PA, Dziorny AC, Moses A, Hernandez S, Khan A, Huth HB, Beus JM, Kirkendall ES. Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics. J Am Med Inform Assoc 2021; 28:2654-2660. [PMID: 34664664 DOI: 10.1093/jamia/ocab179] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/02/2021] [Accepted: 09/10/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. OBJECTIVE (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. MATERIALS AND METHODS We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. RESULTS Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. CONCLUSION Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.
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Affiliation(s)
- Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Naveen Muthu
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juan D Chaparro
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Philip A Hagedorn
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam C Dziorny
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA.,Division of Critical Care Medicine, Golisano Children's Hospital at Strong, Rochester, New York, USA
| | - Adam Moses
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sean Hernandez
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amina Khan
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hannah B Huth
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jonathan M Beus
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric S Kirkendall
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, 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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Brown TN, Brown DW, Tweddell JS, Bates KE, Lannon CM, Anderson JB. Digoxin Associated With Greater Transplant-Free Survival in High- vs Low-Risk Interstage Patients. Ann Thorac Surg 2021; 114:1453-1459. [PMID: 34687658 DOI: 10.1016/j.athoracsur.2021.08.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Digoxin has been associated with reduced interstage mortality for patients with functional single ventricles with aortic hypoplasia or ductal-dependent systemic circulation. The NEONATE (type of stage 1 palliation operation, postoperative extracorporeal membrane oxygenation, discharge with opiates, no digoxin at discharge, postoperative arch obstruction, moderate to severe tricuspid regurgitation without an oxygen requirement, and extra oxygen required at discharge in patients with moderate to severe tricuspid regurgitation) score can stratify patients by risk of death or transplantation (DTx) on the basis of clinical factors. The study investigators suspected a variable transplant-free survival benefit of digoxin in high-risk vs low-risk patients. METHODS National Pediatric Cardiology Quality Improvement Collaborative patients discharged after stage 1 palliation with complete data were categorized as high- or low-risk on the basis of a modified NEONATE score. The primary outcome of DTx was evaluated. A mixed-effect regression evaluated associations between digoxin prescription and risk factors. RESULTS A total of 1199 patients were included; 399 (33%) were high risk. Baseline demographics were similar between the cohorts. Blalock-Taussig shunt or a hybrid operation, postoperative extracorporeal membrane oxygenation, opiate prescription, and significant tricuspid regurgitation or arch obstruction were more common in high-risk patients. The odds of DTx were 65% lower in high-risk patients prescribed digoxin compared with patients who were not (P = .001). Digoxin prescription was associated with 60.8% lower DTx in the high-risk cohort (7.8% vs 19.9%; P = .001). There was no significant difference in the DTx rate according to digoxin prescription in the low-risk cohort (4.7% vs 5.7%; P = .46). Blalock-Taussig shunt, aortic arch obstruction, and significant tricuspid regurgitation were most strongly associated with deriving a benefit from digoxin. CONCLUSIONS Digoxin use is associated with significant improvement in transplant-free survival in high-risk but not in low-risk interstage patients. A tailored approach to the use of digoxin in interstage patients may be warranted.
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Affiliation(s)
- Tyler N Brown
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - James S Tweddell
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katherine E Bates
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Carole M Lannon
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Online Learning and Echocardiography Boot Camp: Innovative Learning Platforms Promoting Blended Learning and Competency in Pediatric Echocardiography. Pediatr Cardiol 2021; 42:389-396. [PMID: 33179179 DOI: 10.1007/s00246-020-02494-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/30/2020] [Indexed: 12/15/2022]
Abstract
Mastering pediatric echocardiography (PE) requires a substantial knowledge base of echo theory and congenital heart disease (CHD), along with technical proficiency. Online self-directed learning has become increasingly utilized among medical trainees to promote competency within medical subspecialties. We sought to evaluate the impact of online learning combined with lecture-based and hands-on teaching on the acquisition of PE knowledge and confidence in pediatric cardiology and pediatric critical care fellows. We prospectively enrolled 124 learners from 2016 to 2019. These included 40 incoming cardiology and critical care fellows at Texas Children's Hospital (TCH) as well as 84 national and international participants recruited from our online echo education website. All participants completed online learning modules through our website ( www.pedecho.org ), which covers pediatric echo physics, Doppler, technique, normal anatomy, atrial septal defects, and ventricular septal defects. TCH cardiology and critical care fellows subsequently participated in an Echo Boot Camp (BC), a 3-day training program with hands-on workshops and didactic lectures. Knowledge was assessed using an 80-question pre and post-test multiple choice exams. The online learning group demonstrated improvement in exam scores following online learning (PRE 49.1 ± 15.3 vs. POST 67.8 ± 17%; p ≤ 0.01). Echo Boot Camp fellows were noted to have further incremental improvement in test scores following BC (PRE 48% ± 13% vs. POST MODULE 68.6% ± 15% vs. POST BC 75.7% ± 13%; p ≤ 0.01). Self-assessment regarding confidence in context areas showed a substantial gain in self perceived interpretive confidence across all groups as well as procedural confidence in BC participants. Online learning significantly promotes the acquisition of echocardiography knowledge. Additional lecture-based and hands-on teaching in the form of an Echo Boot Camp can further enhance knowledge and interpretative skills. Both of these learning platforms appear to work in concert as powerful and effective tools in fellow education.
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Bahaidarah S, Al-Ata J, Abdelmohsen G, Alkhushi N, Abdelsalam M, Mujahed M, Al-Radi O, Elassal A, Zaher Z, Azhar A, Dohain AM. Cardiac catheterization addressing early post-operative complications in congenital heart surgery-a single-center experience. Egypt Heart J 2020; 72:83. [PMID: 33226532 PMCID: PMC7683629 DOI: 10.1186/s43044-020-00117-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac catheterization after congenital heart surgery may play an important role in the diagnosis and management of patients with a complicated or unusual post-operative course. The main objective of this study was to evaluate the safety, efficacy, and outcome of cardiac catheterization performed in the early post-operative period following congenital heart surgery. All patients who underwent cardiac catheterization after congenital heart surgery during the same admission of cardiac surgery from November 2015 to May 2018 were included in the study. RESULTS Thirty procedures were performed for 27 patients (20 interventional and 10 diagnostic). The median age of the patients was 15 months (15 days to 20 years), median weight was 8.2 kg (3.4 to 53 kg), and median time from surgery was 3 days (0-32 days). Eleven procedures were performed for 11 patients on extracorporeal membrane oxygenation (ECMO) support. The main indications for catheterization included the inability to wean from ECMO (10 procedures) and cyanosis (10 procedures). Interventional procedures included angioplasty using stents (10 procedures, success rate of 90%), angioplasty using only balloons (2 procedures, success rate of 50%), and occlusion for residual shunts (8 procedures, success rate of 100%). No mortality was recorded during any procedure. Vasoactive-inotropic score had significantly decreased 48 h after catheterization when compared to pre-catheterization scores (p = 0.0001). Moreover, 72% of patients connected to ECMO support were successfully weaned from ECMO after catheterization. Procedural complications were recorded in 3 interventional procedures. Survival to hospital discharge was 55.5% and overall survival was 52%. Patients on ECMO support had a higher mortality than other patients. CONCLUSION Cardiac catheterization can be performed safely in the early post-operative period, and it could improve the outcome of the patient (depending on the complexity of the cardiac lesions involved).
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Affiliation(s)
- Saud Bahaidarah
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia
| | - Jameel Al-Ata
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia
| | - Gaser Abdelmohsen
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia. .,Pediatric Cardiology Division, Department of Pediatrics, Cairo University, Cairo, 11562, Egypt.
| | - Naif Alkhushi
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia
| | - Mohamed Abdelsalam
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia.,Cardiology Department, Benha University, Benha, Egypt
| | - Mohammed Mujahed
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia
| | - Osman Al-Radi
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Ahmed Elassal
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | - Zaher Zaher
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia
| | - Ahmad Azhar
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia
| | - Ahmed M Dohain
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, P.O Box 80215, Jeddah, 21589, Saudi Arabia.,Pediatric Cardiology Division, Department of Pediatrics, Cairo University, Cairo, 11562, Egypt
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Hirahara N, Miyata H, Kato N, Hirata Y, Murakami A, Motomura N. Development of Bayesian Mortality Categories for Congenital Cardiac Surgery in Japan. Ann Thorac Surg 2020; 112:839-845. [PMID: 32949608 DOI: 10.1016/j.athoracsur.2020.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgery requires a complexity-based ranking system that provides critical information for surgeons to perform strategic operations. However, we still use professional panel systems such as the Risk Adjustment for Congenital Heart Surgery category and the Aristotle Basic Complexity score for this purpose, both of which are subjective. The present study, inspired by more recent development of The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery mortality scores and categories, applied a Bayesian statistical method to the Japanese nationwide congenital heart registry by estimating inhospital mortality to construct a data-driven, more scientific rating system based on complexity. METHODS The study used a 5-year dataset from the Japan Cardiovascular Surgery Database congenital section to construct a Bayesian estimation model. There were 25,968 operations with 186 cardiovascular procedures. To validate the model, we used an independent 2-year dataset with 14,904 operations. RESULTS The model-based inhospital mortality estimation provided a complexity rating system that replicated the past study that had proposed a five-category system based on the estimated mortality scores. The C-index with the validation dataset for the mortality score and category was 0.80 and 0.79, respectively. CONCLUSIONS The data-driven approach to complexity rating systems for congenital cardiovascular surgery is recommended, as it has better scientific advantages and more convenient updating features.
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Affiliation(s)
- Norimichi Hirahara
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan; School of Medicine, Keio University, Tokyo, Japan.
| | - Hiroaki Miyata
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan; School of Medicine, Keio University, Tokyo, Japan
| | - Naohiro Kato
- Radiation Effects Research Foundation, Hiroshima, Japan
| | - Yasutaka Hirata
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan; Faculty of Medicine, University of Tokyo, Japan
| | - Arata Murakami
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan; Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan; Faculty of Medicine, University of Tokyo, Japan; Toho University Sakura Medical Center, Sakura City, Chiba, Japan
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Rudd NA, Ghanayem NS, Hill GD, Lambert LM, Mussatto KA, Nieves JA, Robinson S, Shirali G, Steltzer MM, Uzark K, Pike NA. Interstage Home Monitoring for Infants With Single Ventricle Heart Disease: Education and Management: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2020; 9:e014548. [PMID: 32777961 PMCID: PMC7660817 DOI: 10.1161/jaha.119.014548] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This scientific statement summarizes the current state of knowledge related to interstage home monitoring for infants with shunt-dependent single ventricle heart disease. Historically, the interstage period has been defined as the time of discharge from the initial palliative procedure to the time of second stage palliation. High mortality rates during the interstage period led to the implementation of in-home surveillance strategies to detect physiologic changes that may precede hemodynamic decompensation in interstage infants with single ventricle heart disease. Adoption of interstage home monitoring practices has been associated with significantly improved morbidity and mortality. This statement will review in-hospital readiness for discharge, caregiver support and education, healthcare teams and resources, surveillance strategies and practices, national quality improvement efforts, interstage outcomes, and future areas for research. The statement is directed toward pediatric cardiologists, primary care providers, subspecialists, advanced practice providers, nurses, and those caring for infants undergoing staged surgical palliation for single ventricle heart disease.
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Carrillo SA, Texter KM, Phelps C, Tan Y, McConnell PI, Galantowicz M. Tricuspid Valve and Right Ventricular Function Throughout the Hybrid Palliation Strategy for Hypoplastic Left Heart Syndrome and Variants. World J Pediatr Congenit Heart Surg 2020; 12:9-16. [PMID: 32783502 DOI: 10.1177/2150135120947692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tricuspid valve (TV) and right ventricular (RV) function are major determinants of morbidity and mortality in patients with hypoplastic left heart syndrome (HLHS). We sought to retrospectively evaluate these parameters throughout the hybrid palliation strategy. METHODS From 2002 to 2018, 203 patients with HLHS and variants presented for hybrid stage I (HS1). Echocardiographic evaluation of tricuspid regurgitation (TR) and RV function was assessed at multiple time points. Clinical outcomes including tricuspid valvuloplasty, transplantation, and death were reviewed. RESULTS The most prevalent HLHS subtype was aortic atresia/mitral atresia. The presence of significant TR and/or RV dysfunction was 14.78% and 9.36%, respectively, at the time of initial HS1. There were 185 survivors following HS1 (91.13%, n = 185/203), while 147 patients underwent comprehensive stage II or bidirectional Glenn shunt (72.41%, n = 147/203). Tricuspid valvuloplasty was undertaken in nine patients (4.86%, n = 9/185). Ultimately, 100 patients underwent the Fontan procedure. The odds of development of significant TR and/or RV dysfunction were not statistically different throughout the stages of palliation (TR: odds ratio [OR] = 0.14-0.25, P = .5260; RV dysfunction: OR = 0.02-0.13, P = .3992). However, the risk of death and/or transplant was 2.5- to 3.8-fold when either were present alone or in combination (TR: OR = 2.58, P = .0356; RV dysfunction: OR = 3.84, P = .0262). Transplant-free survival at 15 years was 44.8%. CONCLUSION Following hybrid palliation for HLHS, the majority of survivors have normal RV and TV functions. Tricuspid valvuloplasty was required in few patients. Once significant TR and/or RV dysfunction ensues, there is a two- to three-fold risk of death and/or transplant.
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Affiliation(s)
- Sergio A Carrillo
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen M Texter
- Division of Cardiology, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina Phelps
- Division of Cardiology, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Yubo Tan
- Center for Biostatistics, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick I McConnell
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
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The Fontan outcomes network: first steps towards building a lifespan registry for individuals with Fontan circulation in the United States. Cardiol Young 2020; 30:1070-1075. [PMID: 32635947 DOI: 10.1017/s1047951120001869] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.
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Tsintoni A, Dimitriou G, Karatza AA. Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns. J Matern Fetal Neonatal Med 2020; 33:2487-2492. [PMID: 30608033 DOI: 10.1080/14767058.2018.1548602] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Congenital heart disease is one of the most of the groups of congenital anomalies with an incidence of about 1 per 100 live births. Almost one-third of these infants require some type of intervention, usually in the first year of life and increasingly often in the neonatal period. Innovative reparative and palliative surgical procedures and advanced medical support in the Neonatal Intensive Care Unit have significantly reduced the mortality related to congenital heart disease. Achieving survival is not the only target of clinicians for these patients. Appropriate growth, development, and improved quality of life are also very important. Growth failure is a very common problem of these children and nutritional support and management are a challenge for health care providers. Early intervention and identification of at-risk patients have the potential to decrease morbidity and mortality related to malnutrition.Aim/methods: The purpose of this article is to analyze the existing evidence and common concerns about perioperative and postdischarge nutritional management of neonates with congenital heart disease based on the special issues or complications that may arise. Furthermore, we reviewed the recent literature about current practices and proposed policies that could prevent malnutrition and improve the outcomes of neonates with congenital heart disease.Results/conclusion: A standardized institutional protocol and clear guidelines referring to feeding initiation, prompt estimation of caloric needs and provision of adequate and appropriate nutrient intake is likely to benefit these patients. Clear definitions for the nutritional approach in the setting of medical complications and close assessment of growth by pediatricians and specialized nutritionists are crucial for the long-term outlook and quality of life of these infants.
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Affiliation(s)
- Asimina Tsintoni
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Ageliki A Karatza
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
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Hill GD, Bingler M, McCoy AB, Oster ME, Uzark K, Bates KE. Improved National Outcomes Achieved in a Cardiac Learning Health Collaborative Based on Early Performance Level. J Pediatr 2020; 222:186-192.e1. [PMID: 32417078 DOI: 10.1016/j.jpeds.2020.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/03/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Within the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC), a learning health network developed to improve outcomes for patients with hypoplastic left heart syndrome and variants, we assessed which centers contributed to reductions in mortality and growth failure. STUDY DESIGN Centers within the NPC-QIC were divided into tertiles based on early performance for mortality and separately for growth failure. These groups were evaluated for improvement from the early to late time period and compared with the other groups in the late time period. RESULTS Mortality was 3.8% for the high-performing, 7.6% for the medium-performing, and 14.4% for the low-performing groups in the early time period. Only the low-performing group had a significant change (P < .001) from the early to late period. In the late period, there was no difference in mortality between the high- (5.7%), medium- (7%), and low- (4.6%) performing centers (P = .5). Growth failure occurred in 13.9% for the high-performing, 21.9% for the medium-performing, and 32.8% for the low-performing groups in the early time period. Only the low-performing group had a significant change (P < .001) over time. In the late period, there was no significant difference in growth failure between the high- (19.8%), medium- (21.5%), and low- (13.5%) performing groups (P = .054). CONCLUSIONS Improvements in the NPC-QIC mortality and growth measures are primarily driven by improvement in those performing the worst in these areas initially without compromising the success of high-performing centers. Focus for improvement may vary by center based on performance.
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Affiliation(s)
- Garick D Hill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Michael Bingler
- Department of Cardiology, Nemours Children's Hospital Orlando, Orlando, FL
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew E Oster
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
| | - Karen Uzark
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI; and; University of Michigan Medical School, Department of Cardiac Surgery, Ann Arbor, MI
| | - Katherine E Bates
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI; and
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Hansen JE, Brown DW, Hanke SP, Bates KE, Tweddell JS, Hill G, Anderson JB. Angiotensin-Converting Enzyme Inhibitor Prescription for Patients With Single Ventricle Physiology Enrolled in the NPC-QIC Registry. J Am Heart Assoc 2020; 9:e014823. [PMID: 32384002 PMCID: PMC7660880 DOI: 10.1161/jaha.119.014823] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The routine use of angiotensin‐converting enzyme inhibitors (ACEI) during palliation of hypoplastic left heart syndrome is controversial. We sought to describe ACEI prescription in the interstage between stage 1 palliation (stage I Norwood procedure) discharge and stage 2 palliation (stage II superior cavopulmonary anastomosis procedure) admission using the NPC‐QIC (National Pediatric Cardiology Quality Improvement Collaborative) registry. Methods and Results Analysis of all patients (n=2180) enrolled in NPC‐QIC from 2008 to 2016 included preoperative anatomy, risk factors, and echocardiographic data. ACEI were prescribed at stage I Norwood procedure discharge in 38% of patients. ACEI prescription declined from 2011 to 2016 compared with pre‐2010 (36.8% versus 45%; P=0.005) with significant variation across centers (range 7–100%; P<0.001) and decreased prescribing rates associated with increased center volume (P=0.004). There was no difference in interstage mortality (P=0.662), change in atrioventricular valve regurgitation (P=0.101), or change in ventricular dysfunction (P=0.134) between groups. In multivariable analysis of all patients, atrioventricular septal defect (odds ratio [OR], 1.84; 95% CI, 1.28–2.65) or double outlet right ventricle (OR, 1.47; CI, 1.02–2.11), and preoperative mechanical ventilation (OR, 1.37; 95% CI, 1.12–1.68) were associated with increased ACEI prescription. In multivariable analysis of patients with complete echocardiographic data (n=812), ACEI prescription was more common with at least moderate atrioventricular valve regurgitation (OR, 1.88; 95% CI, 1.22–2.31). Conclusions ACEI prescription remains common in the interstage despite limited evidence of benefit. ACEI prescription is associated with preoperative mechanical ventilation, double outlet right ventricle, and atrioventricular valve regurgitation with marked inter‐center variation. ACEI prescription is not associated with reduction in mortality, ventricular dysfunction, or atrioventricular valve regurgitation during the interstage.
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Affiliation(s)
- Jesse E Hansen
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati, College of Medicine Cincinnati OH
| | - David W Brown
- Boston Children's Hospital and Department of Pediatrics Harvard Medical School Boston MA
| | - Samuel P Hanke
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati, College of Medicine Cincinnati OH.,The James M. Anderson Center for Health Systems Excellence Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Katherine E Bates
- Congenital Heart Center C.S. Mott Children's Hospital University of Michigan Medical School Ann Arbor MI
| | - James S Tweddell
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati, College of Medicine Cincinnati OH
| | - Garick Hill
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati, College of Medicine Cincinnati OH
| | - Jeffrey B Anderson
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati, College of Medicine Cincinnati OH.,The James M. Anderson Center for Health Systems Excellence Cincinnati Children's Hospital Medical Center Cincinnati OH
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Center Variation in Chest Tube Duration and Length of Stay After Congenital Heart Surgery. Ann Thorac Surg 2019; 110:221-227. [PMID: 31760054 DOI: 10.1016/j.athoracsur.2019.09.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Nearly every child undergoing congenital heart surgery has chest tubes placed intraoperatively. Center variation in removal practices and impact on outcomes has not been well described. This study evaluated variation in chest tube management practices and outcomes across centers. METHODS The study included patients undergoing any of 10 benchmark operations from June 2017 to May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC3) and Pediatric Cardiac Critical Care Consortium (PC4) centers. Clinical data from PC4 centers were merged with chest tube data from PAC3 centers. Practices and outcomes were compared across centers in univariate and multivariable analysis. RESULTS The cohort included 1029 patients (N = 9 centers). Median chest tube duration varied significantly across centers for 9 of 10 benchmark operations (all P ≤ .03), with a "model" center noted to have the shortest duration for 9 of 10 operations (range, 27.9% to 87.4% shorter duration vs other centers across operations). This effect persisted in multivariable analysis (P < .0001). The model center had higher volumes of chest tube output before removal (median, 8.5 mL/kg/24 h [model] vs 2.2 mL/kg/24 h [other centers]; P < .001], but it did not have higher rates of chest tube reinsertion (model center 1.3% vs 2.1%; P = .59) or readmission for pleural effusion (model center 4.4% vs 3.0%; P = .31), and had the shortest length of stay for 7 of 10 operations. CONCLUSIONS This study suggests significant center variation in chest tube removal practices and associated outcomes after congenital heart surgery. Best practices used at the model center have informed the design of an ongoing collaborative learning project aimed at reducing chest tube duration and length of stay.
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Outcomes Associated With Unplanned Interstage Cardiac Interventions After Norwood Palliation. Ann Thorac Surg 2019; 108:1423-1429. [DOI: 10.1016/j.athoracsur.2019.06.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/24/2019] [Accepted: 06/10/2019] [Indexed: 11/18/2022]
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Godown J, Gaies M, Wilkinson JD. Leveraging big data to advance knowledge in pediatric heart failure and heart transplantation. Transl Pediatr 2019; 8:342-348. [PMID: 31728327 PMCID: PMC6825960 DOI: 10.21037/tp.2019.07.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/11/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children’s Hospital, Nashville, TN, USA
| | - Michael Gaies
- Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James D. Wilkinson
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital, Nashville, TN, USA
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Terao M, Hoffman JM, Brilli RJ, Finch A, Walsh KE, Coffey M. Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts. ACTA ACUST UNITED AC 2019; 5:111-130. [PMID: 32789105 DOI: 10.1007/s40746-019-00155-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Purpose of review Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives. Recent Findings Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care. Summary Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.
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Affiliation(s)
- Michael Terao
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Office of Quality and Patient Care and Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Richard J Brilli
- Nationwide Children's Hospital; Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Amanda Finch
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
| | - Kathleen E Walsh
- MD, MS, James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Maitreya Coffey
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
- The Hospital for Sick Children, Toronto, Ontario, Canada
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Evaluating the utility of routine screening catheterisation before interstage discharge of infants with single-ventricle physiology. Cardiol Young 2019; 29:660-666. [PMID: 31142394 DOI: 10.1017/s1047951119000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Interstage mortality causes are often unknown in infants with shunt-dependent univentricular defects. For 2 years, screening catheterisation was encouraged before neonatal discharge to determine if routine evaluation improved interstage outcomes. METHODS Retrospective single-centre review of home monitoring programme from December, 2010 to June, 2012. Composite scores were created for physical examination/echocardiography risk factors; catheterisation risk factors; and interstage adverse events. Composite scores were compared between usual care and screening catheterisation groups. The ability of each risk factor composite to predict interstage adverse events, individually and in combination, was assessed with sensitivity, specificity, and receiver operating characteristic curves. RESULTS There were 27 usual care and 32 screening catheterisation patients. There were no significant differences between groups except rates of catheterisation before discharge (29.6 versus 100%, p < 0.001). Usual care patients who underwent catheterisation for clinical indications had higher intervention rates (37.5 versus 3.1%, p = 0.004). Physical examination/echocardiography risk factor frequency was similar, but usual care patients with catheterisation had a higher catheterisation risk factor frequency. Interstage adverse event frequency was similar (48.2 versus 53.1%, p = 0.7). For interstage adverse event prediction, sensitivity for the physical examination/echocardiography, catheterisation, and either risk factor composites was 53.3, 72, and 80%, respectively; specificity was 59, 60, and 48%. The area under the receiver operating characteristic curve was 0.56, 0.66, and 0.64. CONCLUSION Screening catheterisation evaluation offered slightly increased sensitivity and specificity, but no difference in interstage adverse event frequency. Given this small advantage versus known risks, screening catheterisations are no longer encouraged.
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Identifying best practices in interstage care: using a positive deviance approach within the National Pediatric Cardiology Quality Improvement Collaborative. Cardiol Young 2019; 29:398-407. [PMID: 30806343 DOI: 10.1017/s1047951118002548] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED IntroductionTo identify interstage best practices associated with lower mortality, we studied National Pediatric Cardiology Quality Improvement Collaborative centres registry using a positive deviance approach. METHODS Positive deviant and control centre team members were interviewed to identify potential interstage best practices. Subsequently, all collaborative centres were surveyed on the use of these practices to test their associations with centre mortality. Questionnaires were scored using Likert scales; the overall score was linearly transformed to a 0-100-point scale with higher scores indicating increased use of practices. Mortality was based on patients enrolled after a centre's first year in the collaborative. Centre mortality rates were divided into tertiles. Survey scores for the low mortality tertile were compared with the other tertiles. RESULTS For this study, seven positive deviant and four control teams were interviewed. A total of 20 potential best practices were identified, including team composition, improvement practices, and parent involvement. Questionnaires were completed by 36/43 eligible centres, providing 1504 patients for analysis. Average survey score was 50.2 (SD 13.4). Average mortality was 6.1% (SD 4.1). There was no correlation between survey scores and mortality (r=0.14, p=0.41). The one practice associated with the low mortality tertile was frequency of discussion of interstage results: 58.3% of low mortality teams discussed results at least monthly versus 8.4% of the middle and high tertile centres (p=0.02). CONCLUSIONS Low-mortality centres more frequently discuss interstage results than high-mortality centres. Heightened awareness of outcomes may influence practice; however, further study is needed to understand the variation in outcomes across centres.
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Cardiac Networks United: an integrated paediatric and congenital cardiovascular research and improvement network. Cardiol Young 2019; 29:111-118. [PMID: 30567622 DOI: 10.1017/s1047951118001683] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Optimising short- and long-term outcomes for children and patients with CHD depends on continued scientific discovery and translation to clinical improvements in a coordinated effort by multiple stakeholders. Several challenges remain for clinicians, researchers, administrators, patients, and families seeking continuous scientific and clinical advancements in the field. We describe a new integrated research and improvement network - Cardiac Networks United - that seeks to build upon the experience and success achieved to-date to create a new infrastructure for research and quality improvement that will serve the needs of the paediatric and congenital heart community in the future. Existing gaps in data integration and barriers to improvement are described, along with the mission and vision, organisational structure, and early objectives of Cardiac Networks United. Finally, representatives of key stakeholder groups - heart centre executives, research leaders, learning health system experts, and parent advocates - offer their perspectives on the need for this new collaborative effort.
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Hoch JM, Fatusin O, Yenokyan G, Thompson WR, Lefton-Greif MA. Feeding methods for infants with single ventricle physiology are associated with length of stay during stage 2 surgery hospitalization. CONGENIT HEART DIS 2019; 14:438-445. [PMID: 30635975 DOI: 10.1111/chd.12742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/16/2018] [Accepted: 12/07/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tube feedings are often needed to achieve the growth and nutrition goals associated with decreased morbidity and mortality in patients with single ventricle anatomy. Variability in feeding method through the interstage period has been previously described, however, comparable information following stage 2 palliation is lacking. OBJECTIVES To identify types of feeding methods following stage 2 palliation and their influence on length of stay. DESIGN Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative registry was performed on 932 patients. Demographic data, medical characteristics, postoperative complications, type of feeding method, and length of stay for stage 2 palliation were analyzed. RESULTS Type of feeding method remained relatively unchanged during hospitalization for stage 2 palliation. Gastrostomy tube fed only patients were the oldest at time of surgery (182.7 ± 57.7 days, P < .001) and had the lowest weight-for-age z scores at admission (-1.6 ± 1.4, P < .001). Oral + gastrostomy tube groups had the longest median bypass times (172.5 minutes, P = .001) and longest length of stay (median 12 days, P < .001). Multivariable modeling revealed that feeding by tube only (P < .001), oral + tube feeding (P ≤ .001), reintubation (P < .001), and prolonged intubation (P < .001) were associated with increased length of stay. Neither age (P = .156) nor weight-for-age z score at admission (P = .066) was predictive of length of stay. CONCLUSIONS Feeding methods established at admission for stage 2 palliation are not likely to change by discharge. Length of stay is more likely to be impacted by tube feeding and intubation history than age or weight-for-age z score at admission. Better understanding for selection of feeding methods and their impact on patient outcomes is needed to develop evidence-based guidelines to decrease variability in clinical practice patterns and provide appropriate counseling to caregivers.
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Affiliation(s)
- Jeannine M Hoch
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Oluwatosin Fatusin
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - W Reid Thompson
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maureen A Lefton-Greif
- Department of Pediatrics, Otolaryngology, Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Martin GR, Anderson JB, Vincent RN. IMPACT Registry and National Pediatric Cardiology Quality Improvement Collaborative: Contributions to Quality in Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2019; 10:72-80. [DOI: 10.1177/2150135118815059] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The IMproving Pediatric and Adult Congenital Treatments (IMPACT) Registry and the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) are two efforts initiated to improve outcomes in the congenital heart disease field. The IMPACT Registry is focused on evaluating the use, risks, adverse events (AEs), and outcomes associated with diagnostic and common interventional catheterization procedures in all children and adults with congenital heart disease. Utilizing a modular approach, the common procedures include diagnostic cardiac catheterization, atrial septal defect device closure, patent ductus arteriosus device closure, pulmonary valvuloplasty, aortic valvuloplasty, balloon and stent angioplasty of coarctation of the aorta, pulmonary artery balloon stent angioplasty, transcatheter pulmonary valve replacement, and electrophysiology procedures including radiofrequency ablation. To date, important observations on the common procedures have been made and a risk stratification methodology has been created to allow comparisons between centers in AEs and quality improvement activity. The registry is open to international participation. The NPC-QIC was developed to reduce mortality and improve the quality of life of infants with Hypoplastic Left Heart Syndrome (HLHS) during the interstage period between discharge from the Norwood operation and admission for the bidirectional Glenn procedure. Mortality in the interstage has been reduced by 44%. The IMPACT Registry and the NPC-QIC have demonstrated value to the congenital heart disease community. The IMPACT Registry, however, has not yet demonstrated an impact on patient outcomes. The NPC-QIC, which combines both a registry with a learning collaborative with specific aims, key drivers, and change strategies, has made more significant gains with reductions in variation, growth failures, and mortality.
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Affiliation(s)
- Gerard R. Martin
- Division of Cardiology, Children’s National Heart Institute and the George Washington University School of Medicine, Washington, DC, USA
| | - Jeffrey B. Anderson
- Heart Institute at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Robert N. Vincent
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta–Emory University, Atlanta, GA, USA
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Abstract
Limited evidence exists to guide chest tube management following cardiac surgery in children. We assessed chest tube practice variation by surveying paediatric heart centres to prepare for a multi-site quality improvement project. We summarised management strategies highlighting variability in criteria for chest tube removal between and within centres. This lack of standardisation provides an opportunity for quality improvement.
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Davis JAM, Miller-Tate H, Texter KM. Launching a New Strategy for Multidisciplinary Management of Single-Ventricle Heart Defects. Crit Care Nurse 2018; 38:60-71. [PMID: 29437079 DOI: 10.4037/ccn2018190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Children born with single-ventricle heart defects, particularly hypoplastic left heart syndrome, have a lifetime high risk of mortality and comorbidities. They have complex medical challenges in addition to their cardiac needs, including growth and feeding complications and neurodevelopmental issues. These concerns require a coordinated effort among specialties to help patients maximize their potential. Additionally, because many complex heart defects are diagnosed prenatally, coordination of care between the pre- and postnatal care teams is imperative. Nursing leadership improves program coordination and efficiency. The purpose of this article is to describe the development and implementation of our hospital's synchronized, multidisciplinary team to support children with single-ventricle heart defects and their families. (Critical Care Nurse. 2018;38[1]:60-71).
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Affiliation(s)
- Jo Ann M Davis
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio. .,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team. .,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital.
| | - Holly Miller-Tate
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio.,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team.,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital
| | - Karen M Texter
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio.,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team.,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital
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35
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Buelow MW, Rudd N, Tanem J, Simpson P, Bartz P, Hill G. Reintervention following stage 1 palliation: A report from the NPC-QIC Registry. CONGENIT HEART DIS 2018; 13:919-926. [DOI: 10.1111/chd.12655] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/18/2018] [Accepted: 06/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew W. Buelow
- Department of Pediatrics, Division of Cardiology; Medical College of Wisconsin, Children’s Hospital of Wisconsin; Milwaukee Wisconsin
- Department of Medicine, Division of Cardiovascular Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Nancy Rudd
- Department of Pediatrics, Division of Cardiology; Medical College of Wisconsin, Children’s Hospital of Wisconsin; Milwaukee Wisconsin
| | - Jena Tanem
- Department of Pediatrics, Division of Cardiology; Medical College of Wisconsin, Children’s Hospital of Wisconsin; Milwaukee Wisconsin
| | - Pippa Simpson
- Department of Biostatistics and Quantitative Sciences; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Peter Bartz
- Department of Pediatrics, Division of Cardiology; Medical College of Wisconsin, Children’s Hospital of Wisconsin; Milwaukee Wisconsin
- Department of Medicine, Division of Cardiovascular Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Garick Hill
- The Heart Institute; Cincinnati Children’s Hospital Medical Center; Cincinnati Ohio
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Examining variation in interstage mortality rates across the National Pediatric Cardiology Quality Improvement Collaborative: do lower-mortality centres have lower-risk patients? Cardiol Young 2018; 28:1031-1036. [PMID: 29925455 DOI: 10.1017/s1047951118000926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although interstage mortality for infants with hypoplastic left heart syndrome has declined within the National Pediatric Cardiology Quality Improvement Collaborative, variation across centres persists. It remains unclear whether centres with lower interstage mortality have lower-risk patients or whether differences in care may explain this variation. We examined previously established risk factors across National Pediatric Cardiology Quality Improvement Collaborative centres with lower and higher interstage mortality rates. METHODS Lower-mortality centres were defined as those with >25 consecutive interstage survivors. Higher-mortality centres were defined as those with cumulative interstage mortality rates >10%, which is a collaborative historic baseline rate. Baseline risk factors and perioperative characteristics were compared. RESULTS Seven lower-mortality centres were identified (n=331 patients) and had an interstage mortality rate of 2.7%, as compared with 13.3% in the four higher-mortality centres (n=173 patients, p<0.0001). Of all baseline risk factors examined, the only factor that differed between the lower- and higher-mortality centres was postnatal diagnosis (18.4 versus 31.8%, p=0.001). In multivariable analysis, there remained a significant mortality difference between the two groups of centres after adjusting for this variable: adjusted mortality rate was 2.8% in lower-mortality centres compared with 12.6% in higher-mortality centres, p=0.003. Secondary analyses identified multiple differences between groups in perioperative practices and other variables. CONCLUSIONS Variation in interstage mortality rates between these two groups of centres does not appear to be explained by differences in baseline risk factors. Further study is necessary to evaluate variation in care practices to identify targets for improvement efforts.
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Yimgang DP, Sorkin JD, Evans CF, Abraham DS, Rosenthal GL. Angiotensin converting enzyme inhibitors and interstage failure in infants with hypoplastic left heart syndrome. CONGENIT HEART DIS 2018; 13:533-540. [PMID: 30019493 DOI: 10.1111/chd.12622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 04/06/2018] [Accepted: 04/26/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Angiotensin converting enzyme inhibitors are commonly prescribed medications after the Norwood procedure. There are little data that can be used to determine if angiotensin converting enzyme inhibitors improve interstage outcomes in children with single ventricle defects. The objective of this study was to investigate the relationship between angiotensin converting enzyme inhibitors and interstage failure among infants born with hypoplastic left heart syndrome. METHODS We conducted a retrospective cohort study using data from the National Pediatric Cardiology Quality Improvement Collaborative database (collected between 2008 and 2015). We used logistic regression models to assess the exposure-outcome associations and propensity score matching to account for differences in baseline patient characteristics associated with use of angiotensin converting enzyme inhibitors. RESULTS A total of 1 487 neonates participated in the study. Thirty-nine percent of patients were prescribed angiotensin converting enzyme inhibitors after the Norwood procedure; 11% experienced interstage failure (death, heart transplantation, and not being a candidate for the second-stage surgery). Before propensity score matching, patients receiving angiotensin converting enzyme inhibitors were significantly more likely to experience interstage failure, compared to patients not on angiotensin converting enzyme inhibitors (OR = 1.44; 95% CI: 1.04, 1.99; P = 0.03). Although there was an increased odds of interstage failure among patients receiving angiotensin converting enzyme inhibitors compared to patients not receiving angiotensin converting enzyme inhibitors in the propensity score-matched cohort, this association was not significantly different (adjusted OR = 1.29; 95% CI: 0.88, 1.95; P = 0.18). CONCLUSION Angiotensin converting enzyme inhibitor therapy did not demonstrate a beneficial effect on interstage failure among infants with hypoplastic left heart syndrome, even when patient characteristics associated with the use of angiotensin converting enzyme inhibitors were considered.
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Affiliation(s)
- Doris P Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - John D Sorkin
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine and Baltimore VA Medical Center Geriatric Research, Education, and Clinical Center, Baltimore, Maryland, USA
| | - Charles F Evans
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Danielle S Abraham
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey L Rosenthal
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Simsic JM, Phelps C, Kirchner K, Carpenito K, Allen R, Miller‐Tate H, Texter K, Galantowicz M. Interstage outcomes in single ventricle patients undergoing hybrid stage 1 palliation. CONGENIT HEART DIS 2018; 13:757-763. [DOI: 10.1111/chd.12649] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/24/2018] [Accepted: 06/16/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Janet M. Simsic
- The Heart Center at Nationwide Children’s Hospital Columbus Ohio
| | - Christina Phelps
- The Heart Center at Nationwide Children’s Hospital Columbus Ohio
| | - Kristin Kirchner
- The Heart Center at Nationwide Children’s Hospital Columbus Ohio
| | | | - Robin Allen
- The Heart Center at Nationwide Children’s Hospital Columbus Ohio
| | | | - Karen Texter
- The Heart Center at Nationwide Children’s Hospital Columbus Ohio
| | - Mark Galantowicz
- The Heart Center at Nationwide Children’s Hospital Columbus Ohio
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Sturmer D, Beaty C, Clingan S, Jenkins E, Peters W, Si MS. Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery. Transl Pediatr 2018; 7:139-150. [PMID: 29770295 PMCID: PMC5938255 DOI: 10.21037/tp.2018.03.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The development and refinement of cardiopulmonary bypass (CPB) has made the repair of complex congenital heart defects possible in neonates and infants. In the past, the primary goal for these procedures was patient survival. Now that substantial survival rates have been achieved for even the most complex of repairs in these patients, focus has been given to the reduction of morbidity. Although a necessity for these complex neonatal and infant heart defect repairs, CPB can also be an important source of perioperative complications. Recent innovations have been developed to mitigate these risks and is the topic of this review. Specifically, we will discuss improvements in minimizing blood transfusions, CPB circuit design, monitoring, perfusion techniques, temperature management, and myocardial protection, and then conclude with a brief discussion of how further systematic improvements can be made in these areas.
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Affiliation(s)
- David Sturmer
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Claude Beaty
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Sean Clingan
- Deprtment of Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric Jenkins
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Whitney Peters
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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40
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Takahashi A, Kumamaru H, Tomotaki A, Matsumura G, Fukuchi E, Hirata Y, Murakami A, Hashimoto H, Ono M, Miyata H. Verification of Data Accuracy in Japan Congenital Cardiovascular Surgery Database Including Its Postprocedural Complication Reports. World J Pediatr Congenit Heart Surg 2018; 9:150-156. [DOI: 10.1177/2150135117745871] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Japan Congenital Cardiovascluar Surgical Database (JCCVSD) is a nationwide registry whose data are used for health quality assessment and clinical research in Japan. We evaluated the completeness of case registration and the accuracy of recorded data components including postprocedural mortality and complications in the database via on-site data adjudication. Methods: We validated the records from JCCVSD 2010 to 2012 containing congenital cardiovascular surgery data performed in 111 facilities throughout Japan. We randomly chose nine facilities for site visit by the auditor team and conducted on-site data adjudication. We assessed whether the records in JCCVSD matched the data in the source materials. Results: We identified 1,928 cases of eligible surgeries performed at the facilities, of which 1,910 were registered (99.1% completeness), with 6 cases of duplication and 1 inappropriate case registration. Data components including gender, age, and surgery time (hours) were highly accurate with 98% to 100% concordance. Mortality at discharge and at 30 and 90 postoperative days was 100% accurate. Among the five complications studied, reoperation was the most frequently observed, with 16 and 21 cases recorded in the database and source materials, respectively, having a sensitivity of 0.67 and a specificity of 0.99. Conclusions: Validation of JCCVSD database showed high registration completeness and high accuracy especially in the categorical data components. Adjudicated mortality was 100% accurate. While limited in numbers, the recorded cases of postoperative complications all had high specificities but had lower sensitivity (0.67-1.00). Continued activities for data quality improvement and assessment are necessary for optimizing the utility of these registries.
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Affiliation(s)
- Arata Takahashi
- Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ai Tomotaki
- Informatics, National College of Nursing, Tokyo, Japan
| | - Goki Matsumura
- Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Eriko Fukuchi
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasutaka Hirata
- Department of Cardiac Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | | | - Hideki Hashimoto
- Health and Social Behavior, School of Public Health, the University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Lopez NL, Gowda C, Backes CH, Nandi D, Miller-Tate H, Fichtner S, Allen R, Stewart J, Cua CL. Differences in midterm outcomes in infants with hypoplastic left heart syndrome diagnosed with necrotizing enterocolitis: NPCQIC database analysis. CONGENIT HEART DIS 2018. [DOI: 10.1111/chd.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | | | | | | | | | | | - Robin Allen
- Nationwide Children's Hospital; Columbus Ohio USA
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Nieves JA, Rudd NA, Dobrolet N. Home surveillance monitoring for high risk congenital heart newborns: Improving outcomes after single ventricle palliation - why, how & results. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Piggott KD, Babb J, Yong S, Fakioglu H, Blanco C, DeCampli W, Pourmoghadam K. Risk Factors for Gastrostomy Tube Placement in Single Ventricle Patients Following The Norwood Procedure. Semin Thorac Cardiovasc Surg 2018; 30:443-447. [DOI: 10.1053/j.semtcvs.2018.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 11/11/2022]
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Nieves JA, Uzark K, Rudd NA, Strawn J, Schmelzer A, Dobrolet N. Interstage Home Monitoring After Newborn First-Stage Palliation for Hypoplastic Left Heart Syndrome: Family Education Strategies. Crit Care Nurse 2017; 37:72-88. [PMID: 28365652 DOI: 10.4037/ccn2017763] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Children born with hypoplastic left heart syndrome are at high risk for serious morbidity, growth failure, and mortality during the interstage period, which is the time from discharge home after first-stage hypoplastic left heart syndrome palliation until the second-stage surgical intervention. The single-ventricle circulatory physiology is complex, fragile, and potentially unstable. Multicenter initiatives have been successfully implemented to improve outcomes and optimize growth and survival during the interstage period. A crucial focus of care is the comprehensive family training in the use of home surveillance monitoring of oxygen saturation, enteral intake, weight, and the early recognition of "red flag" symptoms indicating potential cardiopulmonary or nutritional decompensation. Beginning with admission to the intensive care unit of the newborn with hypoplastic left heart syndrome, nurses provide critical care and education to prepare the family for interstage home care. This article presents detailed nursing guidelines for educating families on the home care of their medically fragile infant with single-ventricle circulation.
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Affiliation(s)
- Jo Ann Nieves
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida. .,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan. .,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program. .,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator. .,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida. .,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System.
| | - Karen Uzark
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Nancy A Rudd
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Jennifer Strawn
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Anne Schmelzer
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Nancy Dobrolet
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
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Chu DI, Tan JM, Mattei P, Costarino AT, Rossano JW, Tasian GE. Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease. J Pediatr 2017; 185:88-93.e3. [PMID: 28410089 PMCID: PMC5529241 DOI: 10.1016/j.jpeds.2017.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/15/2016] [Accepted: 02/06/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD). STUDY DESIGN Cohort study using the 2013-2014 National Surgical Quality Improvement Program-Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in-hospital postoperative mortality. Secondary outcomes included 30-day mortality and 30-day morbidity (any nondeath adverse event). Among 34?543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD. RESULTS Children with severe CHD had higher overall mortality and 30-day morbidity (OR 12.31, 95% CI 1.59-95.01; OR 2.51, 95% CI 1.57-4.01, respectively), compared with matched controls. Overall mortality and 30-day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49-8.06; OR 2.07, 95% CI 1.65-2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30-day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37-2.13). CONCLUSIONS Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.
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Affiliation(s)
- David I. Chu
- Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia Philadelphia, PA
| | - Jonathan M. Tan
- Department of Anesthesia and Critical Care Medicine, Division of General Anesthesiology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Peter Mattei
- Department of Surgery, Division of General, Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Andrew T. Costarino
- Department of Anesthesia and Critical Care Medicine, Division of Cardiac Critical Care Medicine, The Children’s Hospital of Philadelphia Philadelphia, PA
| | - Joseph W. Rossano
- Department of Cardiology, Cardiac Center, The Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Gregory E. Tasian
- Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Abstract
PURPOSE OF REVIEW Brain-directed critical care for children is a relatively new area of subspecialization in pediatric critical care. Pediatric neurocritical care teams combine the expertise of neurology, neurosurgery, and critical care medicine. The positive impact of delivering specialized care to pediatric patients with acute neurological illness is becoming more apparent, but the optimum way to implement and sustain the delivery of this is complicated and poorly understood. We aim to provide emerging evidence supporting that effective implementation of pediatric neurocritical care pathways can improve patient survival and outcomes. We also provide an overview of the most effective strategies across the field of implementation science that can facilitate deployment of neurocritical care pathways in the pediatric ICU. RECENT FINDINGS Implementation strategies can broadly be grouped according to six categories: planning, educating, restructuring, financing, managing quality, and attending to the policy context. Using a combination of these strategies in the last decade, several institutions have improved patient morbidity and mortality. Although much work remains to be done, emerging evidence supports that implementation of evidence-based care pathways for critically ill children with two common neurological diagnoses - status epilepticus and traumatic brain injury - improves outcomes. SUMMARY Pediatric and neonatal neurocritical care programs that support evidence-based care can be effectively structured using appropriately sequenced implementation strategies to improve outcomes across a variety of patient populations and in a variety of healthcare settings.
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Affiliation(s)
- Christopher Markham
- aDivision of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis Children's Hospital bGeorge Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA
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Variability of antithrombotics use in patients with hypoplastic left heart syndrome and its variants following first- and second-stage palliation surgery: a national report using the National Pediatric Cardiology Quality Improvement Collaborative registry. Cardiol Young 2017; 27:731-738. [PMID: 27981915 DOI: 10.1017/s1047951116001189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Purpose Patients with hypoplastic left heart syndrome and its variants following palliation surgery are at risk for thrombosis. This study examines variability of antithrombotic practice, the incidence of interstage shunt thrombosis, and other adverse events following Stage I and Stage II palliation within the National Pediatric Cardiology Quality Improvement Collaborative registry. METHODS We carried out a multicentre, retrospective review using the National Pediatric Cardiology Quality Improvement Collaborative registry including patients from 2008 to 2013 across 52 surgical sites. Antithrombotic medications used at Stage I and Stage II discharge were evaluated. Variability of antithrombotics use at the individual patient level and intersite variability, incidence of shunt thrombosis, and other adverse events such as cardiac arrest, seizure, stroke, and need for cardiac catheterisation intervention in the interstage period were identified. Antithrombotic strategies for hybrid Stage I patients were evaluated but they were excluded from the variability and outcomes analysis. RESULTS A total of 932 Stage I and 923 Stage II patients were included in the study: 93.8% of Stage I patients were discharged on aspirin and 4% were discharged on no antithrombotics, and 77% of Stage II patients were discharged on aspirin and 17.5% were discharged on no antithrombotics. Only three patients (0.2%) presented with interstage shunt thrombosis. The majority of patients who died during interstage or required shunt dilation and/or stenting were discharged home on aspirin. CONCLUSION Aspirin is the most commonly used antithrombotic following Stage I and Stage II palliation. There is more variability in the choice of antithrombotics following Stage II compared with Stage I. The incidence of interstage shunt thrombosis and associated adverse events was rare.
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Carlo WF, Cnota JF, Dabal RJ, Anderson JB. Practice trends over time in the care of infants with hypoplastic left heart syndrome: A report from the National Pediatric Cardiology Quality Improvement Collaborative. CONGENIT HEART DIS 2017; 12:315-321. [PMID: 28121380 DOI: 10.1111/chd.12442] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 09/29/2016] [Accepted: 11/23/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) was established in 2008 to improve outcomes of hypoplastic left heart syndrome (HLHS) during the interstage period. They evaluated changes in patient variables and practice variation between early and late eras. DESIGN Data including demographic, operative, discharge, and follow-up variables from the first 100 patients (6/2008-1/2010) representing 18 centers were compared with the most recent 100 patients (1/2014-11/2014) from these same centers. RESULTS Prenatal diagnosis increased from 69% to 82% (P = .05). There were no differences in gestational age or weight at Norwood. A composite of any preoperative risk factor occurred more frequently in the early era (59% vs. 34%, P < .01). While mean age at Norwood was similar (8.3 vs. 6.6 days, P = .2), the standard deviation was significantly lower in the recent era (10.4-6.4 days, P = .04). Use of RV-PA conduit increased (67%-84%, P < .01). Rates of complete discharge communication with both the primary care physician (31%-97%, P < .01) and primary cardiologist (44%-97%, P < .01) increased substantially. There were limited changes in feeding strategies. Use of home monitoring program increased (76%-99%, P < .01) with all participants in the late era monitoring both oxygen saturation and weight. CONCLUSIONS Among NPC-QIC centers contributing patients to both eras, there were significant changes in preoperative risk factors, surgical strategy, discharge communication, and interstage care. Further study is required to determine an association between these changes and decreased mortality.
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Affiliation(s)
- Waldemar F Carlo
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - James F Cnota
- The Heart Institute, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Robert J Dabal
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
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Piloting a Statewide Home Visiting Quality Improvement Learning Collaborative. Matern Child Health J 2017; 21:275-282. [DOI: 10.1007/s10995-016-2206-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Interstage Survival for Patients with Hypoplastic Left Heart Syndrome After ECMO. Pediatr Cardiol 2017; 38:50-55. [PMID: 27803957 DOI: 10.1007/s00246-016-1483-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
There is a reported 5-20 % incidence of extracorporeal membrane oxygenation (ECMO) following stage I palliation for hypoplastic left heart syndrome (HLHS). This study compares the interstage mortality of HLHS patients supported with ECMO (HLHS-ECMO) to those who were not supported with ECMO (HLHS-nECMO) using the National Pediatric Cardiology Quality Improvement Initiative database. Patients with HLHS who survived to hospital discharge after stage I palliation were analyzed. HLHS-ECMO patients were compared to HLHS-non-ECMO patients with respect to demographics, surgical variables, and interstage survival. A total of 931 patients were identified in the database. Sixty-six (7.1 %) patients were supported with ECMO during their stage I palliation admission. There were no statistically significant differences between the groups with respect to demographics or anatomic subtype. HLHS-ECMO patients were more likely to have a preoperative risk factor identified (62 vs. 48 %, p = 0.03) or require ECMO prior to stage I palliation (3 vs. 0.5 %, p = 0.03). HLHS-ECMO patients had a significantly higher incidence of death or transplant versus the HLHS-nECMO group (18 vs. 9 %, p = 0.03). Despite survival to discharge, patients with HLHS requiring ECMO after their palliation continue to have an increased risk of death/cardiac transplant versus patients that do not require ECMO. ECMO use is likely a marker for a high-risk patient group. These patients may benefit from closer follow-up during the interstage period.
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