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Gaskin K, Daniels A. Enhancing discharge preparation for parents after complex cardiac surgery: evaluation of an e-learning resource for nurses. Nurs Child Young People 2024:e1515. [PMID: 38973285 DOI: 10.7748/ncyp.2024.e1515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 07/09/2024]
Abstract
Parents need to be appropriately prepared by knowledgeable healthcare professionals before going home with their infant following cardiac surgery for complex congenital heart disease (CHD). A quality improvement project was undertaken between 2018 and 2021 to equip healthcare professionals including children's cardiac nurses with the knowledge required to use the Congenital Heart Assessment Tool (CHAT) to teach parents how to monitor their infant at home. The project involved developing, implementing and evaluating an e-learning resource that included simulated scenarios captured on video. An online survey showed that users perceived the e-learning resource as having a positive effect on their understanding of complex CHD and their practice of preparing parents for discharge and home monitoring.
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Affiliation(s)
- Kerry Gaskin
- School of Nursing and Midwifery, Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, England
| | - Amanda Daniels
- Three Counties School of Nursing and Midwifery, University of Worcester, Worcester, England
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Mayourian J, Brown E, Javalkar K, Bucholz E, Gauvreau K, Beroukhim R, Feins E, Kheir J, Triedman J, Dionne A. Insight into the Role of the Child Opportunity Index on Surgical Outcomes in Congenital Heart Disease. J Pediatr 2023; 259:113464. [PMID: 37172810 DOI: 10.1016/j.jpeds.2023.113464] [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: 01/19/2023] [Revised: 04/20/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To use neighborhood-level Child Opportunity Index (COI) measures to investigate disparities in congenital heart surgery postoperative outcomes and identify potential targets for intervention. STUDY DESIGN In this single-institution retrospective cohort study, children <18 years old who underwent cardiac surgery between 2010 and 2020 were included. Patient-level demographics and neighborhood-level COI were used as predictor variables. COI-a composite US census tract-based score measuring educational, health/environmental, and social/economic opportunities-was dichotomized as lower (<40th percentile) vs higher (≥40th percentile). Cumulative incidence of hospital discharge was compared between groups using death as a competing risk, adjusting for clinical characteristics associated with outcomes. Secondary outcomes included hospital readmission and death within 30 days. RESULTS Among 6247 patients (55% male) with a median age of 0.8 years (IQR, 0.2-4.3), 26% had lower COI. Lower COI was associated with longer hospital lengths of stay (adjusted HR, 1.2; 95% CI, 1.1-1.2; P < .001) and an increased risk of death (adjusted OR, 2.0; 95% CI. 1.4-2.8; P < .001), but not hospital readmission (P = .6). At the neighborhood level, lacking health insurance coverage, food/housing insecurity, lower parental literacy and college attainment, and lower socioeconomic status were associated with longer hospital length of stay and increased risk of death. At the patient-level, public insurance (adjusted OR, 1.4; 95% CI, 1.0-2.0; P = .03) and caretaker Spanish language (adjusted OR 2.4; 95% CI, 1.2-4.3; P < .01) were associated with an increased risk of death. CONCLUSIONS Lower COI is associated with longer length of stay and higher early postoperative mortality. Risk factors identified including Spanish language, food/housing insecurity, and parental literacy serve as potential intervention targets.
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Affiliation(s)
- Joshua Mayourian
- Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston University, Boston, MA
| | - Ella Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Karina Javalkar
- Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston University, Boston, MA
| | - Emily Bucholz
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kimberlee Gauvreau
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Rebecca Beroukhim
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - John Kheir
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - John Triedman
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA.
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KARAŞİN SS, KAZANCI EG, PAKAY K, ÖZYAMACI B, TÜYSÜZ TN, ESEN ŞK, TURANLI CE. Analysis of perinatal outcomes of pregnancies from consanguineous marriages in a tertiary hospital in Bursa, Turkey. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1233784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: In this article, we aimed to contribute to the outcomes of the consanguineous marriage literature by analyzing fetal results in this population.
Material and Method: We included 185 patients in this retrospective research. Demographic, clinical, ultrasonographic and delivery data were received from electronic patient records. Also, we recorded the postnatal results, and findings of the infants. By combining all the data, we reported a descriptive analysis of the results of our consanguineous marriage cases with perinatology follow-up.
Results: We had 231 pregnant women in the study, and their mean age was 28.9 years. 117 (50.6%) of the pregnant women had first-degree, and 114 (50.4%) had second-degree consanguineous marriages. Fetal findings were evaluated as usual in 157 (68%) of the pregnant in the ultrasonographic scans performed between prenatal 20-24 weeks of gestation. When we look at the first postnatal examinations of the babies, no abnormal findings were in 134 babies (58.8%). Twenty-two infants (9.6%) were followed up in the neonatal intensive care unit with the diagnosis of transient tachypnea of the newborn, and phototherapy was required in 14 infants (6.1%) due to hyperbilirubinemia. The number of cases requiring surgical intervention after delivery or with significant life-threatening anomalies included 56 findings in 32 infants. There were spina bifida cases in 8 infants and hydrocephalus in 9 infants.
Conclusion: There was an increased level of congenital anomalies associated with consanguineous marriages. Health care centers should educate individuals regarding the negative role of cousin marriages leading to abnormalities in children.
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Affiliation(s)
| | - Elif Güler KAZANCI
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Kaan PAKAY
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Berin ÖZYAMACI
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Tuba Nur TÜYSÜZ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Şeniz Kurtoğlu ESEN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Cansel Ezgi TURANLI
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
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Della PR, Huang H, Roberts PA, Porter P, Adams E, Zhou H. Risk factors associated with 31-day unplanned hospital readmission in newborns: a systematic review. Eur J Pediatr 2023; 182:1469-1482. [PMID: 36705723 PMCID: PMC10167195 DOI: 10.1007/s00431-023-04819-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/30/2022] [Accepted: 01/12/2023] [Indexed: 01/28/2023]
Abstract
UNLABELLED The purpose of this study is to synthesize evidence on risk factors associated with newborn 31-day unplanned hospital readmissions (UHRs). A systematic review was conducted searching CINAHL, EMBASE (Ovid), and MEDLINE from January 1st 2000 to 30th June 2021. Studies examining unplanned readmissions of newborns within 31 days of discharge following the initial hospitalization at the time of their birth were included. Characteristics of the included studies examined variables and statistically significant risk factors were extracted from the inclusion studies. Extracted risk factors could not be pooled statistically due to the heterogeneity of the included studies. Data were synthesized using content analysis and presented in narrative and tabular form. Twenty-eight studies met the eligibility criteria, and 17 significant risk factors were extracted from the included studies. The most frequently cited risk factors associated with newborn readmissions were gestational age, postnatal length of stay, neonatal comorbidity, and feeding methods. The most frequently cited maternal-related risk factors which contributed to newborn readmissions were parity, race/ethnicity, and complications in pregnancy and/or perinatal period. CONCLUSION This systematic review identified a complex and diverse range of risk factors associated with 31-day UHR in newborn. Six of the 17 extracted risk factors were consistently cited by studies. Four factors were maternal (primiparous, mother being Asian, vaginal delivery, maternal complications), and two factors were neonatal (male infant and neonatal comorbidities). Implementation of evidence-based clinical practice guidelines for inpatient care and individualized hospital-to-home transition plans, including transition checklists and discharge readiness assessments, are recommended to reduce newborn UHRs. WHAT IS KNOWN • Attempts have been made to identify risk factors associated with newborn UHRs; however, the results are inconsistent. WHAT IS NEW • Six consistently cited risk factors related to newborn 31-day UHRs. Four maternal factors (primiparous, mother being Asian, vaginal delivery, maternal complications) and 2 neonatal factors (male infant and neonatal comorbidities). • The importance of discharge readiness assessment, including newborn clinical fitness for discharge and parental readiness for discharge. Future research is warranted to establish standardised maternal and newborn-related variables which healthcare providers can utilize to identify newborns at greater risk of UHRs and enable comparison of research findings.
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Affiliation(s)
- Phillip R Della
- Curtin School of Nursing, Curtin University, GPO Box U 1987, Perth, Western Australia, 6845, Australia
| | - Haichao Huang
- School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Pamela A Roberts
- Curtin School of Nursing, Curtin University, GPO Box U 1987, Perth, Western Australia, 6845, Australia
| | - Paul Porter
- Curtin School of Nursing, Curtin University, GPO Box U 1987, Perth, Western Australia, 6845, Australia.,Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Elizabeth Adams
- Curtin School of Nursing, Curtin University, GPO Box U 1987, Perth, Western Australia, 6845, Australia.,European Federation of Nurses Associations, Clos du Parnasse, Brussels, 11A B-1050, Belgium
| | - Huaqiong Zhou
- Curtin School of Nursing, Curtin University, GPO Box U 1987, Perth, Western Australia, 6845, Australia. .,General Surgical Ward, Perth Children's Hospital, Nedlands, Western Australia, Australia.
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Vergales J, Figueroa M, Frommelt M, Putschoegl A, Singh Y, Murray P, Wood G, Allen K, Villafane J. Transitioning Neonates With CHD to Outpatient Care: A State-of-the-Art Review. Pediatrics 2022; 150:189880. [PMID: 36317969 DOI: 10.1542/peds.2022-056415m] [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: 11/05/2022] Open
Affiliation(s)
- Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Mayte Figueroa
- Divisions of Pediatric Cardiology and Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michele Frommelt
- Children's Wisconsin, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Putschoegl
- Division of Pediatric Cardiology, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Yogen Singh
- Division of Pediatric Cardiology and Neonatology, Cambridge University Hospitals, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Peter Murray
- Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Garrison Wood
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Kiona Allen
- Division of Pediatric Cardiology and Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juan Villafane
- Cincinnati Children's Hospital, Division of Pediatric Cardiology, University of Cincinnati, Cincinnati, Ohio
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Drury NE, Herd CP, Biglino G, Brown KL, Coats L, Cumper MJ, Guerrero RR, Miskin A, Murray S, Pender F, Rooprai S, Simpson JM, Thomson JDR, Weinkauf J, Wootton J, Jones TJ, Cowan K. Research priorities in children and adults with congenital heart disease: a James Lind Alliance Priority Setting Partnership. Open Heart 2022; 9:e002147. [PMID: 36600635 PMCID: PMC9843188 DOI: 10.1136/openhrt-2022-002147] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To bring together patients, parents, charities and clinicians in a Priority Setting Partnership to establish national clinical priorities for research in children and adults with congenital heart disease. METHODS The established James Lind Alliance methodology was used to identify and prioritise research on the management of congenital heart disease, focusing on diagnosis, treatment and outcomes. An initial open survey was used to gather potential uncertainties which were filtered, categorised, converted into summary questions and checked against current evidence. In a second survey, respondents identified the unanswered questions most important to them. At two final workshops, patients, parents, charities and healthcare professionals agreed the top 10 lists of priorities for child/antenatal and adult congenital heart disease research. RESULTS 524 respondents submitted 1373 individual questions, from which 313 out of scope or duplicate questions were removed. The remaining 1060 questions were distilled into summary questions and checked against existing literature, with only three questions deemed entirely answered and removed. 250 respondents completed the child/antenatal survey (56 uncertainties) and 252 completed the adult survey (47 uncertainties). The questions ranked the highest by clinicians and non-clinicians were taken forward to consensus workshops, where two sets of top 10 research priorities were agreed. CONCLUSIONS Through an established and equitable process, we determined national clinical priorities for congenital heart disease research. These will be taken forward by specific working groups, a national patient and public involvement group, and through the establishment of a UK and Ireland network for collaborative, multicentre clinical trials in congenital heart disease.
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Affiliation(s)
- Nigel E Drury
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Clare P Herd
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Giovanni Biglino
- Bristol Medical School, University of Bristol, Bristol, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Katherine L Brown
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Louise Coats
- Adult Congenital Heart Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Rafael R Guerrero
- Department of Paediatric Cardiac Surgery, Alder Hey Children's Hospital, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | | | | | | | - John M Simpson
- Department of Paediatric Cardiology, Evelina London Children's Hospital, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - John D R Thomson
- Department of Paediatric Cardiology, Leeds General Infirmary, Leeds, UK
- Department of Paediatric Cardiology, Johns Hopkins Children's Center, Baltimore, Maryland, USA
| | | | | | - Timothy J Jones
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
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Abstract
BACKGROUND An early warning tool, the Congenital Heart Assessment Tool (CHAT), was designed in 2012 to support parental preparation before discharge, enhancing understanding of their infant's complex CHD, the signs of deterioration to look out for and to support decision-making at home. Acceptability and feasibility of the tool were tested during 2013-2015 in a single centre. AIM OF THIS PROJECT To evaluate the wider implementation across four children's cardiac centres of the CHAT for infants with complex CHD in the community setting. DESIGN A four-centre collaborative mixed-methods quality improvement project funded by The Health Foundation, during 2016-2018. A plan, do, study, act cycle of improvement was employed. This article reports on the planning phases, creation of a modified tool (CHATm); and the implementation phases, including retrospective case note review using CHATm; tabletop simulation exercise using CHATm and clinical implementation of CHATm. RESULTS Key findings included the benefit of using CHATm simulation for practitioners; the effectiveness of CHATm in predicting amber and red triggers, indicating parental actions and escalation of concerns to professionals. Parents using CHATm found it enhanced knowledge in preparation for going home, supported decision-making, and discussions with health care professionals. CONCLUSION Using the CHATm clinically identified the need to develop a structured model of assessment of parental suitability for home-monitoring programmes. A robust and nationally agreed training programme for all staff using CHATm was recommended to ensure successful and complete implementation in practice.
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Affiliation(s)
- Liz Smith
- Great Ormond Street Hospital NHS Foundation Trust, LondonWC1N, UK
| | - Jo Wray
- Professor, Great Ormond Street Hospital NHS Foundation Trust, LondonWC1N, UK
| | - Kerry L Gaskin
- Associate Professor of Nursing, School of Nursing and Midwifery, University of Worcester, Henwick Grove, WorcesterWR26AJ, UK
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Espuny Pujol F, Pagel C, Brown KL, Doidge JC, Feltbower RG, Franklin RC, Gonzalez-Izquierdo A, Gould DW, Norman LJ, Stickley J, Taylor JA, Crowe S. Linkage of National Congenital Heart Disease Audit data to hospital, critical care and mortality national data sets to enable research focused on quality improvement. BMJ Open 2022; 12:e057343. [PMID: 35589356 PMCID: PMC9121475 DOI: 10.1136/bmjopen-2021-057343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To link five national data sets (three registries, two administrative) and create longitudinal healthcare trajectories for patients with congenital heart disease (CHD), describing the quality and the summary statistics of the linked data set. DESIGN Bespoke linkage of record-level patient identifiers across five national data sets. Generation of spells of care defined as periods of time-overlapping events across the data sets. SETTING National Congenital Heart Disease Audit (NCHDA) procedures in public (National Health Service; NHS) hospitals in England and Wales, paediatric and adult intensive care data sets (Paediatric Intensive Care Audit Network; PICANet and the Case Mix Programme from the Intensive Care National Audit & Research Centre; ICNARC-CMP), administrative hospital episodes (hospital episode statistics; HES inpatient, outpatient, accident and emergency; A&E) and mortality registry data. PARTICIPANTS Patients with any CHD procedure recorded in NCHDA between April 2000 and March 2017 from public hospitals. PRIMARY AND SECONDARY OUTCOME MEASURES Primary: number of linked records, number of unique patients and number of generated spells of care. Secondary: quality and completeness of linkage. RESULTS There were 143 862 records in NCHDA relating to 96 041 unique patients. We identified 65 797 linked PICANet patient admissions, 4664 linked ICNARC-CMP admissions and over 6 million linked HES episodes of care (1.1M inpatient, 4.7M outpatient). The linked data set had 4 908 153 spells of care after quality checks, with a median (IQR) of 3.4 (1.8-6.3) spells per patient-year. Where linkage was feasible (in terms of year and centre), 95.6% surgical procedure records were linked to a corresponding HES record, 93.9% paediatric (cardiac) surgery procedure records to a corresponding PICANet admission and 76.8% adult surgery procedure records to a corresponding ICNARC-CMP record. CONCLUSIONS We successfully linked four national data sets to the core data set of all CHD procedures performed between 2000 and 2017. This will enable a much richer analysis of longitudinal patient journeys and outcomes. We hope that our detailed description of the linkage process will be useful to others looking to link national data sets to address important research priorities.
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Affiliation(s)
- Ferran Espuny Pujol
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Katherine L Brown
- Cardiorespiratory Division, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - James C Doidge
- Intensive Care National Audit and Research Centre, London, UK
| | - Richard G Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - Rodney C Franklin
- Department of Paediatric Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Arturo Gonzalez-Izquierdo
- Institute of Health Informatics, University College London, London, UK
- Health Data Research UK, London, UK
| | - Doug W Gould
- Intensive Care National Audit and Research Centre, London, UK
| | - Lee J Norman
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - John Stickley
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Julie A Taylor
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
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Abstract
BACKGROUND CHD was the most prevalent congenital anomaly (60.9 per 10,000, 95% CI 59.0-62.8) in England in 2018, with 1767 babies born with severe cardiac defects. The 30-day survival rates for complex procedures continue to improve; however despite care advances, the early post-operative period and first year of life remain a critical time for these infants. The Congenital Heart Assessment Tool was developed to support parental decision-making, standardise care provision, improve communication, and the safety and quality of care. AIM To further evaluate the Congenital Heart Assessment Tool. DESIGN A four centre collaborative mixed-methods quality improvement project funded by The Health Foundation, involving eight phases conducted during 2016-2018. Phases six to eight (clinical simulation exercise, parent workshop, and updated tool) are reported in this paper. RESULTS Four themes emerged from the clinical simulation exercise (phase six) including: improving documentation; preparation of parents; preparation of health care professionals; and communication. One main theme emerged from the parent workshop (phase seven): "what parents know versus what professionals know [about CHD]". CONCLUSION These phases further validated the effectiveness of the CHATm in terms of triggering amber and red indicators and demonstrated parents' ability to identify deterioration in their infant's clinical condition. Recommendations arising from the quality improvement project enabled the project team to create an updated version of the Congenital Heart Assessment Tool, CHAT2.
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Tran R, Forman R, Mossialos E, Nasir K, Kulkarni A. Social Determinants of Disparities in Mortality Outcomes in Congenital Heart Disease: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:829902. [PMID: 35369346 PMCID: PMC8970097 DOI: 10.3389/fcvm.2022.829902] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSocial determinants of health (SDoH) affect congenital heart disease (CHD) mortality across all forms and age groups. We sought to evaluate risk of mortality from specific SDoH stratified across CHD to guide interventions to alleviate this risk.MethodsWe searched electronic databases between January 1980 and June 2019 and included studies that evaluated occurrence of CHD deaths and SDoH in English articles. Meta-analysis was performed if SDoH data were available in >3 studies. We included race/ethnicity, deprivation, insurance status, maternal age, maternal education, single/multiple pregnancy, hospital volume, and geographic location of patients as SDoH. Data were pooled using random-effects model and outcome was reported as odds ratio (OR) with 95% confidence interval (CI).ResultsOf 17,716 citations reviewed, 65 met inclusion criteria. Sixty-three were observational retrospective studies and two prospective. Of 546,981 patients, 34,080 died. Black patients with non-critical CHD in the first year of life (Odds Ratio 1.62 [95% confidence interval 1.47–1.79], I2 = 7.1%), with critical CHD as neonates (OR 1.27 [CI 1.05-1.55], I2 = 0%) and in the first year (OR 1.68, [1.45-1.95], I2 = 0.3%) had increased mortality. Deprived patients, multiple pregnancies, patients born to mothers <18 years and with education <12 years, and patients on public insurance with critical CHD have greater likelihood of death after the neonatal period.ConclusionThis systematic review and meta-analysis found that Black patients with CHD are particularly vulnerable for mortality. Numerous SDoH that affect mortality were identified for specific time points in CHD course that may guide interventions, future research and policy.Systematic Review Registration[https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019139466&ID=CRD42019139466], identifier [CRD42019139466].
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Affiliation(s)
- Richard Tran
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- *Correspondence: Richard Tran,
| | - Rebecca Forman
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston Methodist Hospital, Houston, TX, United States
| | - Aparna Kulkarni
- Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine, New Hyde Park, NY, United States
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11
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Vemuri S, Butler AE, Brown K, Wray J, Bluebond-Langner M. Palliative care for children with complex cardiac conditions: survey results. Arch Dis Child 2022; 107:282-287. [PMID: 34312164 PMCID: PMC8862095 DOI: 10.1136/archdischild-2020-320866] [Citation(s) in RCA: 4] [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] [Received: 10/05/2020] [Accepted: 07/03/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore perspectives of paediatric cardiac and palliative care professionals on providing palliative care to children with complex cardiac conditions. DESIGN A national survey including closed-ended and open-ended questions as well as clinical scenarios designed to capture referral practices, attitudes towards palliative care, confidence delivering key components of palliative care and perspectives on for whom to provide palliative care. Responses to closed-ended questions and scenarios were analysed using descriptive statistics. Open-ended responses were analysed thematically. PARTICIPANTS Paediatric cardiac and palliative care professionals caring for children with complex cardiac conditions in the UK. RESULTS 177 professionals (91 cardiac care and 86 palliative care) responded. Aspects of advance care planning were the most common reasons for referral to palliative care. Palliative care professionals reported greater confidence than cardiac colleagues with such discussions. Clinicians agreed that children with no further surgical management options, comorbid genetic disorders, antenatal diagnosis of a single ventricle, ventricular device in situ, symptomatic heart failure and those awaiting heart transplantation would benefit from palliative care involvement. CONCLUSIONS Components of palliative care, such as advance care planning, can be provided by cardiac care professionals alongside the disease-directed care of children with complex cardiac conditions. Further research and training are needed to address confidence levels in cardiac care professionals in delivering components of palliative care as well as clarification of professional roles and parent preferences in delivery of family-centred care for children with complex cardiac conditions.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia,Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute for Child Health, London, UK
| | - Ashleigh E Butler
- Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute for Child Health, London, UK,Austin Health Clinical School, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
| | - Katherine Brown
- Institute of Cardiovascular Science, University College London, London, UK,Heart Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Institute of Cardiovascular Science, University College London, London, UK,Heart Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK,Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute for Child Health, London, UK .,Rutgers University, Camden, New Jersey, USA
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12
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Wik G, Jortveit J, Sitras V, Døhlen G, Rønnestad AE, Holmstrøm H. Unexpected death in children with severe congenital heart defects in Norway 2004-2016. Arch Dis Child 2021; 106:961-966. [PMID: 33597179 PMCID: PMC8461410 DOI: 10.1136/archdischild-2020-319936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 01/03/2021] [Accepted: 01/14/2021] [Indexed: 11/18/2022]
Abstract
AIMS Updated knowledge on the rates and causes of death among children with severe congenital heart defects (CHDs) is needed to further improve treatment and survival. This study investigated nationwide mortality rates in children with severe CHDs with an emphasis on unexpected mortality unrelated to cardiac intervention. METHODS AND RESULTS Data on all pregnancies and live-born children in Norway from 2004 to 2016 were obtained from national registries, the Oslo University Hospital's Clinical Registry for CHDs and medical records. Among 2359 live-born children with severe CHDs, 234 (10%) died before 2 years of age. Of these, 109 (46%) died in palliative care, 58 (25%) died of causes related to a cardiac intervention and 67 (29%) died unexpectedly and unrelated to a cardiac intervention, either before (n=26) or following (n=41) discharge after a cardiac intervention. Comorbidity (38/67, 57%), persistent low oxygen saturation (SaO2; <95%; 41/67, 61%), staged surgery (21/41, 51%), residual cardiac defects (22/41, 54%) and infection (36/67, 54%) were frequent in children who died unexpectedly unrelated to an intervention. Two or more of these factors were present in 62 children (93%). The medical reports at hospital discharge lacked information on follow-up in many patients who died unexpectedly. CONCLUSIONS The numbers of unexpected deaths unrelated to cardiac intervention in children <2 years of age without comorbidity were low in Norway. However, close follow-up is recommended for infants with comorbidities, persistent low oxygen saturation, staged surgery or residual cardiac defects, particularly when an infection occurs.
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Affiliation(s)
- Gunnar Wik
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway .,Department of Paediatric and Adolescent Medicine, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Jarle Jortveit
- Department of Cardiology, Sørlandet Hospital Arendal, Arendal, Norway
| | - Vasileios Sitras
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Oslo University Hospital, Oslo, Norway
| | - Gaute Døhlen
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Arild E Rønnestad
- Women and Children’s Division, Department of Neonatal Intensive Care, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Henrik Holmstrøm
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
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Influence of Geographic Access on Surgical Center Readmissions After Index Congenital Heart Surgery. J Pediatr 2021; 234:195-204.e3. [PMID: 33774056 PMCID: PMC8981557 DOI: 10.1016/j.jpeds.2021.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery. STUDY DESIGN Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression. RESULTS Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days. CONCLUSIONS Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population.
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14
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Moore EF, Gephart SM. State of the science of care coordination, rurality, and well-being for infants with single ventricle heart disease in the Interstage period, an integrative review. Heart Lung 2021; 50:720-729. [PMID: 34107397 DOI: 10.1016/j.hrtlng.2021.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ensuring the quality of interstage management of infants with single ventricle heart disease (SVHD) residing in rural communities is difficult. Tailored care coordination through parental discharge education, formal and informal care team and family communication, adequate access to healthcare, and informed provider handoffs are crucial to the infant's well-being and survival. OBJECTIVE To discuss the state of the science related to care coordination factors and infant wellbeing during the interstage period. METHODS An integrative review approach to synthesize findings across studies was used. Through constant comparative analysis, all articles were read and coded, broken down into "data bits" or key phrases. RESULTS Four major themes were inductively derived: 1) education and confidence-building, 2) communication for building relationships, 3) social work and related mental health support, and 4) availability of resources. CONCLUSIONS Despite advances in cardiac surgery and related interventions, a clear gap exists regarding care coordination factors and infant well-being, especially in rural communities.
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Affiliation(s)
- Emily F Moore
- Seattle Children's Hospital 4800 Sand point Way NE, Seattle WA 98105 MS FA.2.114; The University of Arizona College of Nursing PO Box 210203 Tucson, AZ 85721.
| | - Sheila M Gephart
- The University of Arizona College of Nursing PO Box 210203 Tucson, AZ 85721
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15
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Tretter JT, Jacobs JP. Global Leadership in Paediatric and Congenital Cardiac Care: "Coding our way to improved care: an interview with Rodney C. G. Franklin, MBBS, MD, FRCP, FRCPCH". Cardiol Young 2021; 31:11-19. [PMID: 33526161 DOI: 10.1017/s104795112000476x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Dr Rodney Franklin is the focus of our third in a planned series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care." Dr Franklin was born in London, England, spending the early part of his childhood in the United States of America before coming back to England. He then attended University College London Medical School and University College Hospital in London, England, graduating in 1979. Dr Franklin would then go on to complete his general and neonatal paediatrics training in 1983 at Northwick Park Hospital and University College Hospital in London, England, followed by completing his paediatric cardiology training in 1989 at Great Ormond Street Hospital for Children in London, England. During this training, he additionally would hold the position of British Heart Foundation Junior Research Fellow from 1987 to 1989. Dr Franklin would then complete his training in 1990 as a Senior Registrar and subsequent Consultant in Paediatric and Fetal Cardiology at Wilhelmina Sick Children's Hospital in Utrecht, the Netherlands. He subsequently obtained his research doctorate at University of London in 1997, consisting of a retrospective audit of 428 infants with functionally univentricular hearts.Dr Franklin has spent his entire career as a Consultant Paediatric Cardiologist at the Royal Brompton & Harefield Hospital NHS Foundation Trust, being appointed in 1991. He additionally holds honorary Consultant Paediatric Cardiology positions at Hillingdon Hospital, Northwick Park Hospital, and Lister Hospital in the United Kingdom, and Honorary Senior Lecturer at Imperial College, London. He has been the Clinical Lead of the National Congenital Heart Disease Audit (2013-2020), which promotes data collection within specialist paediatric centres. Dr Franklin has been a leading figure in the efforts towards creating international, pan European, and national coding systems within the multidisciplinary field of congenital cardiac care. These initiatives include but are not limited to the development and maintenance of The International Paediatric & Congenital Cardiac Code and the related International Classification of Diseases 11th Revision for CHD and related acquired terms and definitions. This article presents our interview with Dr Franklin, an interview that covers his experience in developing these important coding systems and consensus nomenclature to both improve communication and the outcomes of patients. We additionally discuss his experience in the development and implementation of strategies to assess the quality of paediatric and congenital cardiac care and publicly report outcomes.
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Affiliation(s)
- Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Children's Hospital, Gainesville, FL, USA
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
- Cardiology in the Young, Cambridge, UK
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16
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Post-operative discharge education for parent caregivers of children with congenital heart disease: a needs assessment. Cardiol Young 2020; 30:1788-1796. [PMID: 32959751 DOI: 10.1017/s1047951120002759] [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] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents' hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness. METHODS Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5-7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis. RESULTS We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful. CONCLUSIONS Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.
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Abstract
BACKGROUND We aimed to conduct a multi-centre study characterising emergency department utilisation and critical readmissions experienced by children with Fontan circulation. METHODS We conducted a retrospective review of children who underwent the Fontan operation at three institutions (i.e., centres A, B, and C) between 2009 and 2014, with follow-up through December 2015. Multi-variable analyses were performed to determine factors associated for emergency department utilisation within 1 year of surgery, emergency department utilisation at any time following surgery, or critical readmission (defined as admission to ICU, operating room, or cardiac catheterisation). RESULTS We reviewed 297 patients, of which 147 patients (49%) had 607 emergency department encounters. Forty-six patients (15%) required 71 critical readmissions. Multi-variable analyses revealed centre C (p = 0.02) and post-operative hospitalisation ≥ 14 days (p = 0.03) to be significantly associated with emergency department utilisation within 1 year, whereas centre B (p < 0.001), post-operative hospitalisation ≥ 14 days (p = 0.002), and African-American/Black race (p = 0.04) were significantly associated with critical readmission. CONCLUSIONS In this multi-centre study, nearly half of patients with Fontan circulation received emergency department care, often presenting with high disease acuity requiring readmission. Emergency department utilisation and need for critical readmission were independently influenced by the centre at which surgery was performed, prolonged post-operative hospitalisation, and racial background. These data could help guide quality improvement efforts aimed at reducing morbidity in this unique patient population.
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Gaskin K, Kennedy F. Care of infants, children and adults with congenital heart disease. Nurs Stand 2020; 34:37-42. [PMID: 31468777 DOI: 10.7748/ns.2019.e11405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2019] [Indexed: 12/13/2022]
Abstract
Congenital heart disease refers to an anatomical or physiological defect of the heart that is present at birth. Over the past three decades there have been significant advances in surgical, medical and nursing care for infants and children requiring cardiac surgery for congenital heart disease. This has meant that the number of adults with moderate and complex congenital heart disease now exceeds the number of children with the disease. This article details the background and diagnosis of congenital heart disease. It considers the implications for infants and children with congenital heart disease, as well as their parents, such as screening methods, risk factors, parental stress and psychosocial needs. This article also discusses the care of adults with congenital heart disease, including specialist monitoring and patient education.
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Affiliation(s)
- Kerry Gaskin
- Three Counties School of Nursing and Midwifery, University of Worcester, Worcester, England, and chairperson of the Congenital Cardiac Nurses Association
| | - Fiona Kennedy
- Barts Health NHS Trust, London, England, and member of the British Adult Congenital Cardiac Nurses Association
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20
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Wik G, Jortveit J, Sitras V, Døhlen G, Rønnestad AE, Holmstrøm H. Severe congenital heart defects: incidence, causes and time trends of preoperative mortality in Norway. Arch Dis Child 2020; 105:738-743. [PMID: 32051128 PMCID: PMC7392497 DOI: 10.1136/archdischild-2019-317581] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 12/16/2019] [Accepted: 01/22/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND AIMS Severe congenital heart defects (CHDs) still represent one of the main causes of infant death. The risk factors associated with cardiac surgery and postoperative mortality are well known. We aimed to describe the rates, causes and time trends of mortality before surgery-including termination of pregnancies and palliative care-in fetuses and children below 2 years of age with severe CHDs. METHODS AND RESULTS Data concerning all 789 345 pregnancies in Norway from 2004 to 2016 were retrieved from the Medical Birth Registry of Norway, the Oslo University Hospital's Clinical Registry for Congenital Heart Defects, the Norwegian Cause of Death Registry, the National Registry, Statistics Norway, autopsy reports and medical records. When including termination of pregnancy and stillbirths, the number of fetuses and children with severe CHDs that did not reach the age of 2 years was 31%. Mortality among the 2359 live-born infants with severe CHDs was 10%, of whom 58% died before surgery. Of the preoperative deaths, 81% died in a palliative care setting, and comorbidity and univentricular CHDs were common among these infants. Together, palliative care and termination of pregnancy accounted for 86% of deaths in cases of severe CHDs, and this proportion increased during the study period (annual percent changes 1.3, 95% CI 0.4 to 2.1, p<0.001), mainly due to an increased termination rate. CONCLUSIONS Termination of pregnancy accounted for the majority of the deaths in fetuses and children with severe CHDs. Among live-born children, most preoperative deaths occurred in a palliative care setting and were strongly related to comorbidities and/or univentricular hearts.
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Affiliation(s)
- Gunnar Wik
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway .,Department of Paediatric and Adolescent Medicine, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | - Jarle Jortveit
- Department of Cardiology, Sørlandet Hospital Arendal, Arendal, Norway
| | - Vasileios Sitras
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Oslo University Hospital, Oslo, Norway
| | - Gaute Døhlen
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Arild E Rønnestad
- Women and Children’s Division, Department of Neonatal Intensive Care, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Henrik Holmstrøm
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
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Biomarkers improve prediction of 30-day unplanned readmission or mortality after paediatric congenital heart surgery. Cardiol Young 2019; 29:1051-1056. [PMID: 31290383 PMCID: PMC6711799 DOI: 10.1017/s1047951119001471] [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: 11/06/2022]
Abstract
OBJECTIVE To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery. METHODS Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models. RESULTS Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65-0.86) compared to 0.617 (95% confidence interval: 0.47-0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72-0.89; p-value: 0.003). CONCLUSIONS Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
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22
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Novel Biomarkers Improve Prediction of 365-Day Readmission After Pediatric Congenital Heart Surgery. Ann Thorac Surg 2019; 109:164-170. [PMID: 31323208 DOI: 10.1016/j.athoracsur.2019.05.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the association between preoperative biomarker levels and 365-day readmission or mortality after pediatric congenital heart surgery. METHODS Children aged 18 years or younger undergoing congenital heart surgery (n = 145) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Novel biomarkers suppression of tumorgenicity 2, galectin-3, N-terminal prohormone brain natriuretic peptide, and glial fibrillary acidic protein were measured. The composite study endpoint was unplanned readmission within 365 days after discharge or mortality either in hospital during the surgical admission or within 365 days after discharge. A clinical model based on covariates used in The Society of Thoracic Surgeons Congenital Heart Surgery Database mortality risk model and an augmented model using the clinical model in conjunction with a novel biomarker panel were evaluated. RESULTS Readmission or mortality within 365 days of surgery occurred among 39 pediatric patients (27%). The clinical model alone resulted in a c-statistic of 0.719 (95% confidence interval, 0.63 to 0.81). The clinical model in conjunction with the log-transformed biomarkers improved the c-statistic to 0.805 (95% confidence interval, 0.73 to 0.88). The addition of biomarkers resulted in a significant improvement to the clinical model alone (P value = 0.035). CONCLUSIONS Novel biomarkers may add predictive value when assessing the likelihood of 365-day readmission or mortality after pediatric congenital heart surgery. After adjusting for clinical and novel biomarkers, preoperative and postoperative suppression of tumorgenicity 2 remained associated with 365-day readmission or mortality. Currently, The Society of Thoracic Surgeons clinical congenital mortality risk model can be applied to identify children with increased risk of repeat hospitalizations and postdischarge mortality and may inform preventative care interventions that aim to reduce these adverse events.
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23
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Best KE, Vieira R, Glinianaia SV, Rankin J. Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis. Paediatr Perinat Epidemiol 2019; 33:291-309. [PMID: 31347722 DOI: 10.1111/ppe.12564] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/02/2019] [Accepted: 05/27/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND The impact of socio-economic status (SES) on congenital heart disease (CHD)-related mortality in children is not well established. OBJECTIVES We aimed to systematically review and appraise the existing evidence on the association between SES (including poverty, parental education, health insurance, and income) and mortality among children with CHD. DATA SOURCES Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, citations, and key journals were searched. STUDY SELECTION AND DATA EXTRACTION We included articles reporting original research on the association between SES and mortality in children with CHD if they were full papers published in the English language and regardless of (a) timing of mortality; (b) individual or area-based measures of SES; (c) CHD subtype; (d) age at ascertainment; (e) study period examined. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. SYNTHESIS Meta-analyses were performed to estimate pooled ORs for in-hospital mortality according to health insurance status. RESULTS Of 1388 identified articles, 28 met the inclusion criteria. Increased area-based poverty was associated with increased odds/risk of postoperative (n = 1), neonatal (n = 1), post-discharge (n = 1), infant (n = 1), and long-term mortality (n = 2). Higher parental education was associated with decreased odds/risk of neonatal (n = 1) and infant mortality (n = 5), but not with long-term mortality (n = 1). A meta-analysis of four US articles showed increased unadjusted odds of in-hospital mortality in those with government/public versus private health insurance (OR 1.40, 95% CI 1.24, 1.56). The association between area-based income and CHD-related mortality was conflicting, with three of eight articles reporting significant associations. CONCLUSION This systematic review provides evidence that children of lower SES are at increased risk of CHD-related mortality. As these children are over-represented in the CHD population, interventions targeting socio-economic inequalities could have a large impact on improving CHD survival.
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Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Rute Vieira
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK.,The Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
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24
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Salim TR, Soares GP, Klein CH, Oliveira GMM. Fetal and maternal factors are associated with mortality due to circulatory system disorders in children. Rev Saude Publica 2019; 53:31. [PMID: 30942273 PMCID: PMC6474750 DOI: 10.11606/s1518-8787.2019053000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/09/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To analyze the association of characteristics recorded at the time of birth, including weight, occurrence of asphyxia, gestation duration, maternal age and education level, with death from diseases or malformations of the circulatory system in children under 18 years of age. METHODS The Brazilian Information System on Live Births and Information System on Mortality databases were linked and evaluated following a longitudinal cohort analysis strategy. The following independent variables were evaluated: characteristics recorded at the time of birth, including weight, occurrence of asphyxia, gestation duration, maternal age and education level. Dependent variables were death from diseases or malformations of the circulatory system in children under 18 years of age. Crude relative risks were estimated and relative risks were adjusted for the variables. RESULTS 6,380 deaths were linked to 4,282,260 birth records, yielding 5,062 pairs considered as true. Low birth weight (RR = 2.26), asphyxia at 1 (RR = 1.72) and 5 minutes (RR = 1.51), prematurity (RR = 1.50), maternal age ≥ 40 years (RR = 2.06), and low maternal education level (RR = 1.45) increased the probability of death caused by circulatory system diseases. In the association with death by malformations of the circulatory system, the predictive variables showed the same association profile, but with greater intensity. CONCLUSIONS Fetal and maternal factors are associated with increased mortality due to diseases and malformations of the circulatory system. Measures to control these factors and improve access to their diagnosis and treatment would contribute to reducing the number of deaths caused by diseases and malformations of the circulatory system. However, the identification of environmental influences during gestation and birth on the risk of death should be carefully considered due to being influenced by genetic factors.
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Affiliation(s)
- Thais Rocha Salim
- Universidade Federal do Rio de Janeiro. Faculdade de Medicina. Instituto do Coração Edson Saad. Rio de Janeiro, RJ, Brasil.,Universidade de Vassouras. Curso de Medicina. Vassouras, RJ, Brasil
| | - Gabriel Porto Soares
- Universidade Federal do Rio de Janeiro. Faculdade de Medicina. Instituto do Coração Edson Saad. Rio de Janeiro, RJ, Brasil.,Universidade de Vassouras. Curso de Medicina. Vassouras, RJ, Brasil
| | - Carlos Henrique Klein
- Universidade Federal do Rio de Janeiro. Faculdade de Medicina. Instituto do Coração Edson Saad. Rio de Janeiro, RJ, Brasil.,Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública. Rio de Janeiro, RJ, Brasil
| | - Gláucia Maria Moraes Oliveira
- Universidade Federal do Rio de Janeiro. Faculdade de Medicina. Instituto do Coração Edson Saad. Rio de Janeiro, RJ, Brasil
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Gaskin KL, Wray J, Barron DJ. Acceptability of a parental early warning tool for parents of infants with complex congenital heart disease: a qualitative feasibility study. Arch Dis Child 2018; 103:880-886. [PMID: 29567664 DOI: 10.1136/archdischild-2017-313227] [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] [Received: 04/19/2017] [Revised: 02/27/2018] [Accepted: 03/03/2018] [Indexed: 11/04/2022]
Abstract
AIM To explore the acceptability and feasibility of a parental early warning tool, called the Congenital Heart Assessment Tool (CHAT), for parents going home with their infant between first and second stage of surgery for complex congenital heart disease. BACKGROUND Home monitoring programmes were developed to aid early recognition of deterioration in fragile infants between first and second surgical stage. However, this necessitates good discharge preparation to enable parents to develop appropriate knowledge and understanding of signs of deterioration to look for and who to contact. DESIGN This was a longitudinal qualitative feasibility study, within a constructivist paradigm. Parents were taught how to use the CHAT before taking their infant home and asked to participate in semistructured interviews at four time points: before discharge (T0), 2 weeks after discharge (T1), 8 weeks after discharge (T2) and after stage 2 surgery (T3). Interviews were transcribed verbatim and thematically analysed. SETTING One tertiary children's cardiac centre in the UK. SUBJECTS Twelve parents of eight infants who were discharged following first stage cardiac surgery for complex congenital heart disease, between August 2013 and February 2015. RESULTS Four main themes emerged: (1) parental preparation and vigilance, (2) usability, (3) mastery, and (4) reassurance and support. CONCLUSIONS The study highlighted the benefit of appropriately preparing parents before discharge, using the CHAT, to enable identification of normal infant behaviour and to detect signs of clinical deterioration. The study also demonstrated the importance of providing parents with information about when and who to call for management advice and support.
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Affiliation(s)
- Kerry Louise Gaskin
- Nursing and Midwifery Department, Institute of Health and Society, University of Worcester, Worcester, UK
| | - Jo Wray
- Centre for Nursing and Allied Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Cardiac Surgery Department, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
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Wray J, Tregay J, Bull C, Knowles RL, Crowe S, Brown K. Issues facing families of infants discharged after cardiac surgery: the perceptions of charity helpline staff. Acta Paediatr 2018; 107:1418-1426. [PMID: 29505097 DOI: 10.1111/apa.14304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/15/2018] [Accepted: 02/28/2018] [Indexed: 11/30/2022]
Abstract
AIM To elicit the perceptions of helpline staff who talk to parents of children discharged after cardiac surgery in infancy about parents' key concerns. METHODS A qualitative study involving semistructured interviews with 10 staff at four heart charities. Interviews were recorded, transcribed and analysed using Framework analysis. RESULTS Staff identified the knowledge, communication and support needs of parents which they described in terms of the impact of patient and family factors, sources of support and systems. Staff perceptions of helplines, in terms of the function of a helpline and the roles of its staff, together with staff's personal views based on their experience of multiple encounters with many families, influenced how they viewed families' needs and responded to their requests. CONCLUSION Helpline staff provided important, previously uncaptured evidence about the challenges faced by parents of children discharged after cardiac surgery in infancy. Staff have an important role in supporting communication, in terms of speaking to families about how to talk to professionals and talking to professionals directly to get or give information when parents are unable to do so. Capturing the perspective of helpline staff about communication issues has highlighted the need for interventions with professionals as well as parents.
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Affiliation(s)
- Jo Wray
- Critical Care and Cardiorespiratory Department; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Jenifer Tregay
- Critical Care and Cardiorespiratory Department; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Catherine Bull
- Critical Care and Cardiorespiratory Department; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Rachel L. Knowles
- MRC Centre of Epidemiology for Child Health; UCL Institute of Child Health; London UK
| | - Sonya Crowe
- Clinical Operational Research Unit; University College London; London UK
| | - Katherine Brown
- Critical Care and Cardiorespiratory Department; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
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Xiang L, Su Z, Liu Y, Zhang X, Li S, Hu S, Zhang H. Effect of family socioeconomic status on the prognosis of complex congenital heart disease in children: an observational cohort study from China. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:430-439. [DOI: 10.1016/s2352-4642(18)30100-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 11/16/2022]
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Wray J, Brown K, Tregay J, Crowe S, Knowles R, Bull K, Gibson F. Parents' Experiences of Caring for Their Child at the Time of Discharge After Cardiac Surgery and During the Postdischarge Period: Qualitative Study Using an Online Forum. J Med Internet Res 2018; 20:e155. [PMID: 29743157 PMCID: PMC5966654 DOI: 10.2196/jmir.9104] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 11/21/2022] Open
Abstract
Background Congenital heart disease (CHD) is the most common class of birth defects, which encompasses a broad spectrum of severity ranging from relatively minor to extremely complex. Improvements in surgery and intensive care have resulted in an increasing number of infants with the most complex lesions surviving after surgery until the time of discharge from the hospital, but there remain concerns about out-of-hospital mortality, variability in how services are provided at the time of discharge and beyond, and difficulties experienced by some families in accessing care. Objective As part of a mixed-methods program of research, this study aimed to elicit parental experiences of caring for a child with CHD after hospital discharge following a cardiac surgery and collect information to inform interviews for a subsequent stage of the project. Methods A closed online discussion group was set up via the main Facebook page of the Children’s Heart Federation (CHF), a national charity offering support to children with heart disease and their families. The discussion group was advertised through the charity’s webpage, and interested participants were directed to the charity’s Facebook page from where they could access the closed Facebook group and respond to questions posted. The CHF moderated the forum, and the research team provided questions to be posted on the forum. Responses were collated into a single transcript and subjected to thematic analysis. Results The forum was open for 4 months, and 91 participants (mean age 35 years, range 23-58 years, 89 females, 89 parents, and 2 grandparents) submitted demographic information and were given access to the closed forum group. A common experience of isolation emerged from the data, with descriptions of how that isolation was experienced (physical, social, knowledge) and its psychological impact, together with the factors that made it worse or better. Woven through this theme was the notion that parents developed expertise over time. Conclusions The use of an online forum provided a means for eliciting data from a large number of parents regarding their experiences of caring for their child after hospital discharge following cardiac surgery. Parents engaged with the forum and were able to articulate what went well and what went less well, together with sharing their stories and supporting each other through doing so. Some parents clearly found participating in the forum a positive experience in itself, demonstrating the potential of social media as a mechanism for providing support and reducing isolation. Information gained from the forum was used to shape questions for interviews with parents in a subsequent phase of the study. Furthermore, the themes identified in the online forum have contributed to identifying ways of improving the provision of care and support for parents of high-risk babies following discharge after cardiac surgery.
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Affiliation(s)
- Jo Wray
- Charles West Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Katherine Brown
- Charles West Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jenifer Tregay
- Charles West Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, United Kingdom
| | - Rachel Knowles
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, United Kingdom
| | - Kate Bull
- Charles West Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Faith Gibson
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
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Evaluation of the Adult Congenital Heart Surgery Mortality Score at Two European Centers. Ann Thorac Surg 2018; 105:1441-1446. [DOI: 10.1016/j.athoracsur.2017.12.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/23/2017] [Accepted: 12/15/2017] [Indexed: 12/18/2022]
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Socioeconomic status and outcomes of paediatric cardiac surgery. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:384-385. [PMID: 30169277 DOI: 10.1016/s2352-4642(18)30134-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 11/21/2022]
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Crowe S, Turner S, Utley M, Fulop NJ. Improving the production of applied health research findings: insights from a qualitative study of operational research. Implement Sci 2017; 12:112. [PMID: 28886709 PMCID: PMC5591553 DOI: 10.1186/s13012-017-0643-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 09/04/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Knowledge produced through applied health research is often of a form not readily accessible to or actionable by policymakers and practitioners, which hinders its implementation. Our aim was to identify research activities that can support the production of knowledge tailored to inform policy and practice. To do this, we studied an operational research approach to improving the production of applied health research findings. METHODS A 2-year qualitative study was conducted of the operational research contribution to a multidisciplinary applied health research project that was successful in rapidly informing national policy. Semi-structured interviews (n = 20) were conducted with all members of the project's research team and advisory group (patient and health professional representatives and academics). These were augmented by participant (> 150 h) and non-participant (> 15 h) observations focusing on the process and experience of attempting to support knowledge production. Data were analysed thematically using QSR NVivo software. RESULTS Operational research performed a knowledge mediation role shaped by a problem-focused approach and an intent to perform those tasks necessary to producing readily implementable knowledge but outwith the remit of other disciplinary strands of the project. Three characteristics of the role were found to support this: engaging and incorporating different perspectives to improve services by capturing a range of health professional and patient views alongside quantitative and qualitative research evidence; rendering data meaningful by creating and presenting evidence in forms that are accessible to and engage different audiences, enabling them to make sense of it for practical use; and maintaining perceived objectivity and rigour by establishing credibility, perceived neutrality and confidence in the robustness of the research in order to unite diverse professionals in thinking creatively about system-wide service improvement. CONCLUSIONS Our study contributes useful empirical insights about knowledge mediation activities within multidisciplinary applied health research projects that support the generation of accessible, practice-relevant and actionable knowledge. Incorporating such activities, or a dedicated role, for mediating knowledge production within such projects could help to enhance the uptake of research findings into routine healthcare and warrants further consideration.
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Affiliation(s)
- Sonya Crowe
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London, WC1H 0BT UK
| | - Simon Turner
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London, WC1H 0BT UK
| | - Naomi J. Fulop
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
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Lawley CM, Lain SJ, Figtree GA, Sholler GF, Winlaw DS, Roberts CL. Mortality, rehospitalizations and costs in children undergoing a cardiac procedure in their first year of life in New South Wales, Australia. Int J Cardiol 2017; 241:156-162. [DOI: 10.1016/j.ijcard.2017.03.113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/24/2017] [Indexed: 10/19/2022]
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Pagel C, Rogers L, Brown K, Ambler G, Anderson D, Barron D, Blackshaw E, Crowe S, English K, Franklin R, Jesper E, Meagher L, Pearson M, Rakow T, Salamonowicz M, Spiegelhalter D, Stickley J, Thomas J, Tibby S, Tsang V, Utley M, Witter T. Improving risk adjustment in the PRAiS (Partial Risk Adjustment in Surgery) model for mortality after paediatric cardiac surgery and improving public understanding of its use in monitoring outcomes. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2011, we developed a risk model for 30-day mortality after children’s heart surgery. The PRAiS (Partial Risk Adjustment in Surgery) model uses data on the procedure performed, diagnosis, age, weight and comorbidity. Our treatment of comorbidity was simplistic because of data quality. Software that implements PRAiS is used by the National Congenital Heart Disease Audit (NCHDA) in its audit work. The use of PRAiS triggered the temporary suspension of surgery at one unit in 2013. The public anger that surrounded this illustrated the need for public resources around outcomes monitoring.Objectives(1) To improve the PRAiS risk model by incorporating more information about comorbidities. (2) To develop online resources for the public to help them to understand published mortality data.DesignObjective 1 The outcome measure was death within 30 days of the start of each surgical episode of care. The analysts worked with an expert panel of clinical and data management representatives. Model development followed an iterative process of clinical discussion of risk factors, development of regression models and assessment of model performance under cross-validation. Performance was measured using the area under the receiving operator characteristic (AUROC) curve and calibration in the cross-validation test sets. The final model was further assessed in a 2014–15 validation data set.Objective 2 We developed draft website material that we iteratively tested through four sets of two workshops (one workshop for parents of children who had undergone heart surgery and one workshop for other interested users). Each workshop recruited new participants. The academic psychologists ran two sets of three experiments to explore further understanding of the web content.DataWe used pseudonymised NCHDA data from April 2009 to April 2014. We later unexpectedly received a further year of data (2014–15), which became a prospective validation set.ResultsObjective 1The cleaned 2009–14 data comprised 21,838 30-day surgical episodes, with 539 deaths. The 2014–15 data contained 4207 episodes, with 97 deaths. The final regression model included four new comorbidity groupings. Under cross-validation, the model had a median AUROC curve of 0.83 (total range 0.82 to 0.83), a median calibration slope of 0.92 (total range 0.64 to 1.25) and a median intercept of –0.23 (range –1.08 to 0.85). In the validation set, the AUROC curve was 0.86 [95% confidence interval (CI) 0.83 to 0.89], and its calibration slope and intercept were 1.01 (95% CI 0.83 to 1.18) and 0.11 (95% CI –0.45 to 0.67), respectively. We recalibrated the final model on 2009–15 data and updated the PRAiS software.Objective 2We coproduced a website (http://childrensheartsurgery.info/) that provides interactive exploration of the data, two animations and background information. It was launched in June 2016 and was very well received.LimitationsWe needed to use discharge status as a proxy for 30-day life status for the 14% of overseas patients without a NHS number. We did not have sufficient time or resources to extensively test the usability and take-up of the website following its launch.ConclusionsThe project successfully achieved its stated aims. A key theme throughout has been the importance of collaboration and coproduction. In particular for aim 2, we generated a great deal of generalisable learning about how to communicate complex clinical and mathematical information.Further workExtending our codevelopment approach to cover many other aspects of quality measurement across congenital heart disease and other specialised NHS services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Libby Rogers
- Clinical Operational Research Unit, University College London, London, UK
| | - Katherine Brown
- Cardiac, Critical Care and Respiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - David Anderson
- Cardiology and Critical Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - David Barron
- Cardiothoracic Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | | | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Kate English
- Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | | | | | - Mike Pearson
- Statistical Laboratory, Centre for Mathematical Sciences, University of Cambridge, Cambridge, UK
| | - Tim Rakow
- Department of Psychology, King’s College London, London, UK
| | | | - David Spiegelhalter
- Statistical Laboratory, Centre for Mathematical Sciences, University of Cambridge, Cambridge, UK
| | - John Stickley
- Cardiothoracic Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | | | - Shane Tibby
- Cardiology and Critical Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Victor Tsang
- Cardiac, Critical Care and Respiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Cardiology and Critical Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Burt J. Getting to grips with the beast: the potential of multi-method operational research approaches. BMJ Qual Saf 2017; 26:611-612. [PMID: 28137995 DOI: 10.1136/bmjqs-2017-006484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/04/2022]
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Crowe S, Brown K, Tregay J, Wray J, Knowles R, Ridout DA, Bull C, Utley M. Combining qualitative and quantitative operational research methods to inform quality improvement in pathways that span multiple settings. BMJ Qual Saf 2017; 26:641-652. [PMID: 28062603 PMCID: PMC5537516 DOI: 10.1136/bmjqs-2016-005636] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 11/21/2016] [Accepted: 12/02/2016] [Indexed: 11/11/2022]
Abstract
Background Improving integration and continuity of care across sectors within resource constraints is a priority in many health systems. Qualitative operational research methods of problem structuring have been used to address quality improvement in services involving multiple sectors but not in combination with quantitative operational research methods that enable targeting of interventions according to patient risk. We aimed to combine these methods to augment and inform an improvement initiative concerning infants with congenital heart disease (CHD) whose complex care pathway spans multiple sectors. Methods Soft systems methodology was used to consider systematically changes to services from the perspectives of community, primary, secondary and tertiary care professionals and a patient group, incorporating relevant evidence. Classification and regression tree (CART) analysis of national audit datasets was conducted along with data visualisation designed to inform service improvement within the context of limited resources. Results A ‘Rich Picture’ was developed capturing the main features of services for infants with CHD pertinent to service improvement. This was used, along with a graphical summary of the CART analysis, to guide discussions about targeting interventions at specific patient risk groups. Agreement was reached across representatives of relevant health professions and patients on a coherent set of targeted recommendations for quality improvement. These fed into national decisions about service provision and commissioning. Conclusions When tackling complex problems in service provision across multiple settings, it is important to acknowledge and work with multiple perspectives systematically and to consider targeting service improvements in response to confined resources. Our research demonstrates that applying a combination of qualitative and quantitative operational research methods is one approach to doing so that warrants further consideration.
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Affiliation(s)
- Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Katherine Brown
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jenifer Tregay
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rachel Knowles
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Deborah A Ridout
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Catherine Bull
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
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Crowe S, Knowles R, Wray J, Tregay J, Ridout DA, Utley M, Franklin R, Bull CL, Brown KL. Identifying improvements to complex pathways: evidence synthesis and stakeholder engagement in infant congenital heart disease. BMJ Open 2016; 6:e010363. [PMID: 27266768 PMCID: PMC4908909 DOI: 10.1136/bmjopen-2015-010363] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Many infants die in the year following discharge from hospital after surgical or catheter intervention for congenital heart disease (3-5% of discharged infants). There is considerable variability in the provision of care and support in this period, and some families experience barriers to care. We aimed to identify ways to improve discharge and postdischarge care for this patient group. DESIGN A systematic evidence synthesis aligned with a process of eliciting the perspectives of families and professionals from community, primary, secondary and tertiary care. SETTING UK. RESULTS A set of evidence-informed recommendations for improving the discharge and postdischarge care of infants following intervention for congenital heart disease was produced. These address known challenges with current care processes and, recognising current resource constraints, are targeted at patient groups based on the number of patients affected and the level and nature of their risk of adverse 1-year outcome. The recommendations include: structured discharge documentation, discharging certain high-risk patients via their local hospital, enhanced surveillance for patients with certain (high-risk) cardiac diagnoses and an early warning tool for parents and community health professionals. CONCLUSIONS Our recommendations set out a comprehensive, system-wide approach for improving discharge and postdischarge services. This approach could be used to address challenges in delivering care for other patient populations that can fall through gaps between sectors and organisations.
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Affiliation(s)
- Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Rachel Knowles
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Jo Wray
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jenifer Tregay
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah A Ridout
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Rodney Franklin
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Brown KL, Wray J, Knowles RL, Crowe S, Tregay J, Ridout D, Barron DJ, Cunningham D, Parslow R, Franklin R, Barnes N, Hull S, Bull C. Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWhile early outcomes of paediatric cardiac surgery have improved, less attention has been given to later outcomes including post-discharge mortality and emergency readmissions.ObjectivesOur objectives were to use a mixed-methods approach to build an evidenced-based guideline for postdischarge management of infants undergoing interventions for congenital heart disease (CHD).MethodsSystematic reviews of the literature – databases used: MEDLINE (1980 to 1 February 2013), EMBASE (1980 to 1 February 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1981 to 1 February 2013), The Cochrane Library (1999 to 1 February 2013), Web of Knowledge (1980 to 1 February 2013) and PsycINFO (1980 to 1 February 2013). Analysis of audit data from the National Congenital Heart Disease Audit and Paediatric Intensive Care Audit Network databases pertaining to records of infants undergoing interventions for CHD between 1 January 2005 and 31 December 2010. Qualitative analyses of online discussion posted by 73 parents, interviews with 10 helpline staff based at user groups, interviews with 20 families whose infant either died after discharge or was readmitted urgently to intensive care, and interviews with 25 professionals from tertiary care and 13 professionals from primary and secondary care. Iterative multidisciplinary review and discussion of evidence incorporating the views of parents on suggestions for improvement.ResultsDespite a wide search strategy, the studies identified for inclusion in reviews related only to patients with complex CHD, for whom adverse outcome was linked to non-white ethnicity, lower socioeconomic status, comorbidity, age, complexity and feeding difficulties. There was evidence to suggest that home monitoring programmes (HMPs) are beneficial. Of 7976 included infants, 333 (4.2%) died postoperatively, leaving 7634 infants, of whom 246 (3.2%) experienced outcome 1 (postdischarge death) and 514 (6.7%) experienced outcome 2 (postdischarge death plus emergency intensive care readmissions). Multiple logistic regression models for risk of outcomes 1 and 2 had areas under the receiver operator curve of 0.78 [95% confidence interval (CI) 0.75 to 0.82] and 0.78 (95% CI 0.75 to 0.80), respectively. Six patient groups were identified using classification and regression tree analysis to stratify by outcome 2 (range 3–24%), which were defined in terms of neurodevelopmental conditions, high-risk cardiac diagnosis (hypoplastic left heart, single ventricle or pulmonary atresia), congenital anomalies and length of stay (LOS) > 1 month. Deficiencies and national variability were noted for predischarge training and information, the process of discharge to non-specialist services including documentation, paediatric cardiology follow-up including HMP, psychosocial support post discharge and the processes for accessing help when an infant becomes unwell.ConclusionsNational standardisation may improve discharge documents, training and guidance on ‘what is normal’ and ‘signs and symptoms to look for’, including how to respond. Infants with high-risk cardiac diagnoses, neurodevelopmental conditions or LOS > 1 month may benefit from discharge via their local hospital. HMP is suggested for infants with hypoplastic left heart, single ventricle or pulmonary atresia. Discussion of postdischarge deaths for infant CHD should occur at a network-based multidisciplinary meeting. Audit is required of outcomes for this stage of the patient journey.Future workFurther research may determine the optimal protocol for HMPs, evaluate the use of traffic light tools for monitoring infants post discharge and develop the analytical steps and processes required for audit of postdischarge metrics.Study registrationThis study is registered as PROSPERO CRD42013003483 and CRD42013003484.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The National Congenital Heart Diseases Audit (NCHDA) and Paediatric Intensive Care Audit Network (PICANet) are funded by the National Clinical Audit and Patient Outcomes Programme, administered by the Healthcare Quality Improvement Partnership (HQIP). PICAnet is also funded by Welsh Health Specialised Services Committee; NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, National Office of Clinical Audit Ireland, and HCA International. The study was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Sonya Crowe was supported by the Health Foundation, an independent charity working to continuously improve the quality of health care in the UK.
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Affiliation(s)
- Katherine L Brown
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rachel L Knowles
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Jenifer Tregay
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - David J Barron
- Cardiac Surgery Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research, University College London, London, UK
| | - Roger Parslow
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiac Unit, Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Nick Barnes
- Department of Paediatrics, Northampton General Hospital NHS Trust, Northampton, UK
| | - Sally Hull
- Primary Care Department, Queen Mary University of London, London, UK
| | - Catherine Bull
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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