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Wray J, Ridout D, Jones A, Davis P, Wellman P, Rodrigues W, Hudson E, Tsang V, Pagel C, Brown KL. The Impact of Morbidities Following Pediatric Cardiac Surgery on Family Functioning and Parent Quality of Life. Pediatr Cardiol 2024; 45:14-23. [PMID: 37914854 DOI: 10.1007/s00246-023-03312-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023]
Abstract
We previously selected and defined nine important post-operative morbidities linked to paediatric cardiac surgery, and prospectively measured their incidence following 3090 consecutive operations. Our aim was to study the impact of these morbidities on family functioning and parental quality of life over 6 months in a subset of cases. As part of a prospective case matched study in five of the ten children's cardiac centers in the UK, we compared outcomes for parents of children who had a 'single morbidity', 'multiple morbidities', 'extracorporeal life support (ECLS)' or 'no morbidity'. Outcomes were evaluated using the PedsQL Family impact module (FIM) at 6 weeks and 6 months post-surgery. Outcomes were modelled using mixed effects regression, with adjustment for case mix and clustering within centers. We recruited 340 patients with morbidity (60% of eligible patients) and 326 with no morbidity over 21 months. In comparison to the reference group of 'no morbidity', after adjustment for case mix, at 6 weeks parent health-related quality of life (HRQoL) and total FIM sores were lower (worse) only for ECLS (p < 0.005), although a higher proportion of parents in both the ECLS and multi-morbidity groups had low/very low scores (p < .05). At 6 months, parent outcomes had improved for all groups but parent HRQoL and total score for ECLS remained lower than the 'no morbidity' group (p < .05) and a higher proportion of families had low or very low scores in the ECLS (70%) group (p < .01). Post-operative morbidities impact parent HRQoL and aspects of family functioning early after surgery, with this impact lessening by 6 months. Families of children who experience post-operative morbidities should be offered timely psychological support.
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Affiliation(s)
- Jo Wray
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK.
| | - Deborah Ridout
- Population, Policy and Practice Programme and NIHR GOSH BRC, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Alison Jones
- Department of Intensive Care and Paediatric Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Peter Davis
- Paediatric Intensive Care Unit and Department of Paediatric Cardiac Surgery, Bristol Royal Children's Hospital, Bristol, UK
| | - Paul Wellman
- Department of Paediatric Cardiology and Cardiac Surgery, Evelina Children's Hospital, London, UK
| | - Warren Rodrigues
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - Emma Hudson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Victor Tsang
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Katherine L Brown
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
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Brown KL, Moinuddin M, Jones A, Sheehan K, Wellman P, Rodrigues W, Ridout D, Wray J. The Relationship Between Postoperative Complications and Children's Quality of Life: A Mediation Analysis to Explore the Role of Family Factors. Pediatr Crit Care Med 2023; 24:194-203. [PMID: 36728705 DOI: 10.1097/pcc.0000000000003137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To explore whether postoperative morbidities after pediatric cardiac surgery affected children's health-related quality of life (HRQOL) at 6 months, through potentially modifiable parental psychological factors. DESIGN We undertook a mediation analysis, to explore the causal pathway, based on data from a prospective, case-matched cohort study. PATIENTS Six hundred sixty-six children undergoing cardiac surgery. SETTING Five centers in the United Kingdom. INTERVENTIONS No intervention. MEASUREMENTS AND MAIN RESULTS Cases of morbidity were identified early after pediatric cardiac surgery, and matched controls with no morbidities were identified at discharge. Four mediators were assessed at 6 weeks after surgery, using the PedsQL Family Impact Module (Parent HRQOL and Family Function) and the PHQ-4 (Anxiety and Depression). The study outcome of child HRQOL was assessed at 6 months with the PedsQL. Of 666 children, 408 (65% of those surviving) contributed to the primary outcome. Children who had extracorporeal life support (ECLS) ( n = 11) ( p < 0.05) and multiple morbidities ( n = 62) ( p < 0.01) had worse 6-month HRQOL than those with a single morbidity ( n = 125) or no morbidity ( n = 209). After adjustment for case mix complexity and sociodemographic variables, there were significant indirect effects of parent HRQOL at 6 weeks, on the PedsQL Total Score (ECLS, -5.1 [-8.4 to -1.8]; p = 0.003; multiple morbidities, -2.1 [-3.7 to -0.5]; p = 0.01), PedsQL Physical Score (ECLS, -5.1 [-8.7 to -1.4]; p = 0.007; multiple morbidities, -2.1 [-3.8 to -0.4]; p = 0.016), and PedsQL Psychosocial Score (ECLS: -5.3 [-8.7 to -1.8); p = 0.003; multiple morbidities, -2.2 [-3.9 to -0.5]; p = 0.01). The proportion of the total effect of ECLS and multiple morbidity on the study outcomes mediated through parent HRQOL ranges between 18% and 61%. There was no evidence that the other three mediators had indirect effects on the study outcome. CONCLUSIONS Parental HRQOL at 6 weeks after surgery contributes to child HRQOL at 6 months, among those with the severest types of morbidity, and as such should be a target for future interventions.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Mohammed Moinuddin
- Population, Policy and Practice Programme and NIHR GOSH BRC, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Department of Intensive Care and Paediatric Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Alison Jones
- Paediatric Intensive Care Unit, Department of Paediatric Cardiac Surgery, Bristol Royal Children's Hospital, Bristol, United Kingdom
| | - Karen Sheehan
- Department of Paediatric Intensive Care, Evelina Children's Hospital, London, United Kingdom
| | - Paul Wellman
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Warren Rodrigues
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Deborah Ridout
- Population, Policy and Practice Programme and NIHR GOSH BRC, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jo Wray
- Heart and Lung Division and NIHR GOSH BRC, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
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Read J, Ridout D, Johnson S, Hoskote A, Sheehan K, Wellman P, Jones A, Wray J, Brown K. Postoperative morbidities with infant cardiac surgery and toddlers' neurodevelopment. Arch Dis Child 2022; 107:922-928. [PMID: 35793944 DOI: 10.1136/archdischild-2021-322756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the relationship between morbidities after infant cardiac surgery and neurodevelopment and behaviour at age 2-3 years. DESIGN/SETTING A prospective cohort follow-up study, in four paediatric cardiac centres. We excluded children with known syndromes. Home-based neurodevelopmental assessments using the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) were undertaken in 81 children and secondary outcome measures of development and behaviour were completed by parents. A further 41 families completed the secondary outcome measures remotely. RESULTS Children were grouped as multiple morbidities/extracorporeal life support (ECLS) (n=19), single morbidities (n=36) and no morbidities (n=59). Group comparisons found that children with multiple morbidities/ECLS, compared with no morbidities, had: (a) lower adjusted mean scores for core Bayley-III composites (none reached the level of statistical significance), with mean differences of cognitive -6.1 (95% CI -12.4 to 0.1) p=0.06, language -9.1 (95% CI -18.6 to 0.3) p=0.06 and motor -4.4 (95% CI -12.0 to 3.1) p=25; (b) greater adjusted odds of at least one low or borderline Bayley-III composite result 4.0 (95% CI 1.0 to 16.0) (p=0.05); (c) greater adjusted risk of an abnormal Ages and Stages Questionnaire (ASQ) result 5.3 (95% CI 1.3 to 21.1) (p=0.03) and a borderline ASQ result 4.9 (95% CI 1.0 to 25.0) (p=0.05); and no difference in the risk of an abnormal Strengths and Difficulties Questionnaire result 1.7 (95% CI 0.3 to 10.4) p=0.58. These outcomes were not statistically different between the single morbidity and no morbidity groups. CONCLUSIONS Children who experience multiple morbidities/ECLS after infant heart surgery are at a greater risk of neurodevelopmental difficulties than their peers who had no complications and should be prioritised for neurodevelopmental follow-up.
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Affiliation(s)
- Julie Read
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Deborah Ridout
- Paediatric Epidemiology Biostatistics, University College London Institute of Child Health, London, UK
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
| | - Karen Sheehan
- Department of Paediatric Cardiology, Bristol Royal Children's Hospital, Bristol, UK
| | - Paul Wellman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Alison Jones
- Department of Paediatric Intensive Care, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Katherine Brown
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
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Nanji KC, Garabedian PM, Shaikh SD, Langlieb ME, Boxwala A, Gordon WJ, Bates DW. Development of a Perioperative Medication-Related Clinical Decision Support Tool to Prevent Medication Errors: An Analysis of User Feedback. Appl Clin Inform 2021; 12:984-995. [PMID: 34820790 DOI: 10.1055/s-0041-1736339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Medication use in the perioperative setting presents many patient safety challenges that may be improved with electronic clinical decision support (CDS). The objective of this paper is to describe the development and analysis of user feedback for a robust, real-time medication-related CDS application designed to provide patient-specific dosing information and alerts to warn of medication errors in the operating room (OR). METHODS We designed a novel perioperative medication-related CDS application in four phases: (1) identification of need, (2) alert algorithm development, (3) system design, and (4) user interface design. We conducted group and individual design feedback sessions with front-line clinician leaders and subject matter experts to gather feedback about user requirements for alert content and system usability. Participants were clinicians who provide anesthesia (attending anesthesiologists, nurse anesthetists, and house staff), OR pharmacists, and nurses. RESULTS We performed two group and eight individual design feedback sessions, with a total of 35 participants. We identified 20 feedback themes, corresponding to 19 system changes. Key requirements for user acceptance were: Use hard stops only when necessary; provide as much information as feasible about the rationale behind alerts and patient/clinical context; and allow users to edit fields such as units, time, and baseline values (e.g., baseline blood pressure). CONCLUSION We incorporated user-centered design principles to build a perioperative medication-related CDS application that uses real-time patient data to provide patient-specific dosing information and alerts. Emphasis on early user involvement to elicit user requirements, workflow considerations, and preferences during application development can result in time and money efficiencies and a safer and more usable system.
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Affiliation(s)
- Karen C Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States.,Department of Anaesthesiology, Harvard Medical School, Boston, Massachusetts, United States.,Mass General Brigham, Inc., Boston, Massachusetts, United States
| | | | - Sofia D Shaikh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Marin E Langlieb
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Aziz Boxwala
- Elimu Informatics, Inc., La Jolla, California, United States
| | - William J Gordon
- Mass General Brigham, Inc., Boston, Massachusetts, United States.,Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - David W Bates
- Mass General Brigham, Inc., Boston, Massachusetts, United States.,Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Dorobantu DM, Ridout D, Brown KL, Rodrigues W, Sharabiani MTA, Pagel C, Anderson D, Wellman P, McLean A, Cassidy J, Barron DJ, Tsang VT, Stoica SC. Factors associated with unplanned reinterventions and their relation to early mortality after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2020; 161:1155-1166.e9. [PMID: 33419533 DOI: 10.1016/j.jtcvs.2020.10.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 10/25/2020] [Accepted: 10/25/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Unplanned reintervention (uRE) is used as an indicator of patient morbidity and quality of care in pediatric cardiac surgery. We investigated associated factors and early mortality after uREs. METHODS Morbidity data were prospectively collected in 5 UK centers between 2015 and 2017; uRE included surgical cardiac, interventional transcatheter cardiac, permanent pacemaker, and diaphragm plication procedures. Mortality (30-day and 6-month) in uRE/no-uRE patients was reported before and after matching. Predicted 30-day mortality was calculated using the Partial Risk Adjustment in Surgery score. RESULTS A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 146 uREs, resulting in an uRE rate of 4.7%. Partial Risk Adjustment in Surgery score, 30-day mortality and 6-month mortality in uRE and no-uRE groups were 2.4% versus 1.3%, 8.9% versus 1%, and 17.1% versus 2.4%, respectively. After matching, mortality at 6 months remained higher in uRE compared with no-uRE (12.2% vs 1.4%; P = .02; 74 pairs). In the uRE group, 21 out of 25 deaths at 6 months occurred when at least 1 additional postoperative complication was present. In multivariable analysis, neonatal age (P = .002), low weight (P = .009), univentricular heart (P < .001), and arterial shunt (P < .001) were associated with increased risk of uRE, but Partial Risk Adjustment in Surgery score was not (only in univariable analysis). CONCLUSIONS uREs are a relatively frequent complication after pediatric cardiac surgery and are associated with some patient characteristics, but not the Partial Risk Adjustment in Surgery risk score. Early mortality was higher after uRE, independent of preoperative factors, but linked to other postoperative complications.
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Affiliation(s)
- Dan M Dorobantu
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom; Children's Health and Exercise Research Centre, University of Exeter, Exeter, United Kingdom
| | - Deborah Ridout
- Population, Policy, and Practice Programme, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Katherine L Brown
- Cardiac and Critical Care Division, Great Ormond Street Hospital, London, United Kingdom
| | - Warren Rodrigues
- Cardiac and Critical Care Division, Great Ormond Street Hospital, London, United Kingdom
| | - Mansour T A Sharabiani
- Department of Primary Care & Public Health, School of Public Health, Imperial College of London, London, United Kingdom
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, United Kingdom
| | - David Anderson
- Departments of Paediatric Cardiology, Intensive Care, and Cardiac Surgery, Evelina London Children's Hospital, London, United Kingdom
| | - Paul Wellman
- Departments of Paediatric Cardiology, Intensive Care, and Cardiac Surgery, Evelina London Children's Hospital, London, United Kingdom
| | - Andrew McLean
- Department of Paediatric Cardiac Surgery, Royal Hospital for Children Glasgow, Glasgow, United Kingdom
| | - Jane Cassidy
- Department of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - David J Barron
- Division of Cardiovascular Surgery, Toronto Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Victor T Tsang
- Cardiac and Critical Care Division, Great Ormond Street Hospital, London, United Kingdom
| | - Serban C Stoica
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom; Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, United Kingdom.
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Morbidities After Cardiac Surgery: Impact on Children's Quality of Life and Parents' Mental Health. Ann Thorac Surg 2020; 112:2055-2062. [PMID: 33253670 PMCID: PMC8647554 DOI: 10.1016/j.athoracsur.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022]
Abstract
Background Most children now survive cardiac surgery, and the focus of quality improvement initiatives has shifted toward more complex outcome measures. The aim of this investigation was to study the impact of early postoperative morbidities on parent-reported patient quality of life and parental anxiety or depression over 6 months. Methods This prospective case-matched cohort study was conducted in 5 UK children’s cardiac centers. Measures of impact for patient categories of “single morbidity,” “multiple morbidities,” and “extracorporeal life support (ECLS)” were compared with “no morbidity.” The measures used were the Pediatric Quality of Life Inventory (PedsQL) and the 4-item Patient Health Questionnaire (PHQ-4) at 6 weeks and 6 months postoperatively. The study modeled the outcomes using mixed effects regression, adjusting for case mix and clustering within centers. Results The study included 666 patients who underwent operation at a median age of 81 days (interquartile range, 10 to 325 days). At 6-week follow-up, significant adjusted differences to the reference group with no morbidity were found for total PedsQL scores, which were lower in patients with ECLS (P = .01), multiple morbidities (P < .001), and a single morbidity (P = .04), as well as the proportion of parents with anxiety and depression, which were higher in the group with multiple morbidities (P = .04 and P = .01, respectively). At 6 months, measures had improved in all morbidity groups. The only significant adjusted difference in the reference group was for physical PedsQL scores in ECLS (P = .04) and multiple morbidities (P < .01). Conclusions Patient and parent well-being are strongly influenced by postoperative morbidities early after surgery, with improvement by 6 months. Family psychological support and holistic rehabilitation are vital for children who experience postoperative morbidities.
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Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
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Nanji KC, Merry AF, Shaikh SD, Pagel C, Deng H, Wahr JA, Gelb AW, Orser BA. Global PRoMiSe (Perioperative Recommendations for Medication Safety): protocol for a mixed-methods study. BMJ Open 2020; 10:e038313. [PMID: 32606066 PMCID: PMC7328805 DOI: 10.1136/bmjopen-2020-038313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Medication errors (MEs), which occur commonly in the perioperative period, have the potential to cause patient harm or death. Many published recommendations exist for preventing perioperative MEs; however, many of these recommendations conflict and are often not applicable to middle-income and low-income countries. The goal of this study is to develop and disseminate consensus-based recommendations for perioperative medication safety that are tailored to country income level. METHODS AND ANALYSIS The primary site of this mixed-methods study is Massachusetts General Hospital/Harvard Medical School. Participants include a minimum of 108 international medication safety experts, 27 from each of the World Bank's four country income groups (high, upper-middle, lower-middle and low-income). Using the Delphi method, participants will rate the appropriateness of candidate medication safety recommendations by completing online surveys using RedCAP. We will use Condorcet ranking methods to prioritise the final recommendations for each country income group. We will execute a comprehensive dissemination strategy for the recommendations across each country income group. Finally, we will conduct semistructured interviews with our participants to evaluate the initial adoption and implementation of the recommendations in each country income group. ETHICS AND DISSEMINATION This study was approved by the Human Research Committee/Institutional Review Board at Partners Healthcare (2019P003567). Findings will be published in peer-reviewed journals and presented at local and international conferences. TRIAL REGISTRATION NUMBER NCT04240301.
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Affiliation(s)
- Karen C Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaestheisa, Harvard Medical School, Boston, Massachusetts, USA
| | - Alan Forbes Merry
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Sofia D Shaikh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joyce A Wahr
- Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Adrian W Gelb
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Beverley A Orser
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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9
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Hoskote A, Wray J, Banks V, Brown K, Lakhanpaul M. A referral pathway for potentially abnormal neurodevelopment in children with heart disease in the United Kingdom: a Delphi consensus. BMJ Paediatr Open 2020; 4:e000587. [PMID: 32399503 PMCID: PMC7204815 DOI: 10.1136/bmjpo-2019-000587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/22/2020] [Accepted: 01/30/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Children with congenital heart disease have complex medical and neurodevelopmental needs. We aimed to develop a multi-professional consensus-based referral pathway applicable to action the results of the brief developmental assessment (BDA), a validated early recognition tool, that categorises the neurodevelopmental status as green (appropriate for age), amber (equivocal) or red (delayed) in children aged between 4 months and 5 years. METHODS A Delphi consensus survey detailing two scenarios-a child categorised as delayed (red) and another as equivocal (amber) on administration of the BDA at the time of discharge from the tertiary centre-was sent to 80 expert professionals from primary, secondary and tertiary care seeking agreement on next steps and referral pathways. An iterative process was proposed with a pre-defined rule of 75% for consensus. RESULTS The survey was completed by 77 Delphi panel experts in Round 1, 73 in Round 2 and 70 in Round 3. Consensus was achieved (1) for the child with amber or red BDA, the child should be under the care of a paediatrician with expertise in cardiology (PEC) (or general paediatrician if no PEC) based at their local hospital, (2) for the child with red BDA, the PEC should initiate referral to community services at first assessment, (3) for child with amber BDA, a re-assessment by the health visitor should occur within 1-2 months, with referral to community services and notification to the PEC if on-going concerns. CONCLUSIONS The Delphi process enabled a consensus to be reached between health professionals on referral pathways for specialist neurodevelopmental assessment/treatment for children with heart disease, in response to amber or red BDA results. The agreed referral pathway, if implemented, could underpin a national guideline to address and intervene on the neurodevelopmental difficulties in children with heart disease.
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Affiliation(s)
- Aparna Hoskote
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Victoria Banks
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Katherine Brown
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Monica Lakhanpaul
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Whittington Health NHS Trust, London, UK
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10
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Abstract
Short-term survival after paediatric cardiac surgery has improved significantly over the past 20 years and increasing attention is being given to measuring and reducing incidence of morbidities following surgery. How to best use routinely collected data to share morbidity information constitutes a challenge for clinical teams interested in analysing their outcomes for quality improvement. We aimed to develop a tool facilitating this process in the context of monitoring morbidities following paediatric cardiac surgery, as part of a prospective multi-centre research study in the United Kingdom.We developed a prototype software tool to analyse and present data about morbidities associated with cardiac surgery in children. We used an iterative process, involving engagement with potential users, tool design and implementation, and feedback collection. Graphical data displays were based on the use of icons and graphs designed in collaboration with clinicians.Our tool enables automatic creation of graphical summaries, displayed as a Microsoft PowerPoint presentation, from a spreadsheet containing patient-level data about specified cardiac surgery morbidities. Data summaries include numbers/percentages of cases with morbidities reported, co-occurrences of different morbidities, and time series of each complication over a time window.Our work was characterised by a very high level of interaction with potential users of the tool, enabling us to promptly account for feedback and suggestions from clinicians and data managers. The United Kingdom centres involved in the project received the tool positively, and several expressed their interest in using it as part of their routine practice.
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11
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Rajagopal V, Brown K, Pagel C, Wray J. Parental understanding of our communication of morbidity associated with paediatric cardiac surgery: a qualitative study. BMJ Paediatr Open 2020; 4:e000578. [PMID: 32154385 PMCID: PMC7047488 DOI: 10.1136/bmjpo-2019-000578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/11/2020] [Accepted: 01/22/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Following paediatric cardiac surgery, quality of life may be significantly impacted by morbidities associated with cardiac surgery. Parental understanding of the potential for postoperative morbidity is important for informed decision making. As part of a broader research study, we aimed to elicit parental understanding and experience of the communication of morbidities following their child's cardiac surgery, using traditional focus groups together with an online forum. METHODS The Children's Heart Federation set up and moderated a closed, anonymous online discussion group via their Facebook page, focusing on complications, information needs and methods of providing families with information. Additionally, we ran three focus groups with parents/carers, moderated by an experienced independent professional. Focus groups were recorded and transcribed and a single transcript was generated from the online forum. All transcripts were thematically analysed. RESULTS All data were collected in 2014. The forum ran over 3 months in 2014 and involved 72 participants. Focus groups involved 13 participants. Three broad themes were identified: (1) clinicians' use of language, (2) feeling unprepared for complications and (3) information needs of families. CONCLUSIONS Clinicians' language is often misunderstood, with wide variability in the way morbidities are described, and between differing teams looking after the same child. Information may not be easily absorbed or retained by families, who often felt unprepared for morbidities that arose after their child's heart surgery. Here, we propose key principles of good communication tailored to the individual receiving it.
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Affiliation(s)
- Veena Rajagopal
- Heart and Lung, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Katherine Brown
- Heart and Lung, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Christina Pagel
- Heart and Lung, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,Clinical Operational Research Unit, University College London, London, UK
| | - Jo Wray
- Heart and Lung, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
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Brown KL, Ridout D, Pagel C, Wray J, Anderson D, Barron DJ, Cassidy J, Davis PJ, Rodrigues W, Stoica S, Tibby S, Utley M, Tsang VT. Incidence and risk factors for important early morbidities associated with pediatric cardiac surgery in a UK population. J Thorac Cardiovasc Surg 2019; 158:1185-1196.e7. [DOI: 10.1016/j.jtcvs.2019.03.139] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 11/29/2022]
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13
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Brown KL, Pagel C, Ridout D, Wray J, Anderson D, Barron DJ, Cassidy J, Davis P, Hudson E, Jones A, Mclean A, Morris S, Rodrigues W, Sheehan K, Stoica S, Tibby SM, Witter T, Tsang VT. What are the important morbidities associated with paediatric cardiac surgery? A mixed methods study. BMJ Open 2019; 9:e028533. [PMID: 31501104 PMCID: PMC6738689 DOI: 10.1136/bmjopen-2018-028533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Given the current excellent early mortality rates for paediatric cardiac surgery, stakeholders believe that this important safety outcome should be supplemented by a wider range of measures. Our objectives were to prospectively measure the incidence of morbidities following paediatric cardiac surgery and to evaluate their clinical and health-economic impact over 6 months. DESIGN The design was a prospective, multicentre, multidisciplinary mixed methods study. SETTING The setting was 5 of the 10 paediatric cardiac surgery centres in the UK with 21 months recruitment. PARTICIPANTS Included were 3090 paediatric cardiac surgeries, of which 666 patients were recruited to an impact substudy. RESULTS Families and clinicians prioritised:Acute neurological event, unplanned re-intervention, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, postsurgical infection and prolonged pleural effusion or chylothorax.Among 3090 consecutive surgeries, there were 675 (21.8%) with at least one of these morbidities. Independent risk factors for morbidity included neonatal age, complex heart disease and prolonged cardiopulmonary bypass (p<0.001). Among patients with morbidity, 6-month survival was 88.2% (95% CI 85.4 to 90.6) compared with 99.3% (95% CI 98.9 to 99.6) with none of the morbidities (p<0.001). The impact substudy in 340 children with morbidity and 326 control children with no morbidity indicated that morbidity-related impairment in quality of life improved between 6 weeks and 6 months. When compared with children with no morbidities, those with morbidity experienced a median of 13 (95% CI 10.2 to 15.8, p<0.001) fewer days at home by 6 months, and an adjusted incremental cost of £21 292 (95% CI £17 694 to £32 423, p<0.001). CONCLUSIONS Evaluation of postoperative morbidity is more complicated than measuring early mortality. However, tracking morbidity after paediatric cardiac surgery over 6 months offers stakeholders important data that are of value to parents and will be useful in driving future quality improvement.
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Affiliation(s)
- Katherine L Brown
- Cardiorespiratory Division, Great Ormond Street Hospital for Children, London, UK
| | | | | | - Jo Wray
- Cardiorespiratory Division, Great Ormond Street Hospital for Children, London, UK
| | | | - David J Barron
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jane Cassidy
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Peter Davis
- Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
| | - Emma Hudson
- Health Economics, University College London, London, UK
| | - Alison Jones
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Andrew Mclean
- Congenital Heart Surgery, Royal Hospital for Children, Glasgow, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | | | | | - Serban Stoica
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Shane M Tibby
- Paediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | | | - Victor T Tsang
- Cardiorespiratory Division, Great Ormond Street Hospital for Children, London, UK
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Pagel C, Bull C, Utley M, Wray J, Barron DJ, Stoica S, Tibby SM, Tsang V, Brown KL. Exploring communication between parents and clinical teams following children's heart surgery: a survey in the UK. BMJ Paediatr Open 2019; 3:e000391. [PMID: 31206072 PMCID: PMC6542420 DOI: 10.1136/bmjpo-2018-000391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore communication between clinicians and families of children undergoing heart surgery. DESIGN This study was part of a larger study to select, define and measure the incidence of postoperative complications in children undergoing heart surgery. Parents of children recruited to a substudy between October 2015 and December 2017 were asked to complete a questionnaire about communication during their child's inpatient stay. We explored all responses and then disaggregated by the following patient characteristics: presence of a complication, length of stay, hospital site, ethnicity and child's age. This was a descriptive study only. SETTING Four UK specialist hospitals. RESULTS We recruited 585 children to the substudy with 385 responses (response rate 66%).81% of parents reported that new members of staff always introduced themselves (18% sometimes, 1% no). Almost all parents said they were encouraged to be involved in decision-making, but often only to some extent (59% 'yes, definitely'; 37% 'to some extent'). Almost two-thirds of parents said they were told different things by different people which left them feeling confused (10% 'a lot'; 53% 'sometimes'). Two-thirds (66%) reported that staff were definitely aware of their child's medical history (31% 'to some extent'). 90% said the operation was definitely explained to them (9% 'to some extent') and 79% that they were definitely told what to do if they were worried after discharge (17% 'to some extent').Parents of children with a complication tended to give less positive responses for involvement in decision-making, consistent communication and staff awareness of their child's medical history. Parents whose children had longer stays in hospital tended to report lower levels of consistent communication and involvement in decision-making. CONCLUSIONS Our results emphasise the need for consistent communication with families, particularly where complications arise or for children who have longer stays in the hospital.
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Affiliation(s)
- Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK.,Department of Paediatric Intensive Care, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Catherine Bull
- Department of Paediatric Intensive Care, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - David J Barron
- Department of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Serban Stoica
- Department of Intensive Care and Paediatric Cardiac Surgery, Bristol Children's Hospital, Bristol, UK
| | - Shane M Tibby
- Department Paediatric Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Victor Tsang
- Heart and Lung Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Development and preliminary testing of the Brief Developmental Assessment: an early recognition tool for children with heart disease. Cardiol Young 2018; 28:582-591. [PMID: 29433600 DOI: 10.1017/s1047951117002918] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Introduction Neurodevelopmental abnormalities are common in children with CHD and are the highest-priority concerns for parents and professionals following cardiac surgery in childhood. There is no additional routine monitoring of development for children with CHD in the United Kingdom; hence, neurodevelopmental concerns may be detected late, precluding early referral and intervention. METHODS An early recognition tool - the "Brief Developmental Assessment" - was developed using quality improvement methodology involving several iterations and rounds of pilot testing. Our requirements were for a tool covering important developmental domains and practicable for use within inpatient and outpatient settings by paediatric cardiac health professionals who are non-developmental specialists, without specialised equipment and which involved direct observation, as well as parental report. RESULTS Items were included in the tool based on existing developmental measures, covering the domains of gross and fine motor skills, daily living skills, communication, socialisation, and general understanding. Items were developed for five age bands - 0-16 weeks, 17-34 weeks, 35-60 weeks, 15 months-2.9 years, and 3-4.9 years - and the final versions included a traffic light scoring system for identifying children with possible delay in any or all domains. Preliminary testing indicated excellent inter-rater reliability, an ability to detect children with a diagnosis known to be associated with developmental delay, and largely acceptable internal reliability. CONCLUSION We report the evolution and preliminary testing of an early recognition tool for assessing the development of children with heart disease; this was encouraging and sufficiently good to support further validation in a larger study.
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