Changing practice patterns for children with heart disease: a clinical pathway approach

Clinical pathway for the Fontan patient to standardise care and improve outcomes

INTRODUCTION

The Fontan procedure is the final stage of surgical palliation for the children with functionally single ventricle anatomy. The post-operative medical management of this patient population can be variable and hospital length of stay prolonged. The purpose of this quality improvement project was to determine if the implementation of an evidence-based clinical pathway for post-operative management of the Fontan patient at a large Midwestern academic paediatric medical centre would standardise care and decrease length of stay.

MATERIALS AND METHODS

The clinical pathway was developed using key components from three published pathways for the Fontan procedure from other paediatric institutions across the United States. Components of the clinical pathway included (1) supplemental oxygen until pleural drainage tubes are removed, (2) fluid restriction to 80% daily maintenance and a prescribed low-fat diet, (3) aggressive and standardised diuretic therapy while inpatient and (4) central venous access. The pathway was trialed using Plan-Do-Study-Act cycles in 2016, implemented in 2017 and sustained in 2018-2019. A retrospective electronic medical record review was performed to compare key outcomes from pre-pathway (2014-2015, 37 patients) with post-pathway implementation (2017-2018, 30 patients).

RESULTS

Adherence to the pathway was nearly 100% with a statistically significant decrease in length of stay from 12 to 9 days (p = 0.007) and no increase in readmissions.

CONCLUSION

Standardising care can improve clinical and financial outcomes for the Fontan patient population without negatively impacting quality of care, thus providing a positive benefit to the healthcare institution, industry and patient.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery

Background:

With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery.

Methods:

The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data.

Results:

Decisions pertaining to “immediate implant-based breast reconstruction” were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection.

Conclusions:

Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.

Resource utilization after introduction of a standardized clinical assessment and management plan

INTRODUCTION

A Standardized Clinical Assessment and Management Plan (SCAMP) is a novel quality improvement initiative that standardizes the assessment and management of all patients who carry a predefined diagnosis. Based on periodic review of systemically collected data the SCAMP is designed to be modified to improve its own algorithm. One of the objectives of a SCAMP is to identify and reduce resource utilization and patient care costs.

METHODS

We retrospectively reviewed resource utilization in the first 93 arterial switch operation (ASO) SCAMP patients and 186 age-matched control ASO patients. We compared diagnostic and laboratory testing obtained at the initial SCAMP clinic visit and control patient visits. To evaluate the effect of the SCAMP over time, the number of clinic visits per patient year and echocardiograms per patient year in historical control ASO patients were compared to the projected rates for ASO SCAMP participants.

RESULTS

Cardiac magnetic resonance imaging (MRI), stress echocardiogram, and lipid profile utilization were higher in the initial SCAMP clinic visit group than in age-matched control patients. Total echocardiogram and lung scan usage were similar. Chest X-ray and exercise stress testing were obtained less in SCAMP patients. ASO SCAMP patients are projected to have 0.5 clinic visits and 0.5 echocardiograms per year. Historical control patients had more clinic visits (1.2 vs. 0.5 visits/patient year, P<.01) and a higher echocardiogram rate (0.92 vs. 0.5 echocardiograms/patient year, P<.01)

CONCLUSION

Implementation of a SCAMP may initially lead to increased resource utilization, but over time resource utilization is projected to decrease.

[Septic shock: from recommendations to bedside]

Management of septic shock requires complex and multiple diagnostic as well as therapeutic procedures in a limited time-frame. This issue is a major source of medical errors. The author presents a critical analysis of tools (guidelines, clinical path, algorithm, check-lists) to help physicians for the management of patients with septic shock.

Does preoperative mechanical ventilation affect outcomes in neonates undergoing cardiac surgery?

OBJECTIVE

To review, in retrospective fashion, the effect of preoperative mechanical ventilation on neonatal outcomes after cardiac surgery.

METHODS

We studied 114 newborns less than 15 days old admitted to the cardiac intensive care unit for cardiac surgery. Of the newborns, 71 (62%) were mechanically ventilated at the referring hospital before transport to our institution. Of the 71 ventilated patients, 14 were extubated and breathing spontaneously before cardiac surgery. We compared variable haemodynamics and outcomes between the 57 patients mechanically ventilated at time of cardiac surgery, and the 57 patients breathing spontaneously at this time.

RESULTS

Newborns mechanically ventilated before cardiac surgery had increased preoperative haemodynamic compromise, increased postoperative sepsis (p equal to 0.02) and mortality (p equal to 0.005) compared with those breathing spontaneously before cardiac surgery.

CONCLUSION

Newborns requiring preoperative mechanical ventilation had greater risk of postoperative morbidity and mortality. Heightened vigilance is warranted in this population of patients at high risk.

What's Happening in Paediatric Cardiology?

Recent decades have witnessed dramatic advances in the care of adults with heart disease. However, equally significant advances have occurred in the care of children. In this review we describe some of the advances, which have been made in the care of children with heart disease, focusing not only on technological advances, but also on developments in team-based care, which together have resulted in significant improvements in outcomes.

Virtues of a worldwide congenital heart surgery database

The rationale for a congenital heart surgery database lies in the organized manner in which information can be compiled to accomplish programmatic evaluation, monitor clinical outcomes, comply with governmental requirements, perform retrospective and prospective clinical studies, and participate in local, national, and global improvement strategies. The task of inaugurating an effective congenital heart surgery database has taken many years and involved concurrent development efforts at multiple sites. Two such efforts took place in North America with the Society of Thoracic Surgeons Congenital Heart Surgery Database, and in Europe with the European Congenital Heart Defects Database. These initial efforts provided the impetus for development of an international congenital heart surgery database that would allow scientific exchanges on an international scale and promote multi-institutional evaluation of congenital heart surgery. Sample outcome templates from the Society of Thoracic Surgeons and the European Association for Cardio-thoracic Surgery's accepted minimum database data set are reviewed for the specific diagnostic entry ventricular septal defect, to familiarize the reader with potential available data summaries and outcome analyses, including risk stratification, when data harvest is performed. In Europe, the agreed upon minimum data set are now collected as part of the Pediatric European Cardiac Surgical Registry, while in North America users of the CardioAccess database and users of the minimum data set downloaded from the Society of Thoracic Surgeons web site are being notified of plans for a 2002 data harvest incorporating the minimum database data set. It is likely that the extant voluntary, minimal data set congenital heart surgery database will be replaced by a mandated system required by states, provinces, and countries. Data collection schemes and data validation programs will become standardized, which will result in improved data quality and uniform congenital heart center participation. As participation with valid data approaches 100% of congenital heart centers, the power and importance of the database increases exponentially. Reliable information can be used to assess residency/fellowship programs, resource allocation, major therapeutic trends, manpower issues, and in the end, all initiatives that will require accurate information.

The economic impact of intermittent high-dose intravenous versus oral corticosteroid treatment of juvenile dermatomyositis

OBJECTIVE

To perform a cost-identification and cost-effectiveness analysis comparing oral corticosteroids (OCS) with high-dose intermittent intravenous corticosteroid (IVCS) regimens in the treatment of juvenile dermatomyositis (JDM).

METHODS

Children previously diagnosed and treated for JDM (without myositis-specific or myositis-associated autoantibodies) at a single medical center by a single provider were identified. Two treatment protocols were compared: OCS and IVCS. Data on initial disease severity, time to remission, resource use, and costs generated were collected from patient records. Incremental cost-effectiveness ratios (ICE) were constructed.

RESULTS

Patients treated with IVCS achieved median remission 2 years earlier at median increased cost of $13,736. The ICE ratio comparing IVCS to OCS is $6,868 per year of disease avoided.

CONCLUSION

This study suggests that, although IVCS treatments are costly, they are cost-effective.

The costs and outcomes of multifaceted interventions designed to improve the care of congestive heart failure in the inpatient setting: a review of the literature

Various multifaceted interventions have been developed in response to the overwhelming burden of congestive heart failure and its costs. These interventions range from improvements in the delivery of inpatient care (e.g., by assigning multidisciplinary teams to the care of a patient or ensuring that clinical practice guidelines are followed) to comprehensive discharge planning that includes home health care. While it is intuitive that such interventions improve care, few have been evaluated in randomized controlled trials and fewer still include data on costs. In this article, the authors review the findings of randomized controlled trials of interventions designed to improve the quality of life, decrease hospital admissions, and decrease costs associated with heart disease. They conclude that inpatient-based multifaceted interventions appear to be effective and inexpensive. Future studies should attempt to tease interventions apart to ascertain which are the most effective. Formal cost-effectiveness analyses are also needed.

Risk factors for long intensive care unit stay after cardiopulmonary bypass in children

OBJECTIVES

To determine whether children who experience longer intensive care unit (ICU) stays after open heart surgery may be identified at admission by clinical criteria. To identify factors associated with longer ICU stays that are potential targets for quality improvement.

SETTING

Tertiary pediatric cardiac surgical center.

DESIGN

A retrospective review was performed of pre-, intra-, and postoperative factors for children undergoing open heart surgery. All factors were evaluated for strength of association with length of ICU stay (LOS) using a negative binomial model. After multiple analysis, factors were deemed significant if associated with a LOS with p < .02.

PATIENTS

A total of 355 pediatric patients who had cardiac surgery with cardiopulmonary bypass in a 1-yr period from April 1999 until March 2000.

MEASUREMENTS AND MAIN RESULTS

Children who fell above the 95th percentile for LOS in our institution occupied 30% of bed days and had a three-fold greater mortality. Of all clinical factors considered, those significantly associated with LOS were as follows: preoperative--mechanical ventilation, neonatal status, medical problems, and transfer from abroad; intraoperative--higher operative complexity, increased cardiopulmonary bypass time or ischemic time, and circulatory arrest; and postoperative--delayed sternal closure, sepsis, renal failure, pulmonary hypertension, chylothorax, diaphragm paresis, and arrhythmia. A model combining all factors identified preoperative mechanical ventilation, neonatal status, major medical problems, operative complexity, cardiopulmonary bypass time, and a postoperative complication score as independently associated with LOS (p < .01).

CONCLUSIONS

At the time of ICU admission after open heart surgery, clinical criteria are evident that highlight a child's risk of longer ICU stay. These pre- and intraoperative factors relate to LOS independent of subsequent postoperative events. Those postoperative complications that are most strongly associated with increased LOS are identified and, therefore, made accessible to quality control.

Risk factors prolonging ventilation in young children after cardiac surgery: Impact of noninfectious pulmonary complications

OBJECTIVE: To determine risk factors for prolonged ventilation after cardiac surgery in young children and assess the impact of noninfectious pulmonary complications on ventilatory duration. DESIGN: Retrospective case series analysis. SETTING: A tertiary pediatric cardiac center. PATIENTS: Clinical records of 222 consecutive children aged </=3 yrs undergoing cardiac surgery for congenital heart disease were reviewed. Fifteen patients, consisting of six premature babies and nine who died within 72 hrs of surgery, were excluded. MEASUREMENTS AND MAIN RESULTS: The demographic data, preoperative risk factors, surgical procedures performed, intraoperative variables, and postoperative complications of the remaining 207 children were reviewed. Univariate analysis was performed to compare patients who required prolonged ventilation (>72 hrs) to those who could be extubated at </=72 hrs, and multivariate analyses were performed to identify significant determinants on ventilatory duration and impact of noninfectious complications. Of the 182 patients undergoing open heart surgery, 45 (25%) required prolonged ventilation for a median of 8 days. The latter were significantly younger in age and lighter in weight and were more likely to have Down syndrome, preoperative pulmonary hypertension and ventilatory support, undergone more complex surgery requiring longer bypass and circulatory arrest time, postoperative cardiovascular and pulmonary complications, and extubation failure (all p values <.01). Of the 25 patients who had closed heart surgery, five (20%) required prolonged ventilation for a median of 14 days. The latter were more likely to require preoperative ventilation, have undergone more complex surgery, had postoperative cardiovascular and pulmonary complications, and had extubation failure (all p values <.05). Cox proportional hazard regression identified body weight (p <.001), Down syndrome (p =.02), need for preoperative ventilation (p <.001), complexity of surgery (p <.001), cardiovascular complications (p <.001), and infective (p <.001) and noninfective (p <.001) pulmonary complications to be significant factors that determined the ventilatory duration. Noninfectious pulmonary complications occurred in 31.9% (58/182) and 20% (5/25) of patients after open and closed heart surgery, respectively. In the absence of other risk factors, the median time to extubation was similar between patients with and without noninfectious complications (1 vs. 0.8 day). However, in the presence of other risk factors, noninfectious pulmonary complications prolonged the median time to extubation from 8 to 18 days. Logistic regression identified Down syndrome (p =.005), preoperative ventilation (p =.001), complexity of surgery (p =.006), and bypass time (p =.005) as risk factors for development of noninfectious pulmonary complications. CONCLUSIONS: Noninfectious pulmonary complications that occurred commonly after cardiac surgery in young children prolong ventilatory duration only in the presence of other risk factors, with which it acts in a synergistic fashion.

Heart disease in children

Advances in the understanding of the pathophysiology, diagnosis, and medical and surgical management of neonates with cardiovascular disease has led to their improved survival rates. These improvements have resulted in an increased number of pediatric patients presenting to the primary care physician's office with underlying heart disease. Understanding the genetic, congenital, or acquired etiologies to the various pediatric heart diseases is crucial to preventing these lesions and treating these patients.