Quality Improvement Project in Congenital Cardiothoracic Surgery Patients: Reducing Surgical Site Infections.

BACKGROUND: Healthcare-associated infections are a major focus for quality improvement in hospitals today. Surgical site infections (SSIs), a postoperative complication in cardiac surgery, are associated with increased morbidity, mortality, hospital length of stay, and financial burden. METHODS: A recent increase in cardiothoracic surgery SSIs (CT-SSIs) at our institution instigated a multidisciplinary team to explore infection prevention, bundle element compliance, and to identify interventions to reduce the CT-SSI rate. Key interventions included preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus with repeated intranasal applications of mupirocin, universal skin prep with chlorhexidine for all patients, and additional antibiotic dosing upon initiating cardiopulmonary bypass. RESULTS: In 2014, the CT-SSI rate at our institution was 1.9/100 cases, which increased during the "intervention period" to 3.6 infections/100 cases in 2015 (16 total infections). Postinterventions, the CT-SSI rate decreased to 0.3 infections/100 cases (2 total infections), which was significantly lower than our baseline before the spike in infection rate. CONCLUSIONS: A comprehensive interdisciplinary approach with multiple interventions was successful in significantly reducing the CT-SSI rate in cardiothoracic surgery at a tertiary care pediatric hospital.

There's an App for That; Improving Communication during Pediatric Cardiothoracic Surgery.

INTRODUCTION: Waiting while a loved one is in surgery can be a very stressful time. Current processes for updating families vary from institution to institution. Providing timely and relevant updates, while important to the family, may strain a surgical team's operational system. In our initial experience with the Electronic Access for Surgical Events (EASE) application (app), we tested the extent to which its implementation improved communication with patient families. METHODS: We compared compliance data collected pre-EASE (December 2013 through September 2014) and post-EASE implementation (October 2014 until December 2015). RESULTS: Although the pre-EASE compliance rate for bi-hourly updates was 46% (118/255) of cases, post-EASE implementation achieved a compliance rate of 97% (171/176). A 2-sample test of proportions confirmed a significant improvement in compliance after the introduction of EASE technology (P < 0.001). Analysis of the 177 noncompliant cases in the pre-EASE period indicated that noncompliance occurred most frequently at the end of the case (97/177, 55%) when the patient remained in the operating room > 2 hours after the last update to the family. We also observed noncompliance at the beginning of the case (46/177, 26%), when the patient arrived in the operating room > 2 hours before the time of the first update. Family satisfaction scores that rated their experience during surgery as "Very Good" improved from 80% pre-EASE implementation to 97% postimplementation. We sustained this improvement for 1 year. CONCLUSIONS: A mobile technology app (EASE) improved both frequency and compliance with surgical updates to families, which resulted in a statistically significant increase in family satisfaction scores.

Acquired Cardiac Disease in the Pediatric Intensive Care Unit.

This review focuses on the identification, evaluation, management, and stabilization of a variety of acquired cardiac conditions, such as cardiomyopathies, inflammatory cardiac disease, and Kawasaki disease, which commonly require care in the pediatric intensive care unit (PICU). Pediatric cardiomyopathies comprise a spectrum of acquired or congenital myocardial diseases in which there are abnormalities of cardiac size and ventricular wall thickness, along with ventricular performance. The inflammatory diseases of the heart include acute myocarditis and pericarditis. Cardiac sequelae of Kawasaki disease resemble a self-limited vasculitis, but in rare instances may present with hemodynamic instability requiring vasopressor support. Care in the PICU affords both monitoring and management opportunities. [Pediatr Ann. 2018;47(7):e280-e285.].

Interstage Survival for Patients with Hypoplastic Left Heart Syndrome After ECMO.

There is a reported 5-20 % incidence of extracorporeal membrane oxygenation (ECMO) following stage I palliation for hypoplastic left heart syndrome (HLHS). This study compares the interstage mortality of HLHS patients supported with ECMO (HLHS-ECMO) to those who were not supported with ECMO (HLHS-nECMO) using the National Pediatric Cardiology Quality Improvement Initiative database. Patients with HLHS who survived to hospital discharge after stage I palliation were analyzed. HLHS-ECMO patients were compared to HLHS-non-ECMO patients with respect to demographics, surgical variables, and interstage survival. A total of 931 patients were identified in the database. Sixty-six (7.1 %) patients were supported with ECMO during their stage I palliation admission. There were no statistically significant differences between the groups with respect to demographics or anatomic subtype. HLHS-ECMO patients were more likely to have a preoperative risk factor identified (62 vs. 48 %, p = 0.03) or require ECMO prior to stage I palliation (3 vs. 0.5 %, p = 0.03). HLHS-ECMO patients had a significantly higher incidence of death or transplant versus the HLHS-nECMO group (18 vs. 9 %, p = 0.03). Despite survival to discharge, patients with HLHS requiring ECMO after their palliation continue to have an increased risk of death/cardiac transplant versus patients that do not require ECMO. ECMO use is likely a marker for a high-risk patient group. These patients may benefit from closer follow-up during the interstage period.

Multidisciplinary Review of Code Events in a Heart Center.

OBJECTIVE: To identify a cause for clinical deterioration, examine resuscitation efforts, and identify and correct system issues (thus improving outcomes) via a multidisciplinary code-review process soon after cardiopulmonary arrest. METHODS: Retrospective analysis of code events in a tertiary pediatric heart center from September 2010 to December 2013 and review of surgical-cardiac data from January 2010 to December 2013. RESULTS: A multidisciplinary team reviewed 47 code events, 16 of which (34%) were deemed potentially preventable. At least 2 issues were identified during 66% (31/47) of cardiopulmonary arrests reviewed. Key issues identified were related to communication (62%), environment/culture/policy (47%), patient care (including resuscitation, 41%), and equipment (38%). About 60% of reviewed arrests resulted in educational initiatives (eg, mock code, in-service education) and 47% resulted in a new policy or modification of existing policy. Less common were changes in equipment (32%) or modification of staffing needs (11%). Changes most frequently occurred in the unit specific to the event (68%) but some changes occurred throughout the Heart Center (32%) or across the hospital system (13%). Survival to discharge after cardiopulmonary arrest has improved over time (P = .03) to 81% for cardiac surgical patients in our center. CONCLUSION: A multidisciplinary code-review committee can identify deficiencies and lead to educational initiatives and improvements in care. When coupled with a hospital-wide "code blue" review process, these changes may benefit the institution as a whole.

Influence of graft ischemic time and geographic distance between donor and recipient on survival in children after lung transplantation.

BACKGROUND: The optimal ischemic time in pediatric lung transplantation (LTx) is unclear, as recent studies have challenged the relevance of 6 hours as an upper limit to acceptable ischemic time. METHODS: Pediatric LTx recipients transplanted between 1987 and 2013 were identified in the United Network for Organ Sharing (UNOS) registry to compare survival according to ischemic time, which was categorized as <4 hours, 4 to 6 hours and >6 hours. RESULTS: Nine hundred thirty patients, all <18 years of age and receiving a first-time LTx from a cadaveric donor, were included in our investigation. Compared with <4 hours of ischemic time, univariate analysis showed a significant reduction in mortality hazard with 4 to 6 hours (hazard ratio [HR] = 0.640; 95% confidence interval [CI] 0.502 to 0.816; p < 0.001) but not >6 hours (HR = 0.985; 95% CI 0.755 to 1.284; p = 0.909). A multivariate Cox model confirmed the lowest mortality hazard to be 4 to 6 hours, as compared with <4 hours (HR = 0.533; 95% CI 0.376 to 0.755; p < 0.001). A prolonged ischemic time of >6 hours was associated with increased mortality hazard relative to the 4 to 6 hours (HR = 1.613; 95% CI 1.193 to 2.181; p = 0.002). Supplementary analyses examining geographic distance between donor and recipient identified no association between geographic distance and recipient mortality hazard. CONCLUSIONS: An ischemic time of 4 to 6 hours was associated with optimal long-term survival in first-time pediatric LTx recipients, whereas a very short ischemic time of <4 hours and a prolonged ischemic time >6 hours were both associated with higher mortality hazard in this population.

ECMO: Incidence and Outcomes of Patients Undergoing the Hybrid Procedure.

OBJECTIVE: To document the extracorporeal membrane oxygenation (ECMO) incidence and outcome in patients undergoing the hybrid procedure at an institution that routinely performs this procedure. DESIGN: A retrospective chart review on all patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. Patients were excluded if they underwent the hybrid procedure after 60 days of birth or subsequently underwent a biventricular repair. SETTING: A single center, tertiary pediatric hospital. PATIENTS: One hundred eighty-one patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied a total of 181 patients (105 males: 76 females). Gestational age was 37.8 ± 2.0 weeks and birth weight was 3.0 ± 0.7 kg. Underlying diagnosis was hypoplastic left heart syndrome in 149 patients and other in 32 patients. Age at surgery was 7.8 ± 6.8 days and weight at surgery was 3.1 ± 0.6 kg. Two patients underwent ECMO support after the hybrid procedure. One patient had aortic atresia/mitral atresia and weighed 2.3 kg and the other patient had aortic atresia/mitral stenosis and weighed 2.1 kg at time of surgery. Both patients died. Incidence of ECMO support after hybrid procedure was 1.3% (2/149) for the hypoplastic left heart syndrome patients and 1.1% (2/181) for the entire cohort. CONCLUSION: Mortality in patients who underwent ECMO after the hybrid procedure was higher than reported for the Norwood procedure, however, the incidence of ECMO after hybrid procedure was also significantly lower than reported for the Norwood procedure. Future studies are needed to determine how to improve outcomes in this complex patient population.

Eosinophilic esophagitis in children following cardiac transplantation: association with post-transplant lymphoproliferative disorder and other transplant outcomes.

Although cardiac transplantation is life-saving, morbidities from immunosuppression are significant. EoE is a complication of calcineurin inhibitors following liver transplant causing feeding intolerance, weight loss, vomiting, and dysphagia. There are limited reports of EoE following heart transplantation. We performed a retrospective single-center review of pediatric cardiac transplant patients from 2000 to 2010. A case-control analysis of patients with and without EoE was performed evaluating heart transplantation outcomes such as rates of rejection, CAV, PTLD, and graft loss. Eighty-six transplants were performed in 84 patients; 34 (40%) underwent diagnostic endoscopy, and 10 (12%) had EoE. Median time to diagnosis of EoE was 3.7 yr (IQR: 2.0-5.2). There were no differences in demographics or use of induction medications between patients with or without EoE. Patients with EoE had fewer episodes of treated rejection (1.0 vs. 2.5; p = 0.04). Four of 10 (40%) EoE patients had PTLD compared with only 2/24 (8%) of those without EoE (p = 0.048; OR 7.33 [95% CI: 1.1-50.2]). There were no differences in CAV or graft loss between groups. EoE should be considered as a cause of GI symptoms in children after cardiac transplantation and may be associated with fewer rejection episodes and increased rates of PTLD, thus representing a marker of over-immunosuppression.

Establishing quality review of cardiac and respiratory arrest in a pediatric intensive care unit.

Cardiac arrest in children is a rare event; however, the outcomes following resuscitation are universally disappointing. Despite widespread recognition of its importance, there is no standard approach to conducting reviews surrounding critical resuscitation events. A standardized approach to the review of respiratory and cardiac arrests occurring in the pediatric intensive care unit focusing on processes of care and team performance was undertaken at a single pediatric academic medical center. Data collection and quality improvement tools were created, and a formal code review was established. Improvement in code team performance was observed. Clinician documentation improved, and multiple system redesigns were implemented that ultimately resulted in fewer clinician concerns. The rate of successful resuscitation was consistent with current published benchmarks. The development of an interdisciplinary code review process focusing on the procedure of resuscitation can identify critical issues that may impede successful resuscitation.

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

OBJECTIVES: To determine whether the implementation of a standardized handover protocol could reduce the number of errors occurring during patient transitions from the operating room to the intensive care unit. DESIGN: Prospective, interventional study. SETTING: Pediatric cardiac intensive care unit. SUBJECTS: Seventy-nine patient handovers in patients transitioning from the operating room to the cardiac intensive care unit after congenital cardiac surgery. INTERVENTIONS: A preintervention assessment of patient handovers was obtained by direct observation using a standardized checklist. A teamwork-driven handover process and protocol was developed using traditional and novel quality-improvement techniques. The postimplementation observational assessment of handovers was performed using the same preintervention assessment tool. Preintervention and postintervention data metrics were analyzed and compared. MEASUREMENTS AND MAIN RESULTS: Forty-one and 38 observations were performed in the preintervention and postintervention periods, respectively. Protocol implementation improved key areas of the handover process. Technical errors per handover were reduced from 6.24 to 1.52 (p < .0001), and critical verbal handoff information omissions were reduced from 6.33 to 2.38 (p < .0001) per handover. There was no change in duration of either the verbal handoff briefing or the overall handover process. Caregivers noted improvement in teamwork and handoff content received after the intervention. CONCLUSIONS: A formal, structured handover process for pediatric patients transitioning to the intensive care unit after cardiac surgery can reduce medical errors that occur during the admission process and improve teamwork among caregivers.