Experience with an Acuity Adaptable Care Model for Pediatric Cardiac Surgery.

BACKGROUND: We describe the implementation of and outcomes associated with an acuity adaptable care model for pediatric patients undergoing cardiac surgery. METHODS: Consecutive patients undergoing an index cardiac operation between July 2007 and June 2015 were included. From July 2007 through June 2010, a conventional model existed in which patients moved among units and care teams based on age, severity of illness, and operative status (conventional group). A transitional period existed between July 2010 and June 8, 2012 (transitional group). From June 9, 2012, through June 2015, an acuity adaptable model was used in which patients remained in the cardiac care unit and received care from the same clinical team throughout their hospitalization (acuity adaptable group). RESULTS: Included were 2,363 patients: 925 in the conventional group, 520 in the transitional group, and 918 in the acuity adaptable group. In relation to the conventional group, the adjusted odds of operative mortality in the acuity adaptable group was 0.55 (95% confidence interval: 0.26-1.18; P = .12). The failure to rescue rate (ie, number of deaths in patients with any complication divided by the number of total patients with any complication) decreased (conventional group, 8.7%; acuity adaptable group, 4.2%; P = .04). In relation to the conventional group, postoperative hospital length of stay tended to be shorter in the acuity adaptable group ( P = .07). CONCLUSIONS: The implementation of an acuity adaptable care model was feasible in our pediatric cardiac program. The favorable associations identified between the new model and outcomes are promising but warrant confirmation in a larger, multicenter study.

The effect of cardiopulmonary bypass on the hypothalamic-pituitary-adrenal axis in children.

OBJECTIVE: The pathophysiology of low-cardiac-output syndrome after cardiopulmonary bypass is incompletely understood, but adrenal insufficiency has been proposed as a contributing factor. Our objective was to examine the effect of cardiopulmonary bypass on the hypothalamic-pituitary-adrenal axis, specifically adrenal responsiveness, in patients with congenital heart disease undergoing surgery. We hoped to correlate bound and free cortisol values both postoperatively and after adrenocorticotropic hormone stimulation, in conjunction with corticosteroid-binding globulin levels, with clinical outcomes to determine whether these variables are sensitive indicators of adrenal axis function. DESIGN: Prospective cohort study. SETTING: A children's hospital. PATIENTS: Fifty-two pediatric heart surgery patients undergoing cardiopulmonary bypass. INTERVENTION: Total cortisol and corticosteroid-binding globulin levels were obtained pre- and postoperatively and after a postoperative cosyntropin stimulation test. Free cortisol was calculated by using Coolens' method. MEASUREMENTS AND MAIN RESULTS: Nine of 51 (17.6%) patients had low (<3 µg/dL) baseline postoperative total cortisol, median 1.6 µg/dL, yet all nine had normal (>9 µg/dL increase from postoperative baseline) stimulation tests. The corticosteroid-binding globulin levels declined from a mean of 29 mg/L preoperatively to 22 mg/L postoperatively (p < .001) and showed marked variability between patients. Patients with free cortisol δ >6 µg/dL (n = 18, 35%) had a longer length of stay (median 9 vs. 5 days; p = .002), higher inotrope scores (median 13.3 vs. 10.8; p = .05), greater fluid requirement (median 73.5 vs. 55.6 mL/kg; p = .007), and longer ventilator times (median 41.5 vs. 20 hrs; p = .013). CONCLUSIONS: Although hypothalamic-pituitary-adrenal axis dysfunction may play a role in low-cardiac-output syndrome among children undergoing congenital heart surgery, using total cortisol to investigate such dysfunction may be inadequate. Decreased corticosteroid-binding globulin levels and marked free cortisol increase after stimulation were associated with worse clinical outcomes. Further investigation into the cortisol-corticosteroid-binding globulin complex and its relationship to free cortisol is necessary to examine the problem of adrenal insufficiency from a more integrated perspective.

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications.

This study assessed the perceptions of nurses about the creation and staffing of a dedicated cardiac intensive care unit. Nurses perceived a clinical benefit to cohorting cardiac surgery patients; however, they reported more knowledge deficits in cardiac patient care than other intensive care unit disease categories. More than 25% of nurses reported a patient assignment in which they identified suboptimal skills to provide safe patient care. Years of clinical experience did not reduce concerns for quality of care or safe practice.