The Incidence and Relevance of Hematochezia in the Interstage Congenital Heart Population.

Necrotizing enterocolitis (NEC) increases morbidity and mortality for infants with single ventricle heart disease (SVHD). While hematochezia often proceeds NEC not all hematochezia progresses to NEC. We aimed to examine the incidence, risk-factors, and outcomes associated with hematochezia and NEC for infants with SVHD. A single-center cohort study including SVHD patients requiring Stage I palliation from 12/2010 to 12/2015 was performed. Demographic, clinical, and outcome measures during the interstage period were abstracted from medical records. We defined hematochezia as blood in the stool without alternative etiology and NEC as systemic or intestinal signs concurrent with hematochezia and/or the presence of radiographic pneumatosis. Clinical characteristics and outcome measures were compared between patients with/without hematochezia and with/without NEC. Of 135 patients, 59(44%) had hematochezia and 20(15%) developed NEC. Demographic and operative factors were similar between patients with and without hematochezia. Patients with NEC were more often premature (15% vs 0%, p = 0.04), have lower birth weight (3.0 ± 0.6 vs 3.3 ± 0.5 kg, p = 0.03), longer cardiopulmonary bypass time (median 131 vs. 90 min, p = 0.02) and more often underwent unplanned cardiac catheterization (20% vs 3%, p = 0.04). Patients with hematochezia had more line days (p < 0.0001) and longer post-Stage-I length of stay (p < 0.0001) than those without hematochezia, and those with NEC had more line days than those without NEC (p = 0.02). Hematochezia is frequent following Stage-I palliation, however only one third of these patients develop NEC. Non-NEC Hematochezia is associated with a similar increase in line and hospital days. Further research is needed to identify methods to avoid over treatment.

Management of Hematochezia in Infants with Congenital Heart Disease Admitted to the Acute Care Cardiology Unit: A Multicenter Retrospective Pilot Study.

OBJECTIVE: To assess the evaluation and prevalence of benign hematochezia (BH) vs necrotizing enterocolitis (NEC) in infants with congenital heart disease (CHD) <6 months old admitted to the acute care cardiology unit. STUDY DESIGN: This was a multicenter retrospective review of patient characteristics and evaluation of all hematochezia events in patients with CHD <6 months admitted to acute care cardiology unit at 3 high-volume tertiary care centers from February 2019 to January 2021. NEC was defined by the Bell staging criteria. Patients with gastrointestinal disorders were excluded. RESULTS: In total, 180 hematochezia events occurred in 121 patients; 42 patients had more than 1 event. In total, 61% of affected patients had single-ventricle physiology (38% hypoplastic left heart syndrome). Median age and weight at hematochezia were 38 days (IQR 24, 79) and 3.7 kg (IQR 3.2, 4.4). In total, 77% of hematochezia events were BH, and 23% were NEC. There were no surgical interventions for NEC or deaths from NEC. Those with NEC were significantly younger (34 vs 56 days, P < .01) and smaller (3.7 vs 4 kg, P < .01). Single-ventricle physiology was significantly associated with NEC. Initial bloodwork and diagnostic imaging at each center were assessed. There was no significant difference in white blood cell count or C-reactive protein in those with NEC compared with BH. Blood culture results were all negative. CONCLUSIONS: The majority of infants with CHD with hematochezia have BH over NEC, although single-ventricle and surgical patients remain at greater risk. Infants <45 days are more vulnerable for developing NEC. Bloodwork was noncontributory in the identification of cardiac NEC. Expansion to a prospective study to develop a treatment algorithm is important to avoid overtreatment.

Feeding Practices in Infants with Hematochezia and Necrotizing Enterocolitis on Acute Care Cardiology Units.

Infants with congenital heart disease (CHD) are at risk for developing both benign hematochezia and necrotizing enterocolitis (NEC). Despite these risks there are very few studies that investigate modifiable risk factors such as feeding practices. It remains unclear what feeding practices should be avoided due to higher incidence of CHD-NEC. We aim to assess the feeding practices across three high volume tertiary centers to establish a relationship between various feeding practices and development of NEC. A multicenter retrospective review of feeding practices at the time of documented hematochezia event that occurred between 1/2019 and 1/2021 in infants with CHD who were less than 6 months of age. NEC was defined as Bells Stage 2 or greater. Age, weight, ventricular morphology, primary diagnoses, feeding route, feed change, and formula type were evaluated. 176 hematochezia events occurred in 121 patients, 72% of these events were considered benign hematochezia with the remaining 28% being true NEC. Single ventricle (SV) physiology (p < 0.05), younger age, < 45 days of life, (p < 0.001), and feeding route were statistically associated with true NEC (p < 0.01). Formula type and recent change in feed administration were not associated with NEC. The caloric density of feeds at the time of hematochezia was nearing significance. The majority of hematochezia events are benign in nature, however, there should be heightened awareness in patients who are SV, younger in age, and those who are post-pylorically fed. There may be some risk in using higher caloric density feeds (> 24 kcal/oz), however, additional research is needed to fully establish this relationship.

Ensuring No Death Is Ignored: Development of a Hospital Mortality Review and Notification System.

BACKGROUND AND OBJECTIVES: Standardized review of mortalities may identify potential system improvements. We designed a hospitalwide identification, review, and notification system for inpatient pediatric mortalities. METHODS: Key stakeholders constructed a future state process map for identification and review of deaths. An online mortality review form was modified through a series of Plan-Do-Study-Act cycles and spread to all pediatric services in January 2019. Mortalities occurring within 30 days of discharge were added in December 2019. Our primary outcome was percentage of mortalities reviewed, and the process measure was time to review completion. Additional Plan-Do-Study-Act cycles were used to refine 2 mechanisms for monthly notification of deaths. We surveyed monthly mortality notification e-mail recipients to elicit feedback to further improve notifications. RESULTS: After the pilot, 284 of 328 (86.6%) of mortalities were reviewed. Average time to review completion decreased by 49% compared with baseline after an increase during the first year of the pandemic. Qualitative analysis of a subset of these mortalities showed that 154 of 229 (67.2%) underwent further review. We added a summary of mortalities by unit to a monthly hospitalwide safety report and developed monthly mortality notification e-mails. The survey showed that 89% of respondents (70 of 79) learned about a death they did not know about, 58% (46 of 79) sought additional information through discussion with a colleague, and 76% (65 of 86) agreed that the notifications helped process grief. CONCLUSIONS: We describe an effective and well-received approach to the identification, review, and notification of mortalities at an academic pediatric hospital, which may be useful at other institutions.

Paediatric cardiology training: burnout, fulfilment, and fears.

BACKGROUND: Burnout is well characterised in physicians and residents but not in paediatric cardiology fellows, and few studies follow burnout longitudinally. Training-specific fears have been described in paediatric cardiology fellows but also have not been studied at multiple time points. This study aimed to measure burnout, training-specific fears, and professional fulfilment in paediatric cardiology fellows with the attention to time of year and year-of-training. METHODS: This survey-based study included the Professional Fulfillment Index and the Impact of Events Scale as well as an investigator-designed Fellow Fears Questionnaire. Surveys were distributed at three-time points during the academic year to paediatric cardiology fellows at a large Midwestern training programme. Fellow self-reported gender and year-of-training were collected. Descriptive analyses were performed. RESULTS: 10/17 (59%) of fellows completed all surveys; 60% were female, 40% in the first-year class, 40% in the second-year class, and 20% in the third-year class. At least half of the fellows reported burnout at each survey time point, with lower mean professional fulfilment scores. The second-year class, who rotate primarily in the cardiac ICU, had higher proportions of burnout than the other two classes. At least half of fellows reported that they "often" or "always" worried about not having enough clinical knowledge or skills and about work-life balance. CONCLUSIONS: Paediatric cardiology fellows exhibit high proportions of burnout and training-specific fears. Interventions to mitigate burnout should be targeted specifically to training needs, including during high-acuity rotations.

Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project.

Background Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may impact postoperative length of stay (LOS). We used collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. Methods and Results Nine pediatric heart centers partnered together through 2 learning networks. Patients undergoing 1 of 9 benchmark congenital heart operations were included. Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29). Conclusions We successfully lowered postoperative CT duration and observed an associated reduction in LOS across 9 centers using collaborative learning methodology.

Improving adherence to echocardiogram reporting guidelines in patients with repaired tetralogy of fallot: A quality improvement initiative.

BACKGROUND: In patients with repaired tetralogy of Fallot (TOF), key echocardiogram report elements have been identified, but poor adherence has been demonstrated, particularly for quantitative assessment. We report a quality improvement effort to improve adherence at our institution, with a focus on increasing quantitative assessment of right ventricular (RV) function. METHODS: Baseline compliance was established by a 3-month retrospective review of outpatient echocardiogram reports. Intervention 1 included presenting baseline data and reviewing the guidelines with echocardiogram laboratory staff (physicians and sonographers). Intervention 2, chosen to focus on quantitative assessment of RV function, involved recommending measurement of tricuspid annular plane systolic excursion (TAPSE) for all echocardiograms. Reporting rates were prospectively analyzed for 1 month after each intervention. To evaluate sonographer versus physician compliance, both study images (acquisition of TAPSE images) and reports were reviewed. RESULTS: At baseline, adherence was poor (median 65% of elements reported), with lower rates for measurements versus descriptive elements (median 40% vs 78%, p<.0001). Following intervention 1, total reported elements improved (median 71% vs 65%, p=0.02) due to increase in measurements (median 50% vs 40%, p=0.02). Reports of quantitative RV function did not significantly change after either intervention, but sonographer compliance improved after intervention 1 (33% vs 14%, p=0.03), with further improvement after intervention 2 (53% vs 14%, p=0.001). CONCLUSION: While education on lesion-specific guidelines may modestly improve adherence, standardization has a greater effect. However, interventions may have differential impact on sonographers versus attendings, and iterative interventions may be required to change practice patterns.

Variation in care practices across pediatric acute care cardiology units: Results of the Pediatric Acute Care Cardiology Collaborative (PAC3 ) hospital survey.

BACKGROUND: The Pediatric Acute Care Cardiology Collaborative (PAC3 ) was established in 2014 to improve the quality, value, and experience of hospital-based cardiac acute care outside of the intensive care unit. An initial PAC3 project was a comprehensive survey to understand unit structure, practices, and resource utilization across the collaborative. This report aims to describe the previously unknown degree of practice variation across member institutions. METHODS: A 126-stem question survey was developed with a total of 412 possible response fields across nine domains including demographics, staffing, available resources and therapies, and standard care practices. Five supplemental questions addressed surgical case volume and number of cardiac acute care unit (CACU) admissions. Responses were recorded and stored in Research Electronic Data Capture (REDCap). RESULTS: Surveys were completed by 31 out of 34 centers (91%) with minimal incomplete fields. A majority (61%) of centers have a single dedicated CACU, which is contiguous or adjacent to the intensive care unit in 48%. A nurse staffing ratio of 3:1 is most common (71%) and most (84%) centers employed a resource nurse. Centralized wireless rhythm monitoring is used in 84% of centers with 54% staffed continuously. There was significant variation in the use of noninvasive respiratory support, vasoactive infusions, and ventricular assist devices across the collaborative. Approximately half of the surveyed centers had lesion-specific postoperative pathways and approximately two-thirds had protocols for single-ventricle patients. CONCLUSIONS: The PAC3 hospital survey is the most comprehensive description of systems and care practices unique to CACUs to date. There exists considerable heterogeneity among unit composition and variation in care practices. These variations may allow for identification of best practices and improved quality of care for patients.

Collective quality improvement in the paediatric cardiology acute care unit: establishment of the Pediatric Acute Care Cardiology Collaborative (PAC3).

Collaborative quality improvement and learning networks have amended healthcare quality and value across specialities. Motivated by these successes, the Pediatric Acute Care Cardiology Collaborative (PAC3) was founded in late 2014 with an emphasis on improving outcomes of paediatric cardiology patients within cardiac acute care units; acute care encompasses all hospital-based inpatient non-intensive care. PAC3 aims to deliver higher quality and greater value care by facilitating the sharing of ideas and building alignment among its member institutions. These aims are intentionally aligned with the work of other national clinical collaborations, registries, and parent advocacy organisations. The mission and early work of PAC3 is exemplified by the formal partnership with the Pediatric Cardiac Critical Care Consortium (PC4), as well as the creation of a clinical registry, which links with the PC4 registry to track practices and outcomes across the entire inpatient encounter from admission to discharge. Capturing the full inpatient experience allows detection of outcome differences related to variation in care delivered outside the cardiac ICU and development of benchmarks for cardiac acute care. We aspire to improve patient outcomes such as morbidity, hospital length of stay, and re-admission rates, while working to advance patient and family satisfaction. We will use quality improvement methodologies consistent with the Model for Improvement to achieve these aims. Membership currently includes 36 centres across North America, out of which 26 are also members of PC4. In this report, we describe the development of PAC3, including the philosophical, organisational, and infrastructural elements that will enable a paediatric acute care cardiology learning network.