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

Abstract

BACKGROUND: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery. METHODS: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries. RESULTS: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes. CONCLUSIONS: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.

Redução do período de internação e de despesas no atendimento de portadores de cardiopatias congênitas submetidos à intervenção cirúrgica cardíaca no protocolo da via rápida

“…The length of stay in the different hospital units was shorter in the fast-track protocol, in accordance with that reported in the literature 11 . However, the different authors who studied this issue focused more frequently on the length of hospital stay, the stay in the ICU, the length of postoperative hospitalization, and the duration of orotracheal intubation 11,13,16,23,27,28 . The other time intervals analyzed in this study, such as the length of preoperative hospitalization, which has psychological and clinical implications, even an effect on the skin bacterial flora, had not been previously assessed 29 .…”

“…Although this study provided the opportunity to evaluate both protocols concomitantly, the allocation of patients into the protocols was not randomized, but this restriction has also been reported in other studies 5,11,13 . Other studies 11,13 reported in the literature changed the hospital routine, and comparisons were performed in regard to the experience prior to change.…”

“…The patients' ages ranged from 3 months to 81 years, showing the feasibility of the fast-track protocol for adults and children 5,11,22,25,26 . Patients with less complex heart diseases were studied, and this was observed in other reports in the literature, which included 13,26 .…”

Resource Utilization After Introduction of a Standardized Clinical Assessment and Management Plan

“…Despite these limitations, CPGs have been used with some success in the immediate postoperative management of selected congenital heart lesions reducing resource utilization, duration of hospitalization, and cost of postoperative care. [17][18][19] However, CPGs designed for longitudinal follow-up of children with congenital heart disease are sparse and do not include class indications or levels of evidence. 20 Not surprisingly in a field caring for rare and diverse lesions, pediatric cardiology is characterized by wide institutional and individual practice variation.…”

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

“…The pediatric cost-effectiveness literature describes research efforts that focus on prevention strategies such as prenatal care (2) and vaccination (3) and disease screening protocols. Pediatric cost analyses include critical pathways research to standardize care (4), study of direct and indirect costs to evaluate service utilization (5), and cost-effectiveness studies on alternative medication (6,7) or procedure (8 -11) regimens. There has, however, been little evaluation of the cost of pediatric rheumatic disease.…”