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

Abstract

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.

Analysis of inflammatory cytokines in the chest tube drainage of post-operative superior cavopulmonary connection patients

“…Chest tube removal was based on a decision by the clinical team; standard removal criteria at this institution were output at ≤1 ml/kg/8 hours for two consecutive 8-h shifts. The institution changed its practice to align with the Pediatric Acute Care Cardiology Collaborative (PAC3) chest tube initiative, 15 and thus the last three patients enrolled in the study had chest tubes removed at 48 hours as long as their chest tubes had < 10 ml/kg/day. Samples were not collected after additional procedures in the chest.…”

Reduced Length of Stay after Implementation of a Clinical Pathway following Repair of Ventricular Septal Defect

“…We created a clinical pathway to care for patients following surgical VSD repair with the guidance of a small, interprofessional, task force. The initial framework for the clinical pathway was based on standard of care and group consensus as well as evidence-based care [8][9][10][11][12]. The pathway was then approved by the entire provider and nursing leadership (CICU) team.…”

“…The outpatient cardiologists were also included in education on the pathway to assist in managing parental expectations of care and hospital length of stay. This fast-track pathway [10,11] included timing of when milestones in care should be achieved. Important aspects of this pathway include: 1) Early extubation in the operating room or within six hours of CICU admission 2) Early PO intake allowed (as early as two hours after admission) 3) Early initiation and maintenance of scheduled furosemide (starts three hours after admission) 4) Use of only as needed opioid analgesics rather than a continuous infusion with transition to enteral as early as the first postoperative night 5) Scheduled adjunct medications for pain control (ketorolac within 6 hours of admission and scheduled acetaminophen) 6) Weaning oxygen therapy expeditiously 7) Early mobilization with urinary catheter removal no later than post operative morning one.…”

The horizon of pediatric cardiac critical care

“…These registries/collaboratives have been established with a focus on data sharing, commitment to high quality data and inclusion of multidisciplinary teams. Collaboratives such as the Pediatric Acute Care Cardiology Collaborative (PAC-3) (155), that achieved a reduction in length of postoperative hospital stay, the Pediatric Cardiac Critical Care Consortium (PC4), that achieved a 24, 22, and 12% relative reduction in in-hospital mortality, postoperative mortality and major complications, respectively (141). The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) successfully halved both mortality and growth failure in children with hypoplastic left heart syndrome between stage 1 and 2 palliation and demonstrate that there is a roadmap for multi-center collaborative quality improvement that results in sustained improvement in outcomes (156).…”