Title

Standardization of the Perioperative Management for Neonates Undergoing the Norwood Operation for Hypoplastic Left Heart Syndrome and Related Heart Defects.

Authors

Shobha S Natarajan, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Alyson Stagg, Children's Hospital of Philadelphia, Philadelphia, PAFollow
April M Taylor, Children's Hospital of Philadelphia, Philadelphia, PA
Heather Griffis, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Christy K Bosler, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Margaret Cates, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Aaron DeWitt, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Therese M Giglia, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Christopher E Mascio, Children's Hospital of Philadelphia, Philadelphia, PA
Chitra Ravishankar, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Joseph Rossano, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Lillith C Taylor, Children's Hospital of Philadelphia, Philadelphia, PA
Eileen P Ware, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Susan C Nicolson, Children's Hospital of Philadelphia, Philadelphia, PAFollow
Jonathan Rome, Children's Hospital of Philadelphia, Philadelphia, PAFollow

Publication Title

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Document Type

Article

PubMed ID

32701749

Abstract

OBJECTIVES: In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers. This multidisciplinary quality improvement project standardized perioperative management in a large referral center.

DESIGN: Quality improvement project.

SETTING: High volume cardiac center, tertiary care children's hospital.

PATIENTS: Neonates undergoing Norwood operation.

INTERVENTIONS: The quality improvement team developed and implemented a clinical guideline (preoperative admission to 48 hr after surgery). The composite process metric, Guideline Adherence Score, contained 13 recommendations in the guideline that reflected consistent care for all patients.

MEASUREMENTS AND MAIN RESULTS: One-hundred two consecutive neonates who underwent Norwood operation (January 1, 2013, to July 12, 2016) before guideline implementation were compared with 50 consecutive neonates after guideline implementation (July 13, 2016, to May 4, 2018). No preguideline operations met the goal Guideline Adherence Score. In the first 6 months after guideline implementation, 10 of 12 operations achieved goal Guideline Adherence Score and continued through implementation, reaching 100% for the last 10 operations. Statistical process control analysis demonstrated less variability and decreased hours of postoperative mechanical ventilation and cardiac ICU length of stay during implementation. There were no statistically significant differences in major hospital complications or in 30-day mortality. A higher percentage of patients were extubated by postoperative day 2 after guideline implementation (67% [30/47] vs 41% [41/99], respectively; p = 0.01). Of these patients, reintubation within 72 hours of extubation significantly decreased after guideline implementation (0% [0/30] vs 17% [7/41] patients, respectively; p = 0.02).

CONCLUSIONS: This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2. Establishment of standard processes can lead to best practices to decrease major adverse events.

Keywords

Child, Heart Defects, Congenital, Humans, Hypoplastic Left Heart Syndrome, Infant, Newborn, Norwood Procedures, Reference Standards, Risk Factors, Treatment Outcome

DOI

10.1097/PCC.0000000000002478

Publication Date

9-1-2020

Citation

Natarajan, S., Stagg, A., Taylor, A., Griffis, H., Bosler, C., Cates, M., DeWitt, A., Giglia, T., Mascio, C., Ravishankar, C., Rossano, J., Taylor, L., Ware, E., Nicolson, S., & Rome, J. (2020). Standardization of the Perioperative Management for Neonates Undergoing the Norwood Operation for Hypoplastic Left Heart Syndrome and Related Heart Defects.. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 21 (9), 848-848. https://doi.org/10.1097/PCC.0000000000002478