The Mayo Clinic Hospital Mortality Reduction Project: Description and Results.

EXECUTIVE SUMMARY: Quality improvement, regulatory, and payer organizations use various definitions of hospital mortality as clinical outcome measures. In this prospective study, the authors evaluated a multicomponent intervention aimed at reducing inpatient mortality in a multistate healthcare delivery system. The project was initiated because of a statistically nonsignificant upward trend in mortality suggested by a six-quarter rise in the observed/expected mortality ratio generated by the Vizient Clinical Data Base and Resource Manager. The design of the mortality reduction plan was influenced by the known limitations of using hospital-wide mortality as a quality improvement measure. The primary objective was to reduce mortality through focused care redesign. The project leadership team attempted to implement standardized system-wide improvements while allowing individual hospitals to simultaneously pursue site-specific practice redesign opportunities. Between Q3, 2015, and Q4, 2017, system-wide mortality reduced from 1.78 to 1.53 (per 100 admissions; p = .01). The actual plan implemented in Mayo Clinic's hospitals is included as Appendix A to this article, published online as Supplemental Digital Content. The authors included it to allow comparison with similar efforts at other healthcare systems, as well as to stimulate criticism and discussion by readers.

Lymphocytic choriomeningitis virus in employees and mice at multipremises feeder-rodent operation, United States, 2012.

We investigated the extent of lymphocytic choriomeningitis virus (LCMV) infection in employees and rodents at 3 commercial breeding facilities. Of 97 employees tested, 31 (32%) had IgM and/or IgG to LCMV, and aseptic meningitis was diagnosed in 4 employees. Of 1,820 rodents tested in 1 facility, 382 (21%) mice (Mus musculus) had detectable IgG, and 13 (0.7%) were positive by reverse transcription PCR; LCMV was isolated from 8. Rats (Rattus norvegicus) were not found to be infected. S-segment RNA sequence was similar to strains previously isolated in North America. Contact by wild mice with colony mice was the likely source for LCMV, and shipments of infected mice among facilities spread the infection. The breeding colonies were depopulated to prevent further human infections. Future outbreaks can be prevented with monitoring and management, and employees should be made aware of LCMV risks and prevention.

In vivo measurement of pediatric extracorporeal oxygenator insensible losses; a single center pilot study.

Introduction: Fluid overload on Extracorporeal Membrane Oxygenation (ECMO) is associated with worse outcomes. Previous in vitro studies have attempted to quantify oxygenator-related insensible losses, as failure to account for this fluid loss may lead to inaccurate fluid balance assessment and potentially harmful clinical management, such as unnecessary exposure to diuretics, slow continuous ultrafiltration (SCUF), or continuous kidney replacement therapy (CKRT). We performed a novel in vivo study to measure insensible fluid losses in pediatric ECMO patients. Methods: Pediatric ECMO patients were approached over eleven months in the pediatric and cardiac intensive care units. The water content of the oxygenator inflow sweep gas and exhaust gas were calculated by measuring the ambient temperature and relative humidity at frequent intervals and various sweep flow. Results and discussion: Nine subjects were enrolled, generating 431 data points. The cohort had a median age of 11 years IQR [0.83, 13], weight of 23.2 kg IQR [6.48, 44.28], and body surface area of 0.815 m2 IQR [0.315, 1.3725]. Overall, the cohort had a median sweep of 2.5 L/min [0.9, 4], ECMO flow of 3.975 L/m2/min [0.75, 4.51], and a set ECMO temperature of 37 degrees Celsius [36.6, 37.2]. The calculated net water loss per L/min of sweep was 75.93 ml/day, regardless of oxygenator size or patient weight. There was a significant difference in median documented vs. calculated fluid balance incorporating the insensible fluid loss, irrespective of oxygenator size (pediatric oxygenator: 7.001 ml/kg/day [-12.37, 28.59] vs. -6.11 ml/kg/day [-17.44, 13.01], respectively, p = 0.005 and adult oxygenator: 14.36 ml/kg/day [1.54, 25.77] and 9.204 ml/kg/day [-1.28, 22.05], respectively, p = <0.001). We present this pilot study of measured oxygenator-associated insensible fluid losses on ECMO. Our results are consistent with prior in vitro methods and provide the basis for future studies evaluating the impact of incorporating these fluid losses into patients' daily fluid balance on patient management and outcomes.

A Learning Health System Approach to Hospital Quality Performance Benchmarking: The Composite Hospital Quality Index.

US hospital quality rankings and ratings use disparate methodologies and are weakly correlated. This causes confusion for patients and hospital quality staff. At the authors' institution, a Composite Hospital Quality Index (CHQI) was developed to combine hospital quality ratings. This approach is described and a calculator is shared here for other health systems to explore their performance. Among the US News and World Report Top 50 Hospitals, hospital-specific numeric summary scores were aggregated from the 2021 Centers for Medicare and Medicaid Services (CMS) Hospital Overall Star Rating, the Spring 2021 Leapfrog Safety Grade, and the April 2021 Hospital Consumer Assessment of Healthcare Providers and Systems Star Rating. The CHQI is the hospital-specific sum of the national percentile-rankings across these 3 ratings. In this example, mean (SD) percentiles were as follows: CMS Stars 74 (19), Hospital Consumer Assessment of Healthcare Providers and Systems 63 (19), Leapfrog 65 (24), with mean (SD) CHQI of 202 (49). The CHQI is used at the authors' institution to identify improvement opportunities and ensure that high-quality care is delivered across the health system.

Administrative Data Are Unreliable for Ranking Hospital Performance Based on Serious Complications After Spine Fusion.

STUDY DESIGN: Retrospective analysis of administrative billing data. OBJECTIVE: To evaluate the extent to which a metric of serious complications determined from administrative data can reliably profile hospital performance in spine fusion surgery. SUMMARY OF BACKGROUND DATA: While payers are increasingly focused on implementing pay-for-performance measures, quality metrics must reliably reflect true differences in performance among the hospitals profiled. METHODS: We used State Inpatient Databases from nine states to characterize serious complications after elective cervical and thoracolumbar fusion. Hierarchical logistic regression was used to risk-adjust differences in case mix, along with variability from low case volumes. The reliability of this risk-stratified complication rate (RSCR) was assessed as the variation between hospitals that was not due to chance alone, calculated separately by fusion type and year. Finally, we estimated the proportion of hospitals that had sufficient case volumes to obtain reliable (>0.7) complication estimates. RESULTS: From 2010 to 2017 we identified 154,078 cervical and 213,133 thoracolumbar fusion surgeries. 4.2% of cervical fusion patients had a serious complication, and the median RSCR increased from 4.2% in 2010 to 5.5% in 2017. The reliability of the RSCR for cervical fusion was poor and varied substantially by year (range 0.04-0.28). Overall, 7.7% of thoracolumbar fusion patients experienced a serious complication, and the RSCR varied from 6.8% to 8.0% during the study period. Although still modest, the RSCR reliability was higher for thoracolumbar fusion (range 0.16-0.43). Depending on the study year, 0% to 4.5% of hospitals had sufficient cervical fusion case volume to report reliable (>0.7) estimates, whereas 15% to 36% of hospitals reached this threshold for thoracolumbar fusion. CONCLUSION: A metric of serious complications was unreliable for benchmarking cervical fusion outcomes and only modestly reliable for thoracolumbar fusion. When assessed using administrative datasets, these measures appear inappropriate for high-stakes applications, such as public reporting or pay-for-performance.Level of Evidence: 3.

Deployment of an Interdisciplinary Predictive Analytics Task Force to Inform Hospital Operational Decision-Making During the COVID-19 Pandemic.

In March 2020, our institution developed an interdisciplinary predictive analytics task force to provide coronavirus disease 2019 (COVID-19) hospital census forecasting to help clinical leaders understand the potential impacts on hospital operations. As the situation unfolded into a pandemic, our task force provided predictive insights through a structured set of visualizations and key messages that have helped the practice to anticipate and react to changing operational needs and opportunities. The framework shared here for the deployment of a COVID-19 predictive analytics task force could be adapted for effective implementation at other institutions to provide evidence-based messaging for operational decision-making. For hospitals without such a structure, immediate consideration may be warranted in light of the devastating COVID-19 third-wave which has arrived for winter 2020-2021.

ECMO for Pediatric Lung Transplantation.

Extracorporeal membrane oxygenation (ECMO) has been reported as an alternative to cardiopulmonary bypass during lung transplantation. The reports in the literature have been limited to adult practice and associated with decreased pulmonary and renal complications, lower mortality, and lower in-hospital mortality. We present four pediatric lung transplantations performed on ECMO and discuss relevant perfusion management.

Mechanically assisted bidirectional cavopulmonary shunt in neonates and infants: An acute human pilot study.

OBJECTIVE: Poor survival following surgical palliation for hypoplastic left heart syndrome (HLHS) raises the question of the need for a paradigm shift. This is the first human study to investigate the possibility of primary "in-series" palliation in neonates and infants with HLHS in an acute setting with the aid of 2 types of mechanical assist: superior vena cava (SVC)-to-pulmonary artery (PA) pump assist and SVC-to-right atrium (RA) oxygenation assist. METHODS: By rearranging the cannula sites and flow rates for modified ultrafiltration, 2 types of mechanically assisted bidirectional cavopulmonary shunt (BCPS) circulation were simulated for 20 minutes. Three neonates undergoing a stage I Norwood procedure were assigned to SVC-PA pump assist, and 3 infants undergoing stage II BCPS were assigned to SVC-RA oxygenation assist. Hemodynamic parameters, blood gas values, and arterial (SaO2) and regional cerebral tissue (rCTO2) saturations were analyzed. RESULTS: All 6 patients completed the study without hemodynamic compromise. In the SVC-PA pump assist group, a mean arterial pressure >40 mm Hg was maintained. SVC pressure was lower (P = .01) and cerebral perfusion pressure (CPP) was higher (P = .03) during the last 10 minutes of assist compared with Norwood physiology. SaO2 >80%, rCTO2 >60%, and mixed venous saturation ≥59% were maintained, comparable to values with Norwood physiology. In the SVC-RA oxygenation assist group, with full or 50% support, mean blood pressure >50 mm Hg, SVC pressure <15 mm Hg, mixed venous saturation >50%, and CPP >40 mm Hg were maintained, which were comparable to BCPS physiology. CONCLUSIONS: Two types of mechanical assist to support primary in-series palliation are feasible in the acute setting. Both modes of mechanical assist maintained oxygenation, as well as systemic and cerebral perfusion.

A Citation Tracking System to Facilitate Sponsoring Institution Oversight of ACGME-Accredited Programs.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires the graduate medical education committee and the designated institutional official to ensure that citations for noncompliance with the accreditation standards and institutional trends in citations are reviewed and corrected. OBJECTIVE: To describe a citation tracking system (CTS) that uses Microsoft Office Access to efficiently catalogue, monitor, and document resolution of citations. INNOVATION: The CTS was implemented in a sponsoring institution with oversight of 133 ACGME-accredited programs. The designated institutional official and the graduate medical education committee review all program letters of notification and enter citations into the CTS. A program-correction plan is required for each citation and is entered into the database. Open citations and action plans are reviewed by the graduate medical education committee and the designated institutional official on a quarterly basis, with decisions ranging from "closing" the citation to approving the action plan in process to requiring a new or modified action plan. Citation categories and subcategories are accessed on the ACGME website and entered into the CTS to identify trends. RESULTS: All 236 citations received since the 2006 Mayo School of Graduate Medical Education institutional site visit were entered into the CTS. On November 22, 2011, 26 of 236 citations (11%) were in active status with ongoing action plans, and 210 (89%) citations had been resolved and were closed. CONCLUSIONS: The CTS uses commercially available software to ensure citations are monitored and addressed and to simplify analysis of citation trends. The approach requires minimal staff time for data input and updates and can be performed without institutional information technology assistance.

Primary in-series palliation of hypoplastic left heart syndrome with mechanical lung assist in neonatal pigs.

Less than optimal outcomes for hypoplastic left heart syndrome may be related to unstable in-parallel circulation. Mechanical lung assist by (1) superior vena cava to right atrium pump with oxygenation (oxygenator assist), or (2) superior vena cava to pulmonary artery pump (pump assist) may permit successful neonatal in-series palliation. Nineteen 15-day-old piglets underwent single ventricle and bidirectional cavopulmonary shunt (BCPC) creation without mechanical lung assist (n = 8), with pump assist (n = 5), or with oxygenator assist (n = 6). Baseline hemodynamic measurements were not different between groups. Median survival for the cavopulmonary shunt alone, pump assist, and oxygenator assist groups was 28, 180, and 180 minutes, respectively (p = 0.0006). No differences in arterial oxygen concentration or bicarbonate levels were detected. Arterial carbon dioxide (p < or = 0.007) was higher in the cavopulmonary shunt alone versus lung assist groups. Cavopulmonary shunt alone animals had decreased mean arterial pressure (p < 0.02) and cerebral perfusion pressure (p = 0.029) and elevated left atrial pressure compared with lung assist groups (p < 0.05). This data demonstrates creation of a novel translational neonatal BCPC model in which mechanical lung assist augments survival. Early BCPC death was related to poor ventricular function and an inability to ventilate, issues that were improved with both types of lung assist.

Mechanical cavopulmonary assist maintains pulmonary and cerebral blood flow in a piglet model of a bidirectional cavopulmonary shunt with high pulmonary vascular resistance.

OBJECTIVES: We tested mechanical cavopulmonary blood flow assist by incorporating a novel miniature centrifugal pump into a 1(1/2)-ventricle type cavopulmonary connection in neonatal pigs. METHODS: Nine 3-week-old piglets (mean body weight, 10.2 kg) were used: mechanical cavopulmonary assist (n = 6) and controls (n = 3). A bidirectional cavopulmonary connection between the superior vena cava and the main pulmonary artery was created. The superior vena cava and pulmonary artery were also connected by cannulas with an interposed centrifugal pump. The cavoarterial mechanical cavopulmonary assist was performed at pump speeds of 1500, 2000, 2500, and 3000 rpm. Retrograde superior vena caval flow was limited by a band on the superior vena cava. A bidirectional cavopulmonary connection was created in the control animals, which then had a pure 1(1/2)-ventricle repair physiology without mechanical support. Hemodynamics, blood gas, and cerebral blood flow measured by ultrasound were analyzed. Catheter-based dilatation of the surgically created superior vena cava obstruction was tested. RESULTS: Incremental increases in pump speed augmented bidirectional cavopulmonary shunt blood flow (P =.03) and diminished superior vena caval pressure (P =.03), thereby improving cerebral perfusion pressure. Pump flow of 3000 rpm was equivalent to baseline superior vena caval flow (before caval flow, 392 +/- 48 mL/min vs MCPA, 371 +/- 120 mL/min; mean +/- SD; P = not significant). The mechanical cavopulmonary assist group had higher Doppler velocities of the middle cerebral artery and higher transcerebral oxygen difference(P < .05) than controls. Balloon dilatation of the superior vena cava band was successful. CONCLUSIONS: Mechanical cavopulmonary assist maintained bidirectional cavopulmonary shunt flow, thereby sustaining primary bilateral cavopulmonary shunt physiology in a neonatal pig model of high pulmonary vascular resistance. The mechanical cavopulmonary assist maintained cerebral blood flow and metabolism with an adequate transcerebral pressure gradient.

A novel mechanical lung assist system sustains primary bidirectional cavopulmonary shunt circulation in pigs.

Primary creation of a bidirectional cavopulmonary shunt (BCPS), which provides a stable in-series circulation, might improve survival in patients with hypoplastic left heart syndrome. However, pulmonary vascular immaturity and high pulmonary vascular resistance must be overcome to achieve a successful primary neonatal BCPS. This study tested the hypothesis that a novel mechanical lung assist (MLA) system would permit a primary BCPS in juvenile pigs. A BCPS (1(1/2) ventricle repair physiology) was created in nine 4-5-week-old pigs (mean weight 17.9 kg), followed by MLA with a miniature centrifugal pump and a hand-made double-lumen cannula for 2 hours. Systemic and cerebral hemodynamic and metabolic data were evaluated. A mean BCPS flow of 331 +/- 56 ml/min was obtained with a mean pump speed of 3899 +/- 306 rpm at 30 minutes after MLA initiation. Adequate oxygenation, ventilation, and hemodynamics were maintained. Transcranial Doppler ultrasound demonstrated consistent pre- and postoperative peak systolic and diastolic velocities of the middle cerebral artery, indicating sustained cerebral perfusion pressure. This study demonstrated that the MLA is able to sustain a high-resistance BCPS and provides a strategy or rationale for developing a primary neonatal cavopulmonary connection in appropriately selected neonates with congenital heart disease.