The principles of enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG): a UK tertiary center experience.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have been shown to improve surgical outcomes and patient satisfaction. The aim of the study was to assess whether the implementation of a perioperative enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG) pathway based on ERAS principles was safe, satisfactory to parents and improved outcomes. METHODS: Following a quality improvement project, a multimodal ERaPEG pathway was introduced as standard practice within the department and children undergoing elective same-day admission percutaneous endoscopic gastrostomy (PEG) at a single UK tertiary center were prospectively enrolled. Exclusion criteria were patients undergoing other concurrent procedures and those who underwent a laparoscopic assisted/open procedure. Data included patient demographics, underlying diagnosis, indication, length of stay (LOS) and 30-day readmission. Parental experience and satisfaction were determined using a questionnaire including 5-point Likert scales. A retrospective cohort was used for comparison. Data were analyzed using Chi-Square test and Mann-Whitney U tests. RESULTS: Ninety-five patients met the inclusion criteria: 50 pre and 45 post the implementation of ERaPEG. Median age was 3 and 2 years, respectively. Neurodisability was the underlying diagnosis in most patients (84%-pre-ERaPEG; 76%-post-ERaPEG). Most common PEG indication was medication/nutritional supplementation (52%-pre-ERaPEG; 51%-post-ERaPEG). The LOS significantly decreased from a median of 51.5 h (pre-ERaPEG) to 32 h (post-ERaPEG) (p < 0.001). Thirty-day readmission rates were similar (6% vs 11%). Most parents felt that the educational material was easy to access and understand. Post-operatively the majority of parents (≥ 80%) were confident in managing the gastrostomy device, setting up/giving the feeds and also felt that the LOS was appropriate. CONCLUSION: This study shows that the implementation of an ERaPEG pathway significantly reduced LOS following PEG. In addition, the pathway was satisfactory to parents and offered the benefit of improved resource utilization.

An improved congenital heart assessment tool: a quality improvement outcome.

BACKGROUND: CHD was the most prevalent congenital anomaly (60.9 per 10,000, 95% CI 59.0-62.8) in England in 2018, with 1767 babies born with severe cardiac defects. The 30-day survival rates for complex procedures continue to improve; however despite care advances, the early post-operative period and first year of life remain a critical time for these infants. The Congenital Heart Assessment Tool was developed to support parental decision-making, standardise care provision, improve communication, and the safety and quality of care. AIM: To further evaluate the Congenital Heart Assessment Tool. DESIGN: A four centre collaborative mixed-methods quality improvement project funded by The Health Foundation, involving eight phases conducted during 2016-2018. Phases six to eight (clinical simulation exercise, parent workshop, and updated tool) are reported in this paper. RESULTS: Four themes emerged from the clinical simulation exercise (phase six) including: improving documentation; preparation of parents; preparation of health care professionals; and communication. One main theme emerged from the parent workshop (phase seven): "what parents know versus what professionals know [about CHD]". CONCLUSION: These phases further validated the effectiveness of the CHATm in terms of triggering amber and red indicators and demonstrated parents' ability to identify deterioration in their infant's clinical condition. Recommendations arising from the quality improvement project enabled the project team to create an updated version of the Congenital Heart Assessment Tool, CHAT2.

Development and preliminary testing of the Brief Developmental Assessment: an early recognition tool for children with heart disease.

Introduction Neurodevelopmental abnormalities are common in children with CHD and are the highest-priority concerns for parents and professionals following cardiac surgery in childhood. There is no additional routine monitoring of development for children with CHD in the United Kingdom; hence, neurodevelopmental concerns may be detected late, precluding early referral and intervention. METHODS: An early recognition tool - the "Brief Developmental Assessment" - was developed using quality improvement methodology involving several iterations and rounds of pilot testing. Our requirements were for a tool covering important developmental domains and practicable for use within inpatient and outpatient settings by paediatric cardiac health professionals who are non-developmental specialists, without specialised equipment and which involved direct observation, as well as parental report. RESULTS: Items were included in the tool based on existing developmental measures, covering the domains of gross and fine motor skills, daily living skills, communication, socialisation, and general understanding. Items were developed for five age bands - 0-16 weeks, 17-34 weeks, 35-60 weeks, 15 months-2.9 years, and 3-4.9 years - and the final versions included a traffic light scoring system for identifying children with possible delay in any or all domains. Preliminary testing indicated excellent inter-rater reliability, an ability to detect children with a diagnosis known to be associated with developmental delay, and largely acceptable internal reliability. CONCLUSION: We report the evolution and preliminary testing of an early recognition tool for assessing the development of children with heart disease; this was encouraging and sufficiently good to support further validation in a larger study.

Definition of important early morbidities related to paediatric cardiac surgery.

BACKGROUND: Morbidity is defined as a state of being unhealthy or of experiencing an aspect of health that is "generally bad for you", and postoperative morbidity linked to paediatric cardiac surgery encompasses a range of conditions that may impact the patient and are potential targets for quality assurance. METHODS: As part of a wider study, a multi-disciplinary group of professionals aimed to define a list of morbidities linked to paediatric cardiac surgery that was prioritised by a panel reflecting the views of both professionals from a range of disciplines and settings as well as parents and patients. RESULTS: We present a set of definitions of morbidity for use in routine audit after paediatric cardiac surgery. These morbidities are ranked in priority order as acute neurological event, unplanned re-operation, feeding problems, the need for renal support, major adverse cardiac events or never events, extracorporeal life support, necrotising enterocolitis, surgical site of blood stream infection, and prolonged pleural effusion or chylothorax. It is recognised that more than one such morbidity may arise in the same patient and these are referred to as multiple morbidities, except in the case of extracorporeal life support, which is a stand-alone constellation of morbidity. CONCLUSIONS: It is feasible to define a range of paediatric cardiac surgical morbidities for use in routine audit that reflects the priorities of both professionals and parents. The impact of these morbidities on the patient and family will be explored prospectively as part of a wider ongoing, multi-centre study.

Signs of deterioration in infants discharged home following congenital heart surgery in the first year of life: a qualitative study.

AIMS: To describe the ways in which parents recognise and make decisions about their child's symptoms following discharge home after congenital heart interventions in the first year of life and their experiences of seeking help. METHODS: This was a qualitative study involving semistructured interviews with parents. Twenty-one parents were recruited to the study. Parents all had a child who had congenital heart surgery in their first year of life between September 2009 and October 2013 at one of three UK cardiac centres; the children had either died or were readmitted as an emergency following initial discharge. RESULTS: Some parents were unable to identify any early warning signs. Others described symptoms of deterioration including changes in feeding and appearance, respiratory distress and subtle behavioural changes that may not be routinely highlighted to parents at discharge. Several barriers to accessing prompt medical assistance were identified including parents feeling that their concerns were not taken seriously, long wait times and lack of protocols at A&E. CONCLUSIONS: Our study highlights behavioural symptoms as being a potentially underemphasised sign of deterioration and identifies a number of barriers to parents accessing support when they are concerned. It is important that parents are encouraged to seek advice at the earliest opportunity and that those health professionals at the front line have access to the information they need in order to respond in an appropriate and timely way. A role for home monitoring was also noted as potentially useful in identifying at risk children who appear clinically well.

Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future.

BACKGROUND: The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes. METHODS: The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership. RESULTS: Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges. CONCLUSIONS: Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.

Pharmacogenomic, physiological, and biochemical investigations on safety and efficacy biomarkers associated with the peroxisome proliferator-activated receptor-gamma activator rosiglitazone in rodents: a translational medicine investigation.

Peroxisome proliferator-activated receptor (PPAR)-gamma modulators, a class of antidiabetic drugs, have been associated with cardiovascular risks in type 2 diabetes in humans. The objective of this study was to explore possible cardiovascular risk biomarkers associated with PPAR-gamma in rodents that could provide an alert for risk to humans. Normal, myocardial infarction-induced heart failure (HF) or Zucker diabetic fatty (ZDF) rats were used. Rats (n = 5-6) were treated with either vehicle or rosiglitazone (RGZ; 3 or 45 mg/kg/day p.o.) for 4 weeks. Biomarkers for potential cardiovascular risks were assessed, including 1) ultrasound for cardiac structure and function; 2) neuroendocrine and hormonal plasma biomarkers of cardiovascular risk; 3) pharmacogenomic profiling of cardiac and renal tissue by targeted tissue low-density gene array representing ion channels and transporters, and components of the renin-angiotensin-aldosterone system; and 4) immunohistochemistry for cardiac fibrosis, hypertrophy, and inflammation (macrophages and tumor necrosis factor-alpha). HF was confirmed by increase in cardiac brain natriuretic peptide expression (p < 0.01) and echocardiography. Adequate exposure of RGZ was confirmed by pharmacokinetics (plasma drug levels) and the pharmacodynamic biomarker adiponectin. In normal or HF rats, RGZ had no negative effects on any of the biomarkers investigated. Similarly, RGZ had no significant effects on gene expression except for the increase in interleukin-6 mRNA expression in the heart and decrease in epithelial sodium channel beta in the kidney. In contrast, echocardiography showed improved cardiac structure and function after RGZ in ZDF rats. Taken together, this study suggests a limited predictive power of these preclinical models in respect to observed clinical adverse effects associated with RGZ.