Critical pathways for postoperative care after simple congenital heart surgery.

OBJECTIVE: To evaluate the clinical, financial, and parent/patient satisfaction impact of critical pathways on the postoperative care of pediatric cardiothoracic patients with simple congenital heart lesions. STUDY DESIGN: Critical pathways were developed by pediatric intensive care nurses and implemented under the direction of pediatric cardiothoracic surgeons. PATIENTS AND METHODS: Critical pathways were used during a 12-month study on 46 postoperative patients with simple repair of atrial septal defect (ASD), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). Using the study criteria, a control group of 58 patients was chosen from 1993. Prospective and control group data collected included postoperative intubation time, total laboratory tests, arterial blood gas utilization, morphine utilization, time in the pediatric intensive care unit, total hospital stay, total hospital charges, total hospital cost, and complications. Variances from the critical pathway and satisfaction data were also recorded for study patients. RESULTS: Resource utilization was reduced after implementation of critical pathways. Significant reductions were seen in total hours in the pediatric intensive care unit, total number of laboratory tests, postoperative intubation times, arterial blood gas utilization, morphine utilization, length of hospitalization (ASD, 4.9 to 3.1 days; CoA, 5.2 to 3.2 days; and PDA, 4.1 to 1.4 days; all P < 0.05), total hospital charges (ASD, $16,633 to $13,627; CoA, $14,292 to $8319; and PDA, $8249 to $4216; all P < 0.05), and total hospital costs. There was no increase in respiratory complications or other complications. Patients and families were generally satisfied with their hospital experience, including analgesia and length of hospitalization. CONCLUSIONS: Implementation of critical pathways reduced resource utilization and costs after repair of three simple congenital heart lesions, without obvious complications or patient dissatisfaction.

Impact of prolonged waiting times of neonates awaiting heart transplantation.

OBJECTIVES: This study analyzed waiting times and outcomes of neonates listed for heart transplantation at two medical centers from 1991 through 1994. STUDY DESIGN: Retrospective analysis was performed to examine waiting times, charges, morbidity, and outcomes. RESULTS: Of the 30 neonates listed for transplantation, 15 received hearts, with 10 late survivors. Waiting time increased from 25 +/- 8 days in 1991 and 1992 to 58 +/- 7 days in 1993 and 1994 (p < 0.01), and the hospital charge per patient increased from $118,300 +/- $31,500 to $198,700 +/- $25,400 (p < 0.05). Freedom from sepsis predicted receiving heart transplantation (p < 0.01). Lack of a preoperative central intravenous catheter, no preoperative mechanical ventilation, and A-negative blood type predicted heart transplantation survival (p < 0.05). The chances of receiving and surviving transplantation were the same in the two periods. There was a trend toward greater morbidity among neonates waiting more than 35 days. CONCLUSIONS: Waiting times and charges have increased significantly over the last 4 years. Patients who are free of sepsis, lack a preoperative central intravenous catheter, are not mechanically ventilated preoperatively, and have A-negative blood type have better outcomes.

Cost and efficacy of surgical ligation versus transcatheter coil occlusion of patent ductus arteriosus.

OBJECTIVE: The purpose of this study was to compare cost and efficacy of surgical closure of patent ductus arteriosus using new critical pathway methods with outpatient transcatheter coil occlusion of patent ductus arteriosus. METHODS: Surgical techniques included a transaxillary, muscle-sparing thoracotomy, triple ligation of the patent ductus arteriosus, no chest tube, and discharge from the hospital within 24 hours. Transcatheter coil occlusion of patent ductus arteriosus was done as an outpatient procedure. Costs were compared with inclusion of all hospital and professional charges. RESULTS: From July 1994 until March 1996, 20 patients underwent coil occlusion of patent ductus arteriosus and 20 patients underwent surgical closure of patent ductus arteriosus. Duration of hospitalization was significantly less for the patients receiving coil occlusion (11 +/- 6 hours) as compared with that for the patients having surgical ligation (28 +/- 7 hours, p < 0.05). Total charges were similar for surgical ligation ($7101 +/- $408) as compared with those for coil occlusion ($7104 +/- $886, p > 0.05). Morbidity in coil occlusion included inability to occlude the patent ductus arteriosus in two patients (2/20, 10%) and residual patency in two patients (2/18, 11%). Morbidity in the surgical group included nausea and vomiting necessitating hospitalization for more than 36 hours in one patient (1/20, 5%), transient left recurrent laryngeal nerve palsy in one (1/20, 5%), and pneumothorax in two patients (2/20, 10%). There were no instances of residual patency in the surgical group. CONCLUSIONS: Transaxillary thoracotomy without tube thoracostomy and with critical pathway methods allows safe and effective ligation of a patent ductus arteriosus with early hospital discharge. This surgical method has similar cost, higher efficacy rate, and applicability in all patients as compared with newer transcatheter coil occlusion techniques for closure of a patent ductus arteriosus.

Economic benefits of parasite control in cattle.

The economic losses often associated with parasitism in cattle are universally accepted. The degree of economic significance related to these losses, the burdens of parasites required to cause such losses, and the specific control measures needed to avoid these losses are, however, topics of serious debate and outright disagreement among parasitologists and veterinarians. This is because most cattle have parasite burdens that are truly subclinical, with no obvious signs of parasitism but significant losses in potential production. These losses are often very insidious in nature and often difficult to prove statistically in a consistent manner. This discussion focuses on the need to: (1) define the benefits related to parasite control in cattle; (2) develop clear and effective parasite control recommendations that will allow the producer to realize these benefits; (3) effectively transfer this information to the cattleman.