Viral dynamics of the SARS-CoV-2 Omicron Variant in Paediatric Patients; A prospective cohort study.

BACKGROUND: There are limited data on the viral dynamics of SARS-CoV-2 in children. Understanding viral load changes over the course of illness and duration of viral shedding may provide insight into transmission dynamics to inform public health and infection control decisions. METHODS: We conducted a prospective cohort study of children 18 years and younger with PCR confirmed SARS-CoV-2 between February 1, 2022 and March 14, 2022. SARS-CoV-2 testing occurred on daily samples for 10 days; a subset of participants completed daily rapid antigen testing (RAT). Viral RNA trajectories were described in relation to symptom onset and resolution. The associations between both time since symptom onset/resolution and non-infectious viral load were evaluated using a Cox proportional hazards model. FINDINGS: Among 101 children aged 2 to 17 years, the median time to study-defined non-infectious viral load was 5 days post symptom onset, with 75% meeting this threshold by 7 days, and 90% by 10 days. On the day of and day after symptom resolution, 43 of 87 (49%) and 52 (60%) had met the non-infectious thresholds, respectively. Of the 50 participants completing RAT, positivity at symptom onset and on the day after symptom onset was 67% (16/24) and 75% (14/20). On the first day where the non-infectious threshold was met, 61% (n = 27/44) of participant RAT results were positive. INTERPRETATION: Children often met the study-defined non-infectiousness threshold on the day after symptom resolution. RAT tests were often negative early in the course of illness and should not be relied on to exclude infection. CLINICAL TRIALS REGISTRATION: NCT05240183.

Automated prediction of cardiorespiratory deterioration in patients with single-ventricle parallel circulation: A multicenter validation study.

Objectives: Patients with single-ventricle physiology have a significant risk of cardiorespiratory deterioration between their first- and second-stage palliation surgeries. Detection of deterioration episodes may allow for early intervention and improved outcomes. Methods: A prospective study was executed at Nationwide Children's Hospital, Children's Hospital of Philadelphia, and Children's Hospital Colorado to collect physiologic data of subjects with single ventricle physiology during all hospitalizations between neonatal palliation and II surgeries using the Sickbay software platform (Medical Informatics Corp). Timing of cardiorespiratory deterioration events was captured via chart review. The predictive algorithm previously developed and validated at Texas Children's Hospital was applied to these data without retraining. Standard metrics such as receiver operating curve area, positive and negative likelihood ratio, and alert rates were calculated to establish clinical performance of the predictive algorithm. Results: Our cohort consisted of 58 subjects admitted to the cardiac intensive care unit and stepdown units of participating centers over 14 months. Approximately 28,991 hours of high-resolution physiologic waveform and vital sign data were collected using the Sickbay. A total of 30 cardiorespiratory deterioration events were observed. the risk index metric generated by our algorithm was found to be both sensitive and specific for detecting impending events one to two hours in advance of overt extremis (receiver operating curve = 0.927). Conclusions: Our algorithm can provide a 1- to 2-hour advanced warning for 53.6% of all cardiorespiratory deterioration events in children with single ventricle physiology during their initial postop course as well as interstage hospitalizations after stage I palliation with only 2.5 alarms being generated per patient per day.

Open Chest Duration Following Congenital Cardiac Surgery Increases Risk for Surgical Site Infection.

Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p < 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.

Survival of Children With Pulmonary Embolism Supported by Extracorporeal Membrane Oxygenation.

The purpose of this study was to describe the demographics and in-hospital mortality of children (<18 years) from 2007 to 2018 supported by Extracorporeal Membrane Oxygenation (ECMO) for a primary diagnosis of pulmonary embolism and reported to the Extracorporeal Life Support Organization database. Fifty-six patients were identified and 54 were included in this analysis. A total of 33 patients (61%) survived. No differences in demographics or ECMO details (duration, mode, and support type) were found between survivors and non-survivors. When ECMO complications were compared, pulmonary bleeding occurred more frequently in non-survivors (23.8%, n = 5) compared to survivors (n = 0) (p = 0.006).

Prevalence of SARS-CoV-2 infection among people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic.

OBJECTIVES: People experiencing homelessness are at increased risk of SARS-CoV-2 infection. This study reports the point prevalence of SARS-CoV-2 infection during testing conducted at sites serving people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic. We also explored the association between site characteristics and prevalence rates. METHODS: The study included individuals who were staying at shelters, encampments, COVID-19 physical distancing sites, and drop-in and respite sites and completed outreach-based testing for SARS-CoV-2 during the period April 17 to July 31, 2020. We examined test positivity rates over time and compared them to rates in the general population of Toronto. Negative binomial regression was used to examine the relationship between each shelter-level characteristic and SARS-CoV-2 positivity rates. We also compared the rates across 3 time periods (T1: April 17-April 25; T2: April 26-May 23; T3: May 24-June 25). RESULTS: The overall prevalence of SARS-CoV-2 infection was 8.5% (394/4657). Site-specific rates showed great heterogeneity with infection rates ranging from 0% to 70.6%. Compared to T1, positivity rates were 0.21 times lower (95% CI: 0.06-0.75) during T2 and 0.14 times lower (95% CI: 0.04-0.44) during T3. Most cases were detected during outbreak testing (384/394 [97.5%]) rather than active case finding. CONCLUSION: During the first wave of the pandemic, rates of SARS-CoV-2 infection at sites for people experiencing homelessness in Toronto varied significantly over time. The observation of lower rates at certain sites may be attributable to overall time trends, expansion of outreach-based testing to include sites without known outbreaks, and/or individual site characteristics.

RéSUMé: OBJECTIFS: Les personnes en situation d'itinérance courent un risque accru de contracter une infection par le SRAS-CoV-2. Notre étude rend compte de la prévalence ponctuelle des infections par le SRAS-CoV-2 au cours de tests de dépistage menés dans des lieux de services aux personnes en situation d'itinérance de Toronto au cours de la première vague de la pandémie de COVID-19. Nous avons aussi exploré l'association entre les caractéristiques de ces lieux et les taux de prévalence. MéTHODE: L'étude a inclus les personnes séjournant dans des refuges, des campements, des lieux de distanciation physique et des centres d'accueil et de répit et ayant subi un test de dépistage de proximité du SRAS-CoV-2 entre le 17 avril et le 31 juillet 2020. Nous avons examiné les taux de positivité des tests au fil du temps et nous les avons comparés aux taux dans la population générale de Toronto. Des analyses de régression binomiales négatives ont été effectuées pour étudier la relation entre chaque caractéristique au niveau des refuges et les taux de positivité au SRAS-CoV-2. Nous avons aussi comparé les taux de trois intervalles (I1: 17 au 25 avril; I2: 26 avril au 23 mai; I3: 24 mai au 25 juin). RéSULTATS: La prévalence globale des infections par le SRAS-CoV-2 était de 8,5 % (394/4 657). Les taux d'infection spécifiques aux lieux de services ont présenté une grande hétérogénéité, soit de 0 % à 70,6 %. Comparés au 1er intervalle (I1), les taux de positivité ont été 0,21 fois plus faibles (IC de 95% : 0,06 ­ 0,75) durant l'I2 et 0,14 fois plus faibles (IC de 95% : 0,04 ­ 0,44) durant l'I3. La plupart des cas ont été détectés lors d'un dépistage en cours d'éclosion (384/394 [97,5%]) et non lors d'une recherche active de cas. CONCLUSION: Au cours de la première vague de la pandémie, les taux d'infection par le SRAS-CoV-2 dans les lieux de services aux personnes en situation d'itinérance de Toronto ont varié de façon significative au fil du temps. L'observation de taux plus faibles dans certains lieux pourrait s'expliquer par les tendances temporelles globales, par l'expansion des activités de dépistage de proximité pour inclure les lieux sans éclosion connue et/ou par les caractéristiques individuelles des lieux.

Achieving Sustainability in Reducing Unplanned Extubations in a Pediatric Cardiac ICU.

OBJECTIVES: To determine the incidence of unplanned extubations in a pediatric cardiac ICU in order to prove sustainability of our previously implemented quality improvement initiative. Additionally, we sought to identify risk factors associated with unplanned extubations as well as review the overall outcome of this patient population. DESIGN: Retrospective chart review. SETTING: Pediatric cardiac ICU at Children's Hospital of Colorado on the Anschutz Medical Center of the University of Colorado. PATIENTS: Intubated and mechanically ventilated patients in the cardiac ICU from July 2011 to December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 2,612 hospitalizations for 2,067 patients were supported with mechanical ventilation. Forty-five patients had 49 episodes of unplanned extubations (four patients > 1 unplanned extubation). The average unplanned extubation rate per 100 ventilator days was 0.4. Patients who had an unplanned extubation were younger (0.09 vs 5.45 mo; p < 0.001), weighed less (unplanned extubation median weight of 3.0 kg [interquartile range, 2.5-4.5 kg] vs control median weight of 6.0 kg [interquartile range, 3.5-13.9 kg]) (p < 0.001), and had a longer length of mechanical ventilation (8 vs 2 d; p < 0.001). Patients who had an unplanned extubation were more likely to require cardiopulmonary resuscitation during their hospital stay (54% vs 18%; p < 0.001) and had a higher likelihood of in-hospital mortality (15% vs 7%; p = 0.001). There was a significant difference in surgical acuity as denoted by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score and patients with an unplanned extubation had a higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category (p = 0.019). Contributing factors associated with unplanned extubation were poor endotracheal tube tape integrity, inadequate tube securement, and/or inadequate sedation. A low rate of unplanned extubation was maintained even in the setting of increasing patient complexity and an increase in patient volume. CONCLUSIONS: A low rate of unplanned extubation is sustainable even in the setting of increased patient volume and acuity. Additionally, early identification of patients at higher risk of unplanned extubation may also contribute to decreasing the incidence of unplanned extubation.

Initiating a Fontan multidisciplinary clinic: Decreasing care variability, improving surveillance, and subsequent treatment of Fontan survivors.

BACKGROUND: Children with single ventricle (SV) heart disease who undergo Fontan operation are at risk for developing multiorgan dysfunction. Although survival has improved, significant comorbidities involving multiple organ systems may develop, requiring evaluation and management by many subspecialists. Using data from an internal survey, we documented high care variability for our Fontan population. We then developed a multidisciplinary clinic, designed and implemented a clinical care pathway to decrease variability of patient assessment. METHODS: After creating a multidisciplinary team and a clinical care pathway, we initiated a multidisciplinary clinic (MDC) where patients could see multiple subspecialists during a single encounter. We then monitored our effectiveness by retrospective chart review to determine care pathway adherence (process measure) and incidence of new diagnoses of end-organ injury (outcome measure) as well interventions implemented. Adherence was analyzed using statistical process control (SPC) charts. RESULTS: Eighty-six patients were seen in the MDC from January 2016 to September 2017. The proportion of patients with appropriate testing increased, related to strong care pathway adherence. A significant amount of novel pathology was diagnosed in all evaluated organ systems, both Fontan-associated comorbidities and general pediatric diagnoses. Subsequent interventions included cardiac catheterization n = 21 (31%) with more than half of these patients undergoing intervention n = 17 (20%), and liver biopsy n = 9 (10%). Additionally, 58 patients (67%) were referred to a neuropsychologist based on perceived clinical need, with n = 34 (40%) undergoing a neuropsychological evaluation. CONCLUSIONS: Children who have undergone Fontan palliation are at risk for developing cardiac and noncardiac comorbidities. Use and adherence to an institutional care pathway resulted in the diagnosis of significant novel pathology and subsequently provided opportunity for intervention.

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals.

OBJECTIVE: Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children's hospitals. DESIGN: All adults (≥18 years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO-free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes. SETTING: Tertiary care children's hospitals. RESULTS: A total of 4665 adult patients underwent ACHD surgery in 39 children's hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO. CONCLUSIONS: There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.

Vascular anatomical considerations and clinical decision making during insertion of the Avalon® Elite Dual Lumen single-site veno-venous ECMO cannula in children weighing less than 20 kg.

The correct selection and placement of a single-site Avalon® Elite Dual Lumen Cannula for veno-venous extracorporeal membrane oxygenation (ECMO) in children weighing less than 20 kg is dependent on both the mechanical characteristics of the catheter, including length and diameter, as well as the unique vascular anatomic considerations of the patient. This manuscript describes the development of a clinical strategy, over a four-year period from 2012-2016, for cannula selection to reduce the risk of migration and malposition in 20 critically ill children weighing less than 20 kg who presented for veno-venous ECMO.

Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery.

OBJECTIVES: Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival. METHODS: All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed. RESULTS: Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO. CONCLUSIONS: Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.

Suspected necrotising enterocolitis after surgery for CHD: an opportunity to improve practice and outcomes.

Infants with CHD are at increased risk of necrotising enterocolitis, which can interfere with the achievement of adequate nutrition and, ultimately, growth and development. Necrotising enterocolitis is classified by severity as suspected, confirmed, and advanced. We sought to quantify the incidence of all types of necrotising enterocolitis among infants who underwent surgery, with a particular focus on suspected necrotising enterocolitis. This is a retrospective review of all infants <6 months of age who underwent cardiac surgery during 2012 and 2013 at Children's Hospital Colorado. We examined the hospital course of 265 hospitalisations (n=251 patients) and found 18 patients (19 hospitalisations) with suspected necrotising enterocolitis and 16 patients (16 hospitalisations) with confirmed or advanced necrotising enterocolitis. Single-ventricle physiology, lower weight, and younger age were associated with necrotising enterocolitis. Patients with all types of necrotising enterocolitis experienced prolonged length of hospital stay. We found suspected necrotising enterocolitis to be as common as confirmed necrotising enterocolitis, and it frequently occurred early in the post-operative course. We speculate that suspected necrotising enterocolitis may often be overlooked in research owing to a reliance on billing codes. Nevertheless, suspected necrotising enterocolitis poses a substantial barrier to post-operative progression of the CHD patient, as does confirmed necrotising enterocolitis. Following the diagnosis of all types of necrotising enterocolitis, there was wide variability in practice patterns. In response to this variability, we developed care guidelines for the diagnosis and treatment of necrotising enterocolitis in this population.

Data-Driven Quality Improvement Project to Increase the Value of the Congenital Echocardiographic Report.

Echocardiography is the primary diagnostic modality for congenital heart disease patients. The written report is used to communicate with the care team and organization is often divided into the body with detailed findings and the conclusions with important findings summarized. Strategies to increase workflow efficiency include batch writing of reports after performance of multiple echocardiograms and the use of report templates which may contribute to discrepancies within report leading to potential downstream medical errors. The aim of this project was to measure the rate of inconsistencies in the echocardiogram reports and through an iterative series of process improvement decrease this rate while maintaining sonographer efficiency and diagnostic accuracy. The discrepancy rate, diagnostic error rate, and sonographer productivity were collected one-year prior and during the iterative quality improvement process. The primary outcome and discrepancies in reports were determined by two reviewers: an experienced pediatric echocardiographic cardiologist and a senior sonographer. Minor discrepancies were defined as contradictions between the body and the conclusion of the report that were unlikely to affect patient care. Major discrepancies were defined as discrepancies between the body and the conclusion that had significant potential to affect patient care. Sonographer productivity was measured as studies per sonographer per month. Our primary intervention was to initiate a quarterly QI meeting and to decrease the batch writing of preliminary echocardiogram reports. No major discrepancies were identified pre- or post-intervention. The minor discrepancies decreased from 40.7 to 6%. Sonographer productivity was not significantly changed with a slight increase from 100 studies/sonographer/month during the baseline to 101 studies/sonographer/month during the intervention. There was no change in major or minor diagnostic error rate. Our quality improvement intervention increased the value of our reports by significantly decreasing minor discrepancies without negatively impacting sonographer productivity or diagnostic accuracy.

Toward standardization of care: The feeding readiness assessment after congenital cardiac surgery.

BACKGROUND: Feeding practices after neonatal and congenital heart surgery are complicated and variable, which may be associated with prolonged hospitalization length of stay (LOS). Systematic assessment of feeding skills after cardiac surgery may earlier identify those likely to have protracted feeding difficulties, which may promote standardization of care. METHODS: Neonates and infants ≤3 months old admitted for their first cardiac surgery were retrospectively identified during a 1-year period at a single center. A systematic feeding readiness assessment (FRA) was utilized to score infant feeding skills. FRA scores were assigned immediately prior to surgery and 1, 2, and 3 weeks after surgery. FRA scores were analyzed individually and in combination as predictors of gastrostomy tube (GT) placement prior to hospital discharge by logistic regression. RESULTS: Eighty-six patients met inclusion criteria and 69 patients had complete data to be included in the final model. The mean age of admit was five days and 51% were male. Forty-six percent had single ventricle physiology. Twenty-nine (42%) underwent GT placement. The model containing both immediate presurgical and 1-week postoperative FRA scores was of highest utility in predicting discharge with GT (intercept odds = 10.9, P = .0002; sensitivity 69%, specificity 93%, AUC 0.913). The false positive rate was 7.5%. CONCLUSIONS: In this analysis, systematic and standardized measurements of feeding readiness employed immediately before and one week after congenital cardiac surgery predicted need for GT placement prior to hospital discharge. The FRA score may be used to risk stratify patients based on likelihood of prolonged feeding difficulties, which may further improve standardization of care.

Development of quality metrics for ambulatory pediatric cardiology: Infection prevention.

INTRODUCTION: In 2012, the American College of Cardiology's (ACC) Adult Congenital and Pediatric Cardiology Council established a program to develop quality metrics to guide ambulatory practices for pediatric cardiology. The council chose five areas on which to focus their efforts; chest pain, Kawasaki Disease, tetralogy of Fallot, transposition of the great arteries after arterial switch, and infection prevention. Here, we sought to describe the process, evaluation, and results of the Infection Prevention Committee's metric design process. METHODS: The infection prevention metrics team consisted of 12 members from 11 institutions in North America. The group agreed to work on specific infection prevention topics including antibiotic prophylaxis for endocarditis, rheumatic fever, and asplenia/hyposplenism; influenza vaccination and respiratory syncytial virus prophylaxis (palivizumab); preoperative methods to reduce intraoperative infections; vaccinations after cardiopulmonary bypass; hand hygiene; and testing to identify splenic function in patients with heterotaxy. An extensive literature review was performed. When available, previously published guidelines were used fully in determining metrics. RESULTS: The committee chose eight metrics to submit to the ACC Quality Metric Expert Panel for review. Ultimately, metrics regarding hand hygiene and influenza vaccination recommendation for patients did not pass the RAND analysis. Both endocarditis prophylaxis metrics and the RSV/palivizumab metric passed the RAND analysis but fell out during the open comment period. Three metrics passed all analyses, including those for antibiotic prophylaxis in patients with heterotaxy/asplenia, for influenza vaccination compliance in healthcare personnel, and for adherence to recommended regimens of secondary prevention of rheumatic fever. CONCLUSIONS: The lack of convincing data to guide quality improvement initiatives in pediatric cardiology is widespread, particularly in infection prevention. Despite this, three metrics were able to be developed for use in the ACC's quality efforts for ambulatory practice.

Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs.

OBJECTIVES: Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. DESIGN: Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. PATIENTS: All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS: Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.

Association of Pediatric Cardiac Surgical Volume and Mortality After Cardiac ECMO.

Centers with higher surgical and extracorporeal membrane oxygenation (ECMO) volumes have improved survival for children undergoing pediatric cardiac surgery and ECMO, respectively. We examined the relationship between both cardiac surgical and cardiac ECMO volumes, with survival. Using data from the Pediatric Health Information System, we reviewed patients who underwent ECMO during the hospitalization for cardiac surgery or heart transplantation from January 2003 to June 2014. Among 106,967 patients in 43 centers undergoing a Risk Adjustment for Congenital Heart Surgery-1 1-6 procedure (n = 104,951) or cardiac transplantation (n = 2,016), 2.9% (n = 3,069) underwent ECMO support. Centers were categorized into volume quartiles based on annual ECMO and cardiac surgical volumes. Multivariable logistic regression models controlling for clustering by center and adjusting for factors associated with mortality were constructed. Although mortality was lower in ECMO centers that performed ≥7 ECMO runs (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.22-0.88)] and centers performing ≥158 cardiac surgical cases (OR: 0.37, 95% CI: 0.22-0.63), surgical volume was more strongly associated with ECMO mortality. Centers with higher cardiac surgical volume had fewer ECMO complications. Cardiac surgical volume, compared with ECMO volume, is more strongly associated with cardiac ECMO survival.

Noncompliance to a Postoperative Algorithm Using Feeding Readiness Assessments Prolonged Length of Stay at a Pediatric Heart Institute.

INTRODUCTION: Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS. METHODS: We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a "sentinel" FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm. RESULTS: Sixty-nine patients were included. Forty-nine complied with the algorithm (71%), and 45 received GT (65.2%). Noncompliers had significantly longer LOS (34 versus 25 days; P = 0.01). Among GT recipients, noncompliers waited 6 additional days for a GT compared with compliers (P ≤ 0.001). Subjective decisions to extend oral feeding trials or await results of a swallow study were associated with algorithm noncompliance. CONCLUSIONS: This audit of compliance to a feeding algorithm after pediatric cardiac surgery highlighted variability of practice, including relying on subjective appraisals of feeding skills over objective FRAs. This variability was associated with increased LOS and can be hypothesis-generating for future quality improvement efforts.