Identifying Food Insecurity in Cardiology Clinic and Connecting Families to Resources.

BACKGROUND: Food insecurity (FI) increases children's risk for illness and developmental and behavioral problems, which are ongoing concerns for congenital heart disease (CHD) patients. In 2020, 14.8% of households with children suffered from FI. The Hunger Vital Signs (HVS) asks 2 questions to assess FI. The global aim of the project is to implement HVS and connect FI families to resources. METHODS: Stakeholders identified 6 critical drivers in implementing FI screening at an outpatient cardiology clinic and conducted plan-do-study-act (PDSA) cycles to implement HVS. Over the 13-month study period, time series analyses were performed to assess our process measure (FI screening) and outcome measure (connection of FI families to resources). Demographics and severity of CHD were analyzed for FI families. RESULTS: Screening rates increased from 0% to >85%, screening 5064 families. Process evaluations revealed roadblocks including screening discomfort. FI families were more likely to identify as Black or multiple or other ethnicity. Severe CHD patients were at higher risk for FI (n = 106, odds ratio [OR] 1.67 [1.21-2.29], P = .002). Face-to-face meetings with social work and community partnerships reduced loss to follow-up and our ability to offer all FI families individualized FI resources. CONCLUSION: HVS screening can be implemented in a cardiology clinic to improve identification of FI families. A written tool can combat screening discomfort and improve identification of FI families. Children with severe CHD may be at increased risk for FI. A multidisciplinary team and community partnerships can improve individualized resource distribution.

Standardizing Discharge Furosemide Duration Following Congenital Heart Surgery.

Background: Pediatric cardiothoracic surgery has evolved over the last several decades with shorter bypass times and less need for hypothermic arrest. Diuretics have been commonly used in the post-operative period with no guidelines on duration following cardiopulmonary bypass. As a result, we conducted a single-center quality improvement project to reduce overuse of diuretics in post-operative patients without causing an increase in complications. We devised an early diuretic wean protocol that was implemented upon patient discharge. Methods: All patients who underwent uncomplicated congenital heart surgery after November 2018 were considered for the protocol. We defined an early diuretic wean protocol with a total duration of ten days of single diuretic therapy following hospital discharge. Patients were evaluated in clinic two weeks following discharge, after completion of diuretic therapy, to assess for clinical symptoms and development of effusions. Results: Retrospective pre-protocol data found the average duration a patient was on diuretics was 32 days following hospital discharge from uncomplicated congenital heart surgery. Following implementation of the protocol, there was a decrease in the total duration to 14 days, demonstrating a 56% decrease. With this practice change, there was no notable increase in adverse events. Conclusions: With implementation of the protocol, practice variability was minimized and the average post-operative diuretic duration was decreased without an increase in pleural and/or pericardial effusions or readmissiosn rates. Future directions and ongoing changes include expanding to a multicenter quality improvement collaborative focusing on decreasing the average duration of furosemide to less than five days after hospital discharge.

Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project.

Background Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may impact postoperative length of stay (LOS). We used collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. Methods and Results Nine pediatric heart centers partnered together through 2 learning networks. Patients undergoing 1 of 9 benchmark congenital heart operations were included. Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29). Conclusions We successfully lowered postoperative CT duration and observed an associated reduction in LOS across 9 centers using collaborative learning methodology.

Center Variation in Chest Tube Duration and Length of Stay After Congenital Heart Surgery.

BACKGROUND: Nearly every child undergoing congenital heart surgery has chest tubes placed intraoperatively. Center variation in removal practices and impact on outcomes has not been well described. This study evaluated variation in chest tube management practices and outcomes across centers. METHODS: The study included patients undergoing any of 10 benchmark operations from June 2017 to May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC3) and Pediatric Cardiac Critical Care Consortium (PC4) centers. Clinical data from PC4 centers were merged with chest tube data from PAC3 centers. Practices and outcomes were compared across centers in univariate and multivariable analysis. RESULTS: The cohort included 1029 patients (N = 9 centers). Median chest tube duration varied significantly across centers for 9 of 10 benchmark operations (all P ≤ .03), with a "model" center noted to have the shortest duration for 9 of 10 operations (range, 27.9% to 87.4% shorter duration vs other centers across operations). This effect persisted in multivariable analysis (P < .0001). The model center had higher volumes of chest tube output before removal (median, 8.5 mL/kg/24 h [model] vs 2.2 mL/kg/24 h [other centers]; P < .001], but it did not have higher rates of chest tube reinsertion (model center 1.3% vs 2.1%; P = .59) or readmission for pleural effusion (model center 4.4% vs 3.0%; P = .31), and had the shortest length of stay for 7 of 10 operations. CONCLUSIONS: This study suggests significant center variation in chest tube removal practices and associated outcomes after congenital heart surgery. Best practices used at the model center have informed the design of an ongoing collaborative learning project aimed at reducing chest tube duration and length of stay.

Hybrid Strategy for Neonates With Ductal-Dependent Systemic Circulation at High Risk for Norwood.

BACKGROUND: Hypoplastic left heart syndrome and other cardiac lesions with ductal-dependent systemic circulation continue to be challenging to manage, especially in high-risk (HR) populations (those with prematurity, multiple congenital anomalies, moderate to severe tricuspid regurgitation, hemodynamic instability, intact atrial septum). METHODS: A retrospective study on our institution's experience implementing a hybrid strategy as initial palliation in HR patients with ductal-dependent systemic circulation in HR patients undergoing Norwood versus hybrid procedure. From July 2004 to May 2008, 16 HR patients underwent stage I Norwood procedure. After implementation of a hybrid strategy in 2008, 24 HR patients underwent hybrid procedure from May 2008 to November 2015. RESULTS: There was no difference in gestational age, age at procedure, or hospital length of stay. The HR Hybrid group had lower mean weight (2.6 kg vs 3.1 kg, p = 0.026). Thirty-day mortality was lower in the HR Hybrid group (4% vs 31%, p = 0.019), although there was no difference in interstage mortality (17% vs 9%, p = 0.396). Catheter-based reintervention was more prevalent in the HR Hybrid group, but did not have a negative impact on survival. One-year transplant-free survival was similar (p = 0.416). HR Hybrid patients weighing less than 2.6 kg had higher overall survival (83% vs 25%, p = 0.013), as did patients who were premature (70% vs 0%, p = 0.003). CONCLUSIONS: In high-risk patients, the hybrid procedure appears to have lower 30-day mortality and may have a survival benefit in premature patients and those less than 2.6 kg. Long-term attrition in this high-risk population is ongoing regardless of early strategy.