Department of Pediatrics, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA.
Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
Pediatr Crit Care Med. 2020 Sep;21(9):e848-e857. doi: 10.1097/PCC.0000000000002478.
In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers. This multidisciplinary quality improvement project standardized perioperative management in a large referral center.
Quality improvement project.
High volume cardiac center, tertiary care children's hospital.
Neonates undergoing Norwood operation.
The quality improvement team developed and implemented a clinical guideline (preoperative admission to 48 hr after surgery). The composite process metric, Guideline Adherence Score, contained 13 recommendations in the guideline that reflected consistent care for all patients.
One-hundred two consecutive neonates who underwent Norwood operation (January 1, 2013, to July 12, 2016) before guideline implementation were compared with 50 consecutive neonates after guideline implementation (July 13, 2016, to May 4, 2018). No preguideline operations met the goal Guideline Adherence Score. In the first 6 months after guideline implementation, 10 of 12 operations achieved goal Guideline Adherence Score and continued through implementation, reaching 100% for the last 10 operations. Statistical process control analysis demonstrated less variability and decreased hours of postoperative mechanical ventilation and cardiac ICU length of stay during implementation. There were no statistically significant differences in major hospital complications or in 30-day mortality. A higher percentage of patients were extubated by postoperative day 2 after guideline implementation (67% [30/47] vs 41% [41/99], respectively; p = 0.01). Of these patients, reintubation within 72 hours of extubation significantly decreased after guideline implementation (0% [0/30] vs 17% [7/41] patients, respectively; p = 0.02).
This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2. Establishment of standard processes can lead to best practices to decrease major adverse events.
单心室心脏缺陷的诺伍德手术院内并发症是发病率和死亡率的主要原因。住院治疗的变异性在中心内和中心之间都存在。本多学科质量改进项目在一个大型转诊中心标准化了围手术期管理。
质量改进项目。
大容量心脏中心，三级儿童保健医院。
接受诺伍德手术的新生儿。
质量改进团队制定并实施了临床指南（术前入院至术后 48 小时）。综合过程指标，即指南依从评分，包含指南中的 13 项建议，反映了所有患者的一致护理。
在指南实施前（2013 年 1 月 1 日至 2016 年 7 月 12 日），102 例连续接受诺伍德手术的新生儿与指南实施后（2016 年 7 月 13 日至 2018 年 5 月 4 日）的 50 例连续新生儿进行了比较。没有符合指南依从评分的预指南手术。在指南实施后的头 6 个月内，12 次手术中有 10 次达到了目标指南依从评分，并持续实施，最后 10 次手术达到了 100%。统计过程控制分析表明，在实施过程中，变异性降低，术后机械通气时间和心脏重症监护病房住院时间减少。主要医院并发症或 30 天死亡率无统计学差异。在指南实施后，有更高比例的患者在术后第 2 天拔管（分别为 67%[30/47]和 41%[41/99]；p=0.01）。在这些患者中，拔管后 72 小时内再次插管显著减少（分别为 0%[0/30]和 17%[7/41]；p=0.02）。
本倡议在大型中心成功实施了一项标准化的围手术期护理指南，用于接受诺伍德手术的新生儿。在指南依从评分、术后机械通气时间和心脏重症监护病房住院时间方面，展示了积极的统计过程控制中心线变化。更高比例的患者在术后第 2 天成功拔管。建立标准流程可以采用最佳实践来减少主要不良事件。
