1. Ventricular Septal Defect Pre-PICU Clinical Pathway
Daniel Lercher, MD1, Meg Kihlstrom, MD1, Nicole Conrad, MD2, Matt McDaniel, MD2, Karla Brown, PNP3, Wren Wallace, BSN, RN3, Joy Tokarczyk, CCP, LP3, Nathan Woody, CSSBB, Timothy M. Hoffman, MD1
1Department of Pediatrics, 2Anesthesiology, 3Surgery, University of North Carolina Chapel Hill Hospital
Background
Results
Results, continued
Figure 1. Control charts comparing institutional metrics from Society of Thoracic Surgeons (STS) database from 11/2014 through 1/2017. Vertical blue dashed line represents implementation of the perioperative clinical pathway 2/2017. Metrics include length of stay (LOS), operating room (OR) time, procedure time, and ventilator time.
After pathway implementation, 7 patients post VSD repair were compared to 32 historical controls.
There was a trend toward improvement in all outcomes investigated: Reduction of length of stay by 1.19 days (p-=0.195), OR time by 4 minutes (p= 0.795), procedure time by 24 minutes (p=0.108), and duration of mechanical ventilation by 646 minutes (p=0.195)
Improvement was seen in overall provider satisfaction (6%) and understanding of perioperative care (6%), as well as the transition from OR to PICU (10%)
Provider variability, especially in pediatric cardiac critical care, is inevitable as there is lack of practice models and large trials to guide best practice
Surgical ventricular septal defect (VSD) closure remains the most common pediatric cardiac surgery procedure
Aim to standardize perioperative care of pediatric patients presenting for VSD repair
National benchmarks varied, with length of stay (LOS) 4-6 days
Methods
Conclusions
Clinical pathway created by multi-disciplinary team
Standardization of practice in preoperative, intraoperative, and postoperative settings
LEAN six sigma methodologies
Process mapping from outpatient appointment for surgery through handoff to PICU
Checklist of institutional standards for the perioperative process
Inclusion: Patients presenting for VSD repair as outpatient
Exclusion: Inpatient at time of repair
Prospective data after pathway implementation from February to August 2017 compared to 3 year historical controls
Outcomes assessed included LOS, operating room time, procedure time, and time of mechanical ventilation
Pre- and post-implementation survey to assess satisfaction and perception of care
2-sample t-test used to calculate p-value with an alpha level of 0.05
QI tools to standardize care in our institution impact resource utilization in a positive manner
LOS trending towards national benchmarks, presumably from reduced ventilator time
Limitations include low number of prospective patients, ensuring provider compliance with pathway, and sustainability of pathway with addition of new providers to care team
Future endeavors include extrapolation of this pathway to more complex surgical interventions and assess impact on outcomes
References
Table 1. Survey results before and after pathway implementation. Providers from Pediatric Cardiac Anesthesia, Cardiology, Cardiothoracic Surgery, Critical Care Medicine, and Perfusion completed the survey. A 10 point Likert scale was utilized.
Scully BB et al. Current expectations for surgical repair of isolated ventricular septal defects. Ann Thorac Surg 2010 Feb; 89(2):544-9.
Schipper M et al. Surgical repair of ventricular septal defect: contemporary results and risk factors for a complicated course. Pediatr Cardiol 2017 Feb; 38(2):
Anderson BR et al. Contemporary outcomes of surgical ventricular septal defect closure. J Thorac Cardiovasc Surg 2013 Mar; 145(3):
University of North Carolina Children’s Hospital Project Ticker
VSD Patient Provider Survey Results
BEFORE
AFTER
%Change
Overall provider satisfaction with perioperative care of VSD patients
6.7
N=25
7.1
N=22
+6%
Understanding the perioperative plan for VSD Patients
6.9
7.3
+5.8%
Overall Satisfaction with transition from OR to PICU
7.4
+10%