Congenital heart defects (CHDs) are the most common birth defect, occurring in approximately 1 percent of births.They are the most common cause of infant deaths due to birth defects, and survivors often face health issues into adulthood.Variances in surgical practices to treat patients with congenital heart defects among different healthcare centers have led to inconsistent surgical outcomes, some with negative consequences for patients.
This collaborative project of Pediatric Heart Network (PHN) investigators and operations research experts at Georgia Institute of Technology aims to improve the outcome of CHD surgeries by establishing best clinical practice guidelines (CPGs) that can be adopted rapidly across multiple hospitals.
Systems process analyses were carried out at five pediatric heart centers to identify practice variance and associated processes and factors that offer opportunities for improving care delivery and clinical outcome. The team constructed a comprehensive care model to analyze the interplay of care and coordination, management, resources, and the interdependencies of practice on outcomes. Combining observations and data from each site, a large-scale simulation-decision- optimization model was designed. Recognizing that length of stay (LOS) is a good surrogate for success, the model was designed to identify factors that influence length of stay. Using clustering analysis and machine learning, seven factors were identified: pre-op procedures, surgery length, time of extubation (the removal of the breathing apparatus), tube-removal and chest closing, intensive care unit care management, discharge planning and education, and step down care.
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Further analysis and collaborative learning using multidisciplinary team site visits led to the decision to focus on time of extubation. A clinical practice guideline (CPG) regarding early removal of breathing apparatuses after surgery was established. Each hospital would adopt the new protocol and measure its impact according to the standards set forth by the Pediatric Heart Network.
Comparing outcomes during 12 months pre- and post-CPG implementation, after implementation we observed an increase in early extubation rates from 12 to 67 percent, and a decrease in median duration of postoperative intubation from 21.2 to 4.5 hours.There was also a trend toward shorter ICU length of stay (71.6 hours pre- versus 54.2 hours). Overall, the five hospital sites experienced LOS reductions ranging from 12 to 35 percent, decreased time to oral feeds, and an earlier discontinuation of IV analgesics.
Earlier resumption of normal feeding, and reduction in analgesics usage lessen risks of complications. Indeed, since analgesics have been associated with cognitive impairment and brain development in children, it is noteworthy that our post CPG data indicated a reduction of 25–42 percent analgesics usage. Shorter mechanical ventilation time and LOS for patients reduce exposure to critical care therapies and indwelling devices, which subsequently reduces the risk of hospital- acquired infections (HAI). HAI is one of the top 10 leading causes of death in the United States.
In terms of cost savings, our early extubation CPG results in roughly 27 percent savings, or $13,500 per surgical procedure, on average. It reduces 65 percent in clinical care cost, 46 percent in pharmacy, 44 percent in laboratory, and 32 percent in imaging. Each year approximately 40,000 babies are born in the United States with a congenital heart defect, many of whom require multiple surgical procedures. Hence, our work translates to more than 540 million U.S. dollars on procedural savings alone. In addition, there is great potential to magnify cost savings by adapting the CPG to conditions beyond congenital heart diseases, since intubation is required in many surgical procedures.
Finally, it is noteworthy that the hypothesis testing and dissemination of findings required less than two years, as opposed to conventional randomized trials that often take five years or more. Multiple sites adopted the changes with consistently good outcomes, thus providing high confidence in the clinical findings. Further, this work was accomplished with only a fraction (2 percent) of the budget of a typical clinical trial.The collaborative learning framework used herein can serve as a blueprint for other clinical and process improvement initiatives.