Variation in Implementation and Outcomes of Early Extubation Practices After Infant Cardiac Surgery

• Type of Material: Article
• Authors: Katherine E. Bates, Michigan Medicine; William Mahle, Emory University; Lauren Bush, Michigan Medicine; Janet Donohue, Michigan Medicine; Michael G. Gaies, Michigan Medicine; Susan C. Nicolson, University of Pennsylvania; Lara Shekerdemian, Texas Children’s Hospital; Madolin Witte, University of Utah; Michael Wolf, Emory University; Judy A. Shea, University of Pennsylvania; Donald S. Likosky, Michigan Medicine; Sara K. Pasquali, Michigan Medicine
• Language: English
• Date: 2019-05-01
• Publisher: Elsevier Science Inc.
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 by The Society of Thoracic Surgeons Published by Elsevier.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.athoracsur.2018.11.031
• Title of Journal or Parent Work: Annals of Thoracic Surgery
• Volume: 107
• Issue: 5
• Start Page: 1434
• End Page: 1440
• Grant/Funding Information: None declared
• Keywords: Life Sciences & Biomedicine; Science & Technology; Quality improvement; Cardiovascular System & Cardiology; Intervention; Respiratory System; Cardiac & Cardiovascular Systems; Surgery
• Research Categories: Health Sciences, Health Care Management; Health Sciences, Public Health; Health Sciences, Medicine and Surgery; Health Sciences, Human Development

Abstract

Background: The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes. Methods: Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites. Results: A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p < 0.001); however, there was variation in the post-CPG median time to extubation (0.3 to 5.3 hours, p = 0.01) and magnitude of change (−73.3% to −99.2%). Site A achieved the shortest post-CPG time to extubation and had the greatest percentage change. Two sites had significant decreases in medical ICU LOS in TOF patients; no hospital LOS changes were seen. All sites valued the collaborative learning strategy, site visits, CPG flexibility, and had similar core team composition. Site A used several unique strategies: inclusion of other staff and fellows, regular in-person data reviews, additional data collection, and creation of complementary protocols. Conclusions: All PHN CLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.