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

• 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
• Journal Title: Annals of Thoracic Surgery
• Volume: Volume 107, Number 5
• Publisher: Elsevier Science Inc. | 2019-05-01, Pages 1434-1440
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.athoracsur.2018.11.031
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Health Care Management; Health Sciences, Public Health; Health Sciences, Human Development
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Respiratory System; Surgery; Cardiovascular System & Cardiology; Quality improvement; Intervention

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.