28. Proactive Risk Mitigation Reduces Post-Procedural Cardiac Arrests in High Risk Congenital Cardiac Patients

Objective: The prevalence of postoperative cardiac arrest (CA) increases with cardiothoracic surgical case complexity in pediatric cardiac patients and is associated with an overall mortality of 50%. Despite being a high performing cardiothoracic program with an overall surgical mortality rate under 2%, our rates of postoperative CA were higher than desired when compared to national registry data with an observed to expected (O/E) ratio well above 1. Utilizing quality improvement methodology we evaluated the impact of pro-active risk mitigation on post-procedural CA (pCA) in a high risk cohort of pediatric and congenital cardiac patients.

Methods: This single-center study utilized the Institute for Healthcare Improvement model to achieve the project aim. The PROMISE (PRO-active MItigation to decrease Serious adverse Events) program was implemented in July 2020 with prospective enrollment of pre-identified high-risk patients based on institution-specific historical data. PROMISE patients underwent a scheduled multi-disciplinary review via virtual platform at 4 timepoints peri-procedure (1 pre and 3 post) with discussion of patient-specific, anesthetic and procedural risks and subsequent development of a pro-active risk mitigation plan. Process measures analyzed included compliance with enrollment of eligible high-risk patients and completion of peri-procedural reviews. Outcome measures were derived from the Pediatric Cardiac Critical Care Consortium (PC4) national registry and included pCA occurring within 7 days of the index procedure and institution-specific O/E ratio for risk adjusted postoperative CA.

Results: Our baseline median cases between pCA in high risk patients was 3.5 cases and baseline median calendar days between pCA events was 21 days. Following implementation of the PROMISE program, we saw a shift on our statistical process control charts (Figure 1) with an increase in median cases between events to 14 cases and median calendar days between events to 110 days. Despite a low mortality rate, in the 12 months preceding PROMISE implementation, our O/E ratio for postoperative CA was 2.56, indicating more CAs than expected based on case-mix. In comparison to all PC4 centers (n = 49), we were the poorest performing center and a statistical outlier during the baseline period. In the 12 months following PROMISE implementation, we saw a reduction in our O/E ratio to 1.01, indicating a rate that would be expected based on case-mix and consistent with the aggregate mean PC4 CA rate (n = 61 centers).

Conclusions: Implementation of proactive risk mitigation strategies peri-procedurally in a high risk cohort of pediatric and congenital cardiac patients led to improvement in pCA with an increase in cases and calendar days between events. We additionally observed a decrease in postoperative CA O/E ratio.

Tara Cosgrove (1), Sergio Carrillo (1), Steven Cassidy (1), Jennifer Gauntt (1), Robert Gajarski (1), Mark Galantowicz (1), Catherine Krawczeski (1), (1) Nationwide Children's Hospital, Columbus, OH

Nathalie Roy

Invited Discussant

Dr. Nathalie Roy is a Fellow of the Royal College of Surgeons of Canada in Cardiac Surgery and Board Certified in Critical Care. She Graduated from Laval University Faculty of Medicine where she trained in General Surgery, followed by a residency in Cardiac Surgery at McGill University, with fellowships in Congenital Cardiovascular Surgery from the Hospital For Sick Children and the University of Toronto, UCSF, Stollery Children's Hospital and Boston Children's Hospital. Her critical care training was at Brigham and Women's Hospital. Dr. Roy's clinical interests focus on surgical critical care of the pediatric and adult patient with congenital heart disease, acute mechanical circulatory support (MCS), and thoracic transplantation. She is the Director of Cardiac Surgery Critical Care at Boston Children's Hospital and is involved in the training of fellows in the CICU.

Dr. Roy led the development and implementation of an Ehanced Recovery after Congential Cardiac Surgery program, a large heart center quality improvement initiative at Boston Children's Hospital, Her research was funded by a surgical investigator award from the AATS foundation. She and her colleagues have authored many publications and presented the program outcomes at national and international conferences. Dr. Roy was an active member of the 2021 American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group consensus document on a comprehensive approach to enhanced recovery ater pediatric cardiac surgery published in the Journal of Throacic and Cardiovascular Surgery. She became a member of the AATS in 2022.

Tara Cosgrove

Abstract Presenter

Tara Cosgrove is a pediatric cardiologist and Co-Executive Champion for Quality and Safety at The Heart Center at Nationwide Children's Hospital.  She is a Certified Professional in Patient Safety, a Lean Six Sigma Black Belt, and Master of Buisness Operational Excellence serving as an institutional leader for quality in safety as the Co-Lead for the Medication Safety Core Team and The Heart Center Quality Improvement Steering Committee.  Dr. Cosgrove's clinical practice as a general pediatric caridologist is broad with a primary focus on post-operative and acute care management.  

Specialties: Congenital, Perioperative Management/Critical Care