The Western Thoracic Surgical Association

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Quality Assurance in a Small Pediatric Cardiac Surgery program: Intraoperative monitoring, Technical Performance and Outcomes
*John M Karamichalis1, Alexandra Anastasopulos2, Hua Liu3, Meena Nathan3, Matthew Kimberling1, Kathy Jenkins3
1The Children's Hospital at Saint Francis, Tulsa, OK;2Brigham and Women's Hospital, Boston, MA;3Boston Children's Hospital, Boston, MA

OBJECTIVES: Quality assurance in small pediatric cardiac programs is particularly important, but can be challenging. We implemented comprehensive systems monitoring of intraoperative course, technical performance, and relation to clinical outcomes.METHODS: Intraoperative course including adverse events (revisions, reinstitution of bypass, technical issues), and technical performance scores (TPS) were prospectively monitored in all patients undergoing pediatric cardiac operations from April 2014 to June 2017 by a single surgeon. Previously published criteria for TPS based on predischarge echocardiographic findings and need for early postoperative reinterventions were used. TPS were assigned as class 1 (no residual lesion), 2 (minor residual lesion) or 3 (major residual lesion or reintervention). Outcomes were postoperative length of stay (PLOS) and major postoperative adverse events (MPAE), including mortality, stroke, cardiac arrest, ECMO and reoperations. Additional variables included weight, age, preoperative risk factors, procedure mortality STAT categories and unexpected intraoperative complex anatomical findings (UICAF). RESULTS: Among 142 surgical cases prospectively monitored, 38 with patent ductus arteriosus ligation only were excluded. Outcomes were Class 1 in 76 (73%); Class 2 20 (19%) and Class 3 8 (8%). Median LOS among 81 STAT 1-3 cases was 4 days and among 23 STAT 4-5 was 11 days. Univariate analysis showed that worse TPS was associated with longer cross-clamp and bypass times, higher STAT category, intraoperative events and the combination of preoperative risk factors with UICAF (p<0.05). Subgroup analysis showed a significant association between worse TPS and intraoperative events in the high risk STAT category group (p=0.02). Univariate analysis showed that MPAE were associated with the younger age, lower weight, prolonged cross-clamp and bypass times, high STAT categories and worse TPS (p<0.05). Subgroup analyses showed that (1) prolonged PLOS was associated with worse TPS in the low risk STAT category (p<0.001) and (2) worse TPS was associated with MPAE including mortality in both low (p<0 .0001) and high risk (p=0.007) STAT categories. Multivariate analysis showed that the best predictors of major postoperative events were TPS and STAT categories. CONCLUSIONS: The implementation of systems in a small pediatric cardiac surgery program monitoring TPS and intraoperative course is feasible and offers a robust quality improvement initiative. Suboptimal TPS (class 2 or 3) with high STAT categories operations are strongly associated with major postoperative adverse events.

STAT CategoryTechnical Performance ScoresMajor Postop Adverse EventsIntraoperative EventsPostop Length of Stay in days (median, IQ Range)
Low Risk (1-3)n=81class1:58(71.6%)
class2:18(22.2%)
class3:5(6.2%)
class 1:1(1.7%)
class 2:0(0%)
class 3:3(60%)
p value:<0.0001
class1:4(6.9%)
class2:3(16.7%)
class3:2(40%)
p value:054
class 1:3(1,16)
class 2:8(3,24)
class 3:27(3,72)
p value:<0.0001
High Risk(4-5)
n=23
class1:18(78.3%)
class2:2(8.7%)
class3:3(13.0%)
class1:3(16.7%)
class 2:0(0%)
class3:3(100%)
p value:0.007
class1:4(22.2%)
class 2:0(0%)
class3:3(100%)
p value:0.016
class 1:10(3,91)
class 2:10(5,15)
class 3:42(2,73)
p value:0.736
Total
n=104
class1:76(73.1%)
class2:20(19.2%)
class3:8(7.7%)
class 1:4(5.3%)
class 2:0(0%)
class 3:6(75%)
p value:<0.0001
class1:8(10.5%)
class 2:3(15%)
class3:5(62.5%)
p value:0.001
class 1:4(1,91)
class 2:8(3,24)
class 3:33(2,73)
p value:<0.0001


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