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Relationship between caseload and morbidity and mortality in pediatric cardiac surgery--a four year experience
Ovadia Dagan1, Einat Birk, Yakov Katz
1Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel. cicu_schneider@clalit.org.il
Insights
Increased caseload in pediatric cardiac surgery correlated with better outcomes and reduced mortality. Concentrating resources in high-volume centers may optimize care for children with congenital heart defects.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Congenital Heart Defects
Background:
- Mortality rates in congenital heart surgery are linked to surgical caseload.
- Long-term caseload changes at a single center may impact patient management and outcomes.
Purpose of the Study:
- To investigate the effect of increasing caseload on management and outcomes in pediatric cardiac surgery.
- To analyze trends in patient demographics, surgical practices, and complication rates over a four-year period.
Main Methods:
- Prospective data collection from a pediatric intensive care unit registry over four years.
- Analysis of parameters including age, surgery type, preventive measures, complications, and mortality.
- Specific analysis of arterial switch operations for bypass time and mechanical ventilation.
Main Results:
- Caseload increased, with a decrease in overall mortality rate (4.9% to 3.2%).
- Improved outcomes observed, including reduced diaphragm paralysis and acute renal failure-related deaths.
- Significant improvements in bypass time and mechanical ventilation duration for arterial switch operations.
Conclusions:
- Increased caseload in pediatric cardiac surgery is associated with improved management and reduced mortality.
- Concentrating quality management resources in high-caseload centers is recommended for optimal care of children with congenital heart disorders.
Background:
The mortality rate associated with congenital heart surgery is apparently related to caseload.
Objective:
To determine whether an increase in caseload over the long term at a single center affects management and outcome in children undergoing cardiac surgery.
Methods:
Data were collected prospectively over a 4 year period from the computerized registry of the hospital's pediatric intensive care unit. Five parameters were analyzed: age at surgery, type of surgery, preventive measures (open chest), surgery-related and other complications (diaphragm paralysis and acute renal failure, respectively), and mortality. The data of a single-type surgery (arterial switch) were analyzed for bypass time and mechanical ventilation on an annual basis.
Results:
The age distribution changed over the years, with more children under 1 year of age (20% newborns) undergoing surgery by the fourth year of the study. The caseload increased from 216 in the first year to 330 in the fourth, with a concomitant decrease in mortality rate from 4.9% to 3.2%. The chest was left open in 3.2% of patients in the first year and in 9.2% in the fourth year. The rate of diaphragm paralysis decreased from 6% to 2.4%. Death due to acute renal failure in patients requiring dialysis decreased from more than 80% in the first 2 years to 36% in the last two. These changes show an improvement but failed to reach statistical significance. Regarding the arterial switch operation, there was a significant improvement in pump time and duration of mechanical ventilation.
Conclusions:
The increase in caseload in pediatric cardiac surgery was accompanied by improved management, with a lower complications-related mortality rate. We suggest that for optimal care of children with congenital heart disorders, quality management resources should be concentrated in centers with high caseloads.