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Target-Based Care: An Intervention to Reduce Variation in Postoperative Length of Stay
Andrew Y Shin1, Isabelle J Rao2, Hannah K Bassett3
1Department of Pediatrics, Stanford University, Stanford, CA; Center for Pediatric and Maternal Value, Stanford University, Stanford, CA.
Insights
Implementing care targets at the point of care significantly reduced length of stay (LOS) and variation in LOS for pediatric cardiac surgery patients. This novel intervention improved efficiency without impacting patient safety metrics.
Area of Science:
- Pediatric Cardiac Surgery
- Healthcare Quality Improvement
- Clinical Workflow Optimization
Background:
- Postoperative length of stay (LOS) is a key metric in pediatric cardiac surgery.
- Reducing variation in LOS is crucial for efficient resource allocation and patient care.
- Current care pathways may lack standardized targets for critical postoperative milestones.
Purpose of the Study:
- To establish care targets for key postoperative events in pediatric cardiac surgery.
- To evaluate the impact of displaying these targets at the point of care on postoperative LOS.
- To assess the effect of this intervention on patient safety and family satisfaction.
Main Methods:
- Prospective cohort study with 2 years of historical controls.
- Intervention involved displaying care targets for extubation, ICU transfer, and discharge.
- Data collected on LOS, mechanical ventilation duration, reintubation, readmission, and family satisfaction.
Main Results:
- Significant reduction in variation for ICU LOS (SD difference -2.56, P < .01) and total LOS (SD difference -2.84, P < .001).
- Average reduction in ICU LOS by 0.97 days (P < .001) and total LOS by 1.18 days (P < .001).
- Intervention associated with shorter ICU LOS (β = -0.19, P < .001) and total postoperative LOS (β = -0.12, P = .02).
Conclusions:
- Target-based care is a simple, novel intervention.
- This approach is associated with reduced variation and absolute LOS.
- Effective across a diverse spectrum of complex pediatric cardiac surgeries.
Objectives:
To derive care targets and evaluate the impact of displaying them at the point of care on postoperative length of stay (LOS).
Study Design:
A prospective cohort study using 2 years of historical controls within a freestanding, academic children's hospital. Patients undergoing benchmark cardiac surgery between May 4, 2014, and August 15, 2016 (preintervention) and September 6, 2016, to September 30, 2018 (postintervention) were included. The intervention consisted of displaying at the point of care targets for the timing of extubation, transfer from the intensive care unit (ICU), and hospital discharge. Family satisfaction, reintubation, and readmission rates were tracked.
Results:
The postintervention cohort consisted of 219 consecutive patients. There was a reduction in variation for ICU (difference in SD -2.56, P < .01) and total LOS (difference in SD -2.84, P < .001). Patients stayed on average 0.97 fewer days (P < .001) in the ICU (median -1.01 [IQR -2.15, -0.39]), 0.7 fewer days (P < .001) on mechanical ventilation (median -0.54 [IQR -0.77, -0.50]), and 1.18 fewer days (P < .001) for the total LOS (median -2.25 [IQR -3.69, -0.15]). Log-transformed multivariable linear regression demonstrated the intervention to be associated with shorter ICU LOS (β coefficient -0.19, SE 0.059, P < .001), total postoperative LOS (β coefficient -0.12, SE 0.052, P = .02), and ventilator duration (β coefficient -0.21, SE 0.048, P < .001). Balancing metrics did not differ after the intervention.
Conclusions:
Target-based care is a simple, novel intervention associated with reduced variation in LOS and absolute LOS across a diverse spectrum of complex cardiac surgeries.
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