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Published on: January 17, 2011
Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study
Madolin K Witte1, William T Mahle2, Sara K Pasquali3
1Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.
Insights
Collaborative learning strategies improved early extubation rates for lower-complexity infant heart surgeries, with effects varying by hospital and procedure. Higher-complexity surgeries showed no change in extubation outcomes.
Area of Science:
- Pediatric Cardiac Surgery
- Clinical Practice Implementation
- Quality Improvement in Healthcare
Background:
- The Pediatric Heart Network Collaborative Learning Study implemented a clinical practice guideline to enhance early extubation after infant cardiac surgeries.
- This study investigated whether the guideline's success in improving extubation for specific procedures (tetralogy of Fallot, coarctation of the aorta) extended to other infant cardiac surgeries.
Purpose of the Study:
- To assess the impact of collaborative learning strategies on early extubation rates in infants undergoing cardiac surgeries not initially targeted by the clinical practice guideline.
- To determine if improvements in extubation practices demonstrated a 'spillover' effect to other patient populations.
Main Methods:
- Observational analysis of data from four hospitals participating in the Pediatric Heart Network Collaborative Learning Study.
- Comparison of aggregate early extubation rates and time to extubation between the 12 months pre-guideline and 12 months post-guideline implementation periods.
- Analysis stratified by surgical complexity (lower vs. higher) and specific procedures (ventricular septal defect repair, atrioventricular septal defect repair, superior cavopulmonary anastomosis, arterial switch operation, isolated aortopulmonary shunt).
Main Results:
- Early extubation rates significantly increased for lower-complexity surgeries (30.2% vs. 18.8%, p=0.006) post-guideline, with reduced time to extubation.
- Ventricular septal defect repair showed a significant increase in early extubation (47% vs. 26%, p=0.006), but outcomes varied by surgery type and hospital.
- No significant changes in early extubation rates or time to extubation were observed for higher-complexity surgeries.
Conclusions:
- The clinical practice guideline demonstrated a sustainable spillover effect on early extubation for lower-complexity infant cardiac surgeries one year after study completion.
- The observed variation in outcomes across different surgical procedures and study sites suggests that center-specific factors influence the adoption and effectiveness of clinical practice guidelines.
- Postoperative extubation outcomes for higher-complexity surgeries were not impacted by the implemented guideline.
Objectives:
The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants.
Design:
Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry.
Setting:
Four Pediatric Heart Network Collaborative Learning Study active-site hospitals.
Patients:
Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity).
Interventions:
None.
Measurements And Main Results:
Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras.
Conclusions:
We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices.
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