Punkaj Gupta1, Mallikarjuna Rettiganti2, Howard E Jeffries3, Nancy Brundage4, Barry P Markovitz5, Matthew C Scanlon6, Janet M Simsic7. 1. Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Electronic address: pgupta2@uams.edu. 2. Section of Biostatistics, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas. 3. Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington. 4. Virtual PICU Systems, LLC, Los Angeles, California. 5. Virtual PICU Systems, LLC, Los Angeles, California; Division of Critical Care Medicine, Department of Pediatrics and Anesthesiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California. 6. Virtual PICU Systems, LLC, Los Angeles, California; Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin. 7. Division of Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio.
Abstract
BACKGROUND: Multicenter data regarding the around-the-clock (24/7) presence of an in-house critical care attending physician with outcomes in children undergoing cardiac operations are limited. METHODS: Patients younger than 18 years of age who underwent operations (with or without cardiopulmonary bypass [CPB]) for congenital heart disease at 1 of the participating intensive care units (ICUs) in the Virtual PICU Systems (VPS, LLC) database were included (2009-2014). The study population was divided into 2 groups: the 24/7 group (14,737 patients; 32 hospitals), and the No 24/7 group (10,422 patients; 22 hospitals). Propensity-score matching was performed to match patients 1:1 in the 24/7 group and in the No 24/7 group. RESULTS: Overall, 25,159 patients from 54 hospitals qualified for inclusion. By propensity matching, 9,072 patients (4,536 patient pairs) from 51 hospitals were matched 1:1 in the 2 groups. After matching, mortality at ICU discharge was lower among the patients treated in hospitals with 24/7 coverage (24/7 versus No 24/7, 2.8% versus 4.0%; p = 0.002). The use of extracorporeal membrane oxygenation (ECMO), the incidence of cardiac arrest, extubation within 48 hours after operation, the rate of reintubation, and the duration of arterial line and central venous line use after operation were significantly improved in the 24/7 group. When stratified by surgical complexity, survival benefits of 24/7 coverage persisted among patients undergoing both high-complexity and low-complexity operations. CONCLUSIONS: The presence of 24-hour in-ICU attending physician coverage in children undergoing cardiac operations is associated with improved outcomes, including ICU mortality. It is possible that 24-hour in-ICU attending physician coverage may be a surrogate for other factors that may bias the results. Further study is warranted.
BACKGROUND: Multicenter data regarding the around-the-clock (24/7) presence of an in-house critical care attending physician with outcomes in children undergoing cardiac operations are limited. METHODS:Patients younger than 18 years of age who underwent operations (with or without cardiopulmonary bypass [CPB]) for congenital heart disease at 1 of the participating intensive care units (ICUs) in the Virtual PICU Systems (VPS, LLC) database were included (2009-2014). The study population was divided into 2 groups: the 24/7 group (14,737 patients; 32 hospitals), and the No 24/7 group (10,422 patients; 22 hospitals). Propensity-score matching was performed to match patients 1:1 in the 24/7 group and in the No 24/7 group. RESULTS: Overall, 25,159 patients from 54 hospitals qualified for inclusion. By propensity matching, 9,072 patients (4,536 patient pairs) from 51 hospitals were matched 1:1 in the 2 groups. After matching, mortality at ICU discharge was lower among the patients treated in hospitals with 24/7 coverage (24/7 versus No 24/7, 2.8% versus 4.0%; p = 0.002). The use of extracorporeal membrane oxygenation (ECMO), the incidence of cardiac arrest, extubation within 48 hours after operation, the rate of reintubation, and the duration of arterial line and central venous line use after operation were significantly improved in the 24/7 group. When stratified by surgical complexity, survival benefits of 24/7 coverage persisted among patients undergoing both high-complexity and low-complexity operations. CONCLUSIONS: The presence of 24-hour in-ICU attending physician coverage in children undergoing cardiac operations is associated with improved outcomes, including ICU mortality. It is possible that 24-hour in-ICU attending physician coverage may be a surrogate for other factors that may bias the results. Further study is warranted.
Authors: Brett R Anderson; S Ram Kumar; Danielle Gottlieb-Sen; Matthew H Liava'a; Kevin D Hill; Jeffrey P Jacobs; Francis X Moga; David M Overman; Jane W Newburger; Sherry A Glied; Emile A Bacha Journal: World J Pediatr Congenit Heart Surg Date: 2019-03