Katherine E Bates1, William T Mahle2, Lauren Bush3, Janet Donohue3, Michael G Gaies3, Susan C Nicolson4, Lara Shekerdemian5, Madolin Witte6, Michael Wolf2, Judy A Shea7, Donald S Likosky8, Sara K Pasquali3. 1. Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan. Electronic address: kebates@med.umich.edu. 2. Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia. 3. Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan. 4. Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania. 5. Department of Critical Care, Texas Children's Hospital, Houston, Texas. 6. Department of Pediatrics, University of Utah, Salt Lake City, Utah. 7. Department of Internal Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania. 8. Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan.
Abstract
BACKGROUND: The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes. METHODS: Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites. RESULTS: A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p < 0.001); however, there was variation in the post-CPG median time to extubation (0.3 to 5.3 hours, p = 0.01) and magnitude of change (-73.3% to -99.2%). Site A achieved the shortest post-CPG time to extubation and had the greatest percentage change. Two sites had significant decreases in medical ICU LOS in TOF patients; no hospital LOS changes were seen. All sites valued the collaborative learning strategy, site visits, CPG flexibility, and had similar core team composition. Site A used several unique strategies: inclusion of other staff and fellows, regular in-person data reviews, additional data collection, and creation of complementary protocols. CONCLUSIONS: All PHN CLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.
BACKGROUND: The Pediatric Heart Network Collaborative Learning Study (PHNCLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes. METHODS:Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites. RESULTS: A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p < 0.001); however, there was variation in the post-CPG median time to extubation (0.3 to 5.3 hours, p = 0.01) and magnitude of change (-73.3% to -99.2%). Site A achieved the shortest post-CPG time to extubation and had the greatest percentage change. Two sites had significant decreases in medical ICU LOS in TOFpatients; no hospital LOS changes were seen. All sites valued the collaborative learning strategy, site visits, CPG flexibility, and had similar core team composition. Site A used several unique strategies: inclusion of other staff and fellows, regular in-person data reviews, additional data collection, and creation of complementary protocols. CONCLUSIONS: All PHNCLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.
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