Standardization of Care Reduces Length of Stay for Postoperative Congenital Heart Disease Patients

Abstract

Congenital heart disease (CHD), the most common congenital malformation, often requires surgical correction. As surgical mortality rates are low, a common quality marker linked with surgical outcomes is hospital length of stay (LOS). Reduced LOS is associated with better long-term outcomes, reduced hospital-acquired complications, and improved patient-family satisfaction. This project aimed to reduce aggregate median postoperative LOS for four CHD lesions from a baseline of 6.2 days by 10%.

Methods: This single-center study utilized the Institute for Healthcare Improvement model to achieve the project aim. A diuretic wean protocol implemented in April 2018 entailed weaning to a homegoing diuretic regimen upon transfer from the cardiac intensive care unit to the inpatient step-down unit. A discharge milestone checklist implemented in September 2018 contained milestones necessary for discharge and an anticipated date of discharge. Outcome measures included aggregate median postoperative LOS and ∆LOS. Balancing measures included cardiac intensive care unit bounce back, pleural chest tube replacement, and readmission rates.

Results: Our baseline aggregate median postoperative LOS for the lesions studied was 6.2 days. Following diuretic protocol implementation, the aggregate median LOS decreased to 4.4 days. Baseline ∆LOS decreased from 5.5 to 0.42 days. Postoperative cost fell by an average of $11,874. Balancing measures demonstrated no unintended consequences.

Conclusions: Implementation of a diuretic wean protocol led to sustained improvement in postoperative LOS, and ∆LOS in a subset of CHD patients with no unintended consequences supporting that standardization of postoperative care is effective for improvement efforts and can reduce overall practice variation.

Fig. 1.

Key Driver Diagram. ECHO, echocardiogram; H4A is synonymous with Acute Care Cardiology Unit.

Fig. 2.

Discharge Milestone Checklist.

Fig. 3.

Statistical Process Control Chart with Primary Outcome Measure: Aggregate Median Length of Stay for four Congenital Heart Defects following their initial complete surgical repair including TOF, VSD, D-TGA, and CAVC. Arrows and annotations correspond to interventions.

Fig. 4.

Statistical Process Control Chart with Secondary Outcome Measure: Post-Operative Mean Variation from Target (∆LOS). Arrows and annotations correspond to interventions.