BACKGROUND:Infective endocarditis is a leading cause of morbidity and mortality in children and adolescents with underlying CHD. Appropriate diagnostic workup and management in the inpatient setting can be challenging in this patient population due to the spectrum of disease complexity and the dynamic nature of the field. Therefore, the Paediatric Acute Care Cardiology Collaborative has undertaken the creation of this clinical practice guideline. METHODS:A panel of paediatric cardiologists, infectious disease specialists, intensivists, advanced practice practitioners, pharmacists, cardiothoracic surgeons, and a dentist was convened. The literature was systematically reviewed for relevant articles on the management of infective endocarditis in patients with CHD. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus for inclusion. RESULTS:Based on 127 articles that met the inclusion criteria, 82 recommendations were generated, 50 of which achieved consensus for inclusion and are included in this guideline. They address risk factors specific to CHD lesion type and prior interventions including implanted material, diagnostic considerations, management strategies, and recommendations on counselling other healthcare providers, patients, and families. Of the 50 consensus recommendations, 36 are strong recommendations, though 20 have low or very low quality of evidence. CONCLUSIONS:A central theme in this guideline is that an individual's specific CHD lesion and prior interventions must be carefully considered for risk stratification, diagnostic approach, and management. While most are strong recommendations, many are supported by low quality of evidence, emphasising the need for further research in this subject.

PURPOSE:Limited data suggest that pediatric cardiology (PC) fellows are unprepared to provide sexual and reproductive health (SRH) care to adolescents and young adults (AYA) with congenital heart disease (CHD), an expanding population. We sought to explore PC fellow training, attitudes, and clinical practices surrounding the provision of SRH care for AYA with CHD. METHODS:This national survey-based study of PC fellows in American College of Graduate Medical Education accredited fellowship programs collected demographic data, data related to participant training program, participants' attitudes, practices, and experiences regarding SRH for AYA with CHD, and participants' knowledge of SRH for these patients. Bivariate logistic regression was performed to assess associations between categorical variables of interest. RESULTS:There were 97 responses submitted and an estimated 466 PC fellows, resulting in an estimated response rate of 20%. Approximately half of the participants indicated that the training received during fellowship has not prepared them to counsel patients with heart and/or vascular disease on contraceptive options (52%) or provide preconception counseling to their patients (49%). Fewer than half of the participants indicated feeling comfortable discussing SRH with cardiology patients in fellowship (43%), while most participants do not regularly discuss or initiate discussions about SRH with cardiology patients (79%). Nearly all participants indicated that additional training resources for SRH counseling for AYA with CHD would be helpful. DISCUSSION:Our results demonstrate that PC fellows are inadequately prepared to provide SRH care to AYA with CHD, and there is a need for curricular reform within PC fellowship programs.

Background: Improved survival and healthcare system changes have led to increasing complexity of the typical hospitalized pediatric patient. This has led to the development of inpatient specialists such as Pediatric Hospitalists with resultant improved clinical outcomes. Similar trends in pediatric cardiology have catalyzed the creation of acute care cardiology (ACC). Yet, the broad impact on pediatric cardiology clinical outcomes secondary to the ACC inpatient model has not been previously studied prospectively. Hypothesis: Adoption of an ACC model will improve clinical outcomes. Methods: This was a QI initiative at a tertiary care children’s hospital focused on a redesign of the care model for inpatients with cardiac disease requiring non-ICU level of care through adoption of an ACC model. We selected complication rate and back transfer to ICU as outcome measures, discharge time as a process measure, and 7-day unplanned readmissions and length of stay (LOS) as balancing measures. Baseline data was gathered for 6 months and measures were prospectively studied using statistical process control charts for 12 months post-transition. Standard rules for identifying special cause variation (SCV) were applied. We compared patient and family experience scores (PFE) pre- and post-transition using an independent t-test. There were no changes in surgical or nursing staffing, beds, or average daily census between baseline and post-transition periods suggesting any changes in measures could be attributed to the ACC model and not external factors. Results: All outcome and process measures significantly improved from baseline to post-transition periods showing SCV following adoption of the ACC model (complications: 23.6% vs 16.0%; back transfer to ICU: 11.4% vs 6.9%; patient discharge time: 15:22 vs 14:26) (Figure 1). LOS and 7-day unplanned readmissions were unchanged post-transition suggesting no major inadvertent negative consequences of the ACC model (Figure 2). PFE improved post-transition ( p =0.04) (Figure 3). Conclusions: Adoption of an ACC model significantly improved outcomes and PFE without evidence of impactful negative effects. Though ACC has been widely adopted nationally, this is the first report documenting the prospectively measured impact of such a change in the established model of care. Ongoing evaluation of resource utilization, sustainability of improvement, and newly embedded improvement efforts is underway.

BACKGROUND:Perioperative immunisation administration surrounding congenital heart surgery is controversial. Delayed immunisation administration results in children being at risk of vaccine-preventable illnesses and is associated with failure to complete immunisation schedules. Among children with CHD, many of whom are medically fragile, vaccine-preventable illnesses can be devastating. Limited research shows perioperative immunisation may be safe and effective. METHODS:We surveyed Pediatric Acute Care Cardiology Collaborative member centres and explored perioperative immunisation practices. We analysed responses using descriptive statistics. RESULTS:Complete responses were submitted by 35/46 (76%) centres. Immunisations were deferred for any period prior to surgery by 23 (66%) centres and after surgery by 31 (89%) centres. Among those who deferred post-operative immunisation, 20 (65%) required deferral only for patients whose operations required cardiopulmonary bypass. Duration of deferral in the pre- and post-operative periods was variable. Many centres included exceptions to their policy for specific vaccine-preventable illnesses. Almost all (34, 97%) centres administer routine childhood immunisation to patients who remain admitted for prolonged periods. CONCLUSIONS:Most centres defer routine childhood immunisation for some period before and after congenital heart surgery. Centre specific practices vary. Immunisation deferral confers risk to patients and may not be warranted in this population. Further research would be necessary to understand the immunologic impact of these practices.

Introduction: Family-centred rounds benefit families and clinicians and improve outcomes in general paediatrics, but are understudied in subspecialty settings. We sought to improve family presence and participation in rounds in a paediatric acute care cardiology unit. Methods: We created operational definitions for family presence, our process measure, and participation, our outcome measure, and gathered baseline data over 4 months of 2021. Our SMART aim was to increase mean family presence from 43 to 75% and mean family participation from 81 to 90% by 30 May, 2022. We tested interventions with iterative plan-do-study-act cycles between 6 January, 2022 and 20 May, 2022, including provider education, calling families not at bedside, and adjustment to rounding presentations. We visualised change over time relative to interventions with statistical control charts. We conducted a high census days subanalysis. Length of stay and time of transfer from the ICU served as balancing measures. Results: Mean presence increased from 43 to 83%, demonstrating special cause variation twice. Mean participation increased from 81 to 96%, demonstrating special cause variation once. Mean presence and participation were lower during high census (61 and 93% at project end) but improved with special cause variation. Length of stay and time of transfer remained stable. Conclusions: Through our interventions, family presence and participation in rounds improved without apparent unintended consequences. Family presence and participation may improve family and staff experience and outcomes; future research is warranted to evaluate this. Development of high level of reliability interventions may further improve family presence and participation, particularly on high census days.

Objectives: Critical CHD is associated with morbidity and mortality, worsened by delayed diagnosis. Paediatric residents are front-line clinicians, yet identification of congenital CHD remains challenging. Current exposure to cardiology is limited in paediatric resident education. We evaluated the impact of rapid cycle deliberate practice simulation on paediatric residents' skills, knowledge, and perceived competence to recognise and manage infants with congenital CHD. Methods: We conducted a 6-month pilot study. Interns rotating in paediatric cardiology completed a case scenario assessment during weeks 1 and 4 and participated in paired simulations (traditional debrief and rapid cycle deliberate practice) in weeks 2-4. We assessed interns' skills during the simulation using a checklist of "cannot miss" tasks. In week 4, they completed a retrospective pre-post knowledge-based survey. We analysed the data using summary statistics and mixed effect linear regression. Results: A total of 26 interns participated. There was a significant increase in case scenario assessment scores between weeks 1 and 4 (4, interquartile range 3-6 versus 8, interquartile range 6-10; p-value < 0.0001). The percentage of "cannot miss" tasks on the simulation checklist increased from weeks 2 to 3 (73% versus 83%, p-value 0.0263) and from weeks 2-4 (73% versus 92%, p-value 0.0025). The retrospective pre-post survey scores also increased (1.67, interquartile range 1.33-2.17 versus 3.83, interquartile range 3.17-4; p-value < 0.0001). Conclusion: Rapid cycle deliberate practice simulations resulted in improved recognition and initiation of treatment of simulated infants with congenital CHD among paediatric interns. Future studies will include full implementation of the curriculum and knowledge retention work.

Family-centered rounding has emerged as the gold standard for inpatient paediatrics rounds due to its association with improved family and staff satisfaction and reduction of harmful errors. Little is known about family-centered rounding in subspecialty paediatric settings, including paediatric acute care cardiology.In this qualitative, single centre study, we conducted semi-structured interviews with providers and caregivers eliciting their attitudes toward family-centered rounding. An a priori recruitment approach was used to optimise diversity in reflected opinions. A brief demographic survey was completed by participants. We completed thematic analysis of transcribed interviews using grounded theory.In total, 38 interviews representing the views of 48 individuals (11 providers, 37 caregivers) were completed. Three themes emerged: rounds as a moment of mutual accountability, caregivers' empathy for providers, and providers' objections to family-centered rounding. Providers' objections were further categorised into themes of assumptions about caregivers, caregiver choices during rounds, and risk for exacerbation of bias and inequity.Caregivers and providers in the paediatric acute care cardiology setting echoed some previously described attitudes toward family-centered rounding. Many of the challenges surrounding family-centered rounding might be addressed through access to training for caregivers and providers alike. Hospitals should invest in systems to facilitate family-centered rounding if they choose to implement this model of care as the current state risks erosion of provider-caregiver relationship.

Early postoperative wound management following congenital heart surgery remains an area without equipoise. Precautionary restrictions can impact quality of life, development, and delay access to other needed care. The influence of different practices on wound healing and complications is unknown. We surveyed Pediatric Acute Care Cardiology Collaborative member centers regarding postoperative wound closure, wound vacuum-assisted closure (VAC) use, sternal precautions, and restrictions in the early postoperative period. We analyzed responses using descriptive statistics. Responses were submitted by 35/46 (76%) centers. Most centers perform primary skin closure with subcutaneous sutures. Wound covers are removed after 48 h at 43% (15/35) of centers and after ≥72 h at 34% (12/35) of centers. For delayed sternal closure, 16 centers close skin with interrupted, externalized sutures, 5 utilize wound VAC-assisted closure, and 12 use variable practices. Generally, 33 centers use wound VACs for wound care. Patient selection for VAC use and length of therapy varies. We found great variability in duration of sternal precautions and in activity, bathing, and submersion restrictions. Finally, 29 centers require a waiting period between cardiothoracic surgery and other surgeries such as tracheostomy or gastrostomy tube placement. Postoperative wound and sternal management lack consistency across North American pediatric heart institutes. Some restrictive practices may prolong length of stay and/or negatively impact quality of life and neurodevelopment. Practices may also impact wound infection rates. Research linking practices with clinical outcomes is needed to better define standards of care and reduce potential negative consequences of overly conservative or aggressive practices.

Patient- and family-centered care is a core dimension of modern healthcare, with patient and family-centered rounds (PFCR) being its most tangible manifestation in the inpatient setting. PFCR may vary in structure but generally incorporate discussions at the bedside that include families in formulating the care plan.1 In pediatrics, PFCR adoption has been extensive.2 In internal medicine, tenets of PFCR, particularly shared decision-making, have been widely adopted though it is unknown how often formal PFCR are practiced.3, 4 While the value of PFCR is self-evident from ethical and professional perspectives, their financial benefits to hospitals are less clear. A common criticism of PFCR is their time and resource consumption.1 Additionally, though clinicians may accept PFCR's moral value or acknowledge research demonstrating improved patient outcomes, safety, and experience,1, 2, 5-8 they may feel uninvested or unequipped to execute PFCR due to inadequate training or resources.9, 10 Given variable PFCR uptake and structure, clinicians need support and training to execute high-quality PFCR. However, without demonstrating PFCR's economic benefits, resource allocation for PFCR is difficult to justify for hospital leadership. There are three potential mechanisms by which high-quality PFCR may affect the bottom line: (1) lower legal expenses and improved resource utilization via reduction in medical errors, (2) higher revenue through improvement in patient/family experience scores that affect reimbursement and opportunities for more efficient care under capitated payment models, (3) reduced staffing and training costs by decreasing nursing turnover. Here we present a theoretical framework of the business case for PFCR to bolster existing moral and ethical imperatives for PFCR. First, PFCR are associated with reduction of medical errors.1, 2, 6-8 Medical errors significantly increase healthcare costs for inpatient populations.11 Errors may result in additional diagnostic testing and treatment for iatrogenic illness and injury, prolonged length of stay, hospital readmission, and increased healthcare utilization. Further, harmful errors are associated with increased mortality, at great cost to society and hospital performance ratings. PFCR may reduce errors by improving communication and promoting shared understanding of care among physicians, nurses, patients/families, and care coordinators. PFCR may also provide opportunities for patients/families as well as nurses to speak up, share concerns, clarify plans, ask questions, and engage in shared decision-making. By reducing errors, PFCR are positioned to improve the cost-effectiveness of inpatient care. Additionally, PFCR may reduce risk of readmission and errors even following hospital discharge if patients/families are engaged throughout admissions and have improved awareness of medication regimens, return precautions, and planned follow-up.5 This better understanding of health and self-efficacy may improve safety and lead to cost savings. In some hospital systems, PFCR are less frequently practiced in intensive, subspecialty, or complex care settings. While not yet widely studied, error reduction via PFCR might be even greater in subspecialty and complex care populations.12 These patients have chronic disease, often require polypharmacy, and experience frequent hospitalization, all of which may make them more prone to and disproportionally impacted by errors. Information that medically complex patients share with care teams via PFCR related to personal knowledge of their disease, past treatment response, and prior complications can likely lead to even greater error reduction. Further, as these patients have frequent hospitalizations, the possible economic benefits of PFCR may be magnified in centers caring for large numbers of subspecialty and complex patients. Thus, efforts to expand PFCR beyond general pediatrics and more broadly in internal medicine are needed to impart their ethical, moral, and potential financial value. Second, PFCR are associated with improved patient/family experience.1, 2 Provider belief in the importance of patient/family experience from an ethical and moral standpoint has been a large driver of PFCR uptake. Historically, patient/family experience has not been tied directly to financial health of institutions, but this paradigm is changing. Since 2011, patient/family experience has impacted hospital payments through the Center for Medicare and Medicaid Services Hospital Value-Based Purchasing.13, 14 The Value-Based Purchasing program applies to >3500 hospitals across the United States, including general acute care, children's, and critical access hospitals. The 2015 Medicare Access and CHIP Reauthorization Act links physician payment to patient/family experience, including during hospitalizations. Although they may not work exactly as intended,13, 15 these reimbursement strategies are likely to remain in place for the foreseeable future. By improving patient/family experience, PFCR are positioned to increase revenue through improved hospital reimbursement. There is also emerging evidence showing that PFCR can reduce length of stay through engaging patients/families in day-to-day care and enhancing understanding of postdischarge care requirements.2, 16 Rather than waiting until the end of a hospitalization to complete time-consuming patient/family education—or identify barriers to discharge—education and open collaboration happen continuously during PFCR. This may be an additional mechanism through which PFCR affects revenue as payors move toward capitated payments: it is easy to imagine a hospitalization extending a day (or more) when discharge instructions are complex, or unforeseen case management or care coordination challenges arise, even though the patient is medically ready for discharge. These extra days are unreimbursed under capitated payment structures and incur a material opportunity cost if that bed could be occupied by a patient in greater need and whose reimbursement has not been capped—which is likely as many units operate at or near capacity. This logic also extends to the prolongation of hospital stays caused by medical errors—capped payment structures mean procedures and resources to remedy errors can go uncompensated, and on the margin, these preventable bed-days effectively displace another patient whose care could be fully reimbursed. Finally, PFCR are associated with improved nursing satisfaction, which is closely correlated to turnover.1, 17 Nursing turnover is a significant financial burden through tangible costs to hospitals resulting from attrition (e.g., recruiting, training, and hiring new nurses), and has become increasingly salient in the wake of the COVID-19 pandemic. Less obvious are the intangible costs of turnover: damage to a hospital's reputation in the provider community, morale reduction from the loss of experienced staff, loss of institutional and unit-based knowledge (which itself may cause medical errors), and lower productivity of new hires.17 The cost of turnover is well-recognized—hospital systems have invested in costly nurse retention programs because of favorable cost–benefit analyses.18 We believe such programs provide clear precedent for hospital investment in PFCR, despite the associated short-term costs. Additionally, it is often challenging for nursing staff (and trainees) to effectively participate in rounds conducted in variable styles. Therefore, widespread adoption of PFCR across specialties and inpatient settings may help standardize practice for nurses and trainees, in turn improving satisfaction and reducing burnout. Through increased nurse engagement and satisfaction, PFCR have financial benefits by reducing nurse turnover. Through these mechanisms, PFCR generate value for hospitals via increased economic benefits and reduced costs. However, a critical and required acknowledgment is that the data supporting each of these avenues for financial benefit come from studies which lack a universal definition of PFCR. There are descriptions of high-quality PFCR in the literature,1 like the Patient and Family-Centered I-PASS program,6 which include structured communication, family and nurse engagement, health literacy best practices, and closed-loop communication. However, simply inviting families to listen to rounds without participation is unlikely to achieve the outcomes needed to also achieve financial benefits. To reap the benefits of PFCR, true engagement with families is needed through high-quality PFCR. Additionally, concerns about resource consumption, in particular clinician time, require further investigation. In pediatric hospitalist medicine, studies have shown that PFCR do not result in longer rounding encounters, but this may not be generalizable to other settings.1 While clinicians broadly view PFCR positively,1, 4 consideration of how PFCR affect clinicians and potential alterations to existing workflows to accommodate PFCR is required. Additional research is also needed to substantiate the link between PFCR and outcomes of interest, such as length of stay, which may in turn help solidify the case for the financial benefit of PFCR. To date, most hospitals have not invested significantly in PFCR delivery by making it a clear strategic priority, and instead rely on rank-and-file clinicians to implement and execute PFCR in an ad-hoc manner. To fully realize the goals and financial benefits of PFCR and not overburden already busy providers, hospital administrators should purposefully invest in the personnel, technology, and equipment to facilitate state-of-the-art PFCR, across settings and specialties. This could include dedicated FTE for Rounds Coordinators, expanded access to interpreter services, investment in telehealth solutions for families not at bedside, and increased training and education on PFCR for clinicians, all of which will improve inpatient teams' abilities to deliver high-quality PFCR.6, 7, 10, 19-21 Though these resources create additional short-term costs, hospitals should view them as capital investments in an organizational asset: a high-quality PFCR discipline. The future dividends of PFCR can offset the cost of resources needed to foster high-quality PFCR practice. PFCR are not only a professional and ethical imperative; they may also be fiscally prudent and help hospitals create a sustained competitive advantage over peer institutions through error reduction, improved reimbursement, and reduced attrition. Dana B. Gal conceptualized and outlined the perspective, drafted the initial manuscript, and critically reviewed and revised the manuscript. Alisa Khan and Jennifer Baird contributed to outlining the manuscript and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. The work was supported by PCORI AD-2021C3-24848 (PI Khan). The authors declare no conflict of interest.

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Introduction: Disparities in healthcare outcomes are well described among patients of different races and ethnicities including pediatric cardiology. Multicenter studies examining these outcomes are lacking in pediatric acute care cardiology. We hypothesize that Black and Hispanic patients admitted to pediatric acute care cardiology units have increased hospital and acute care encounter length of stay (LOS) and complication rates compared to their White and non-Hispanic peers. Methods: Utilizing the Pediatric Acute Care Cardiology Collaborative registry, we examined all acute care cardiology unit encounters from 2/1/2019 to 7/30/2021 ending in discharge to home or death. Hospitalizations were categorized by race and ethnicity. In-hospital complications included health-care acquired infections, iatrogenic incidents, pneumonia, sepsis, seizures and stroke. Data were analyzed for differences in LOS and complication rates using chi-square and ANOVA testing. We used Bonferroni correction to establish a significance threshold of 0.007. Results: Analysis included 30,404 hospitalizations from 29 centers. There were 16,233 White (70%), 4,533 Black (19%), 919 Asian (4%) and 1,629 other races (7%) encounters. There were 23,592 (78%) non-Hispanic and 4,583 (15%) Hispanic encounters. Black patients had higher rates of premature birth (21.4%) and low birth weight (10.7%), compared to White patients (15.6% and 5.9% respectively, p<0.0001). Both non-Hispanic Black and Hispanic patients had longer total hospital and acute care LOS than non-Hispanic White patients. Complication rates analyzed by race trended towards significance between Black and White patients, and Hispanic patients had a higher complication rate than non-Hispanics. ( Table 1 ) Conclusions: Despite improved outcomes for patients with congenital and acquired heart disease, significant racial and ethnic disparities continue to exist. Directed efforts are needed to achieve equitable results.

Background: Guidelines recommend observation for atrioventricular node recovery until postoperative days (POD) 7 to 10 before permanent pacemaker placement (PPM) in patients with heart block after congenital cardiac surgery. To aid in surgical decision-making for early PPM, we established criteria to identify patients at high risk of requiring PPM. Methods: We reviewed all cases of second degree and complete heart block (CHB) on POD 0 from August 2009 through December 2018. A decision tree model was trained to predict the need for PPM amongst patients with persistent CHB and prospectively validated from January 2019 through March 2021. Separate models were developed for all patients on POD 0 and those without recovery by POD 4. Results: Of the 139 patients with postoperative heart block, 68 required PPM. PPM was associated with older age (3.2 versus 1.0 years; P =0.018) and persistent CHB on POD 0 (versus intermittent CHB or second degree heart block; 87% versus 58%; P =0.001). Median days [IQR] to atrioventricular node recovery was 2 [0–5] and PPM was 9 [6–11]. Of the 100 cases of persistent CHB (21 in the validation cohort), 59 (59%) required PPM. A decision tree model identified 4 risk factors for PPM in patients with persistent CHB: (1) aortic valve replacement, subaortic stenosis repair, or Konno procedure; (2) ventricular L-looping; (3) atrioventricular valve replacement; (4) and absence of preoperative antiarrhythmic agent (in POD 0 model only). The POD 4 model specificity was 0.89 [0.67–0.99] and positive predictive value was 0.94 [95% CI 0.81–0.98], which was stable in prospective validation (positive predictive value 1.0). Conclusions: A data-driven analysis led to actionable criteria to identify patients requiring PPM. Patients with left ventricular outflow tract surgery, atrioventricular valve replacement, or ventricular L-Looping could be considered for PPM on POD 4 to reduce risks of temporary pacing and improve care efficiency.

Supravalvar aortic stenosis (SVAS) severity guides management, including decisions for surgery. Physiologic and technical factors limit the determination of SVAS severity by Doppler echocardiography and cardiac catheterization in Williams syndrome (WS). We hypothesized SVAS severity could be determined by the sinotubular junction-to-aortic annulus ratio (STJ:An). We reviewed all preintervention echocardiograms in patients with WS with SVAS cared for at our center. We measured STJ, An, peak and mean Doppler gradients, and calculated STJ:An. We created 2 mean gradient prediction models. Model 1 used the simplified Bernoulli's equation, and model 2 used computational fluid dynamics (CFD). We compared STJ:An to Doppler-derived and CFD gradients. We reviewed catheterization gradients and the waveforms and analyzed gradient variability. We analyzed 168 echocardiograms in 54 children (58% male, median age at scan 1.2 years, interquartile range [IQR] 0.5 to 3.6, median echocardiograms 2, IQR 1 to 4). Median SVAS peak Doppler gradient was 24 mm Hg (IQR 14 to 46.5). Median SVAS mean Doppler gradient was 11 mm Hg (IQR 6 to 21). Median STJ:An was 0.76 (IQR 0.63 to 0.84). Model 1 underpredicted clinical gradients. Model 2 correlated well with STJ:An through all severity ranges and demonstrated increased pressure recovery distance with decreased STJ:An. The median potential variability in catheterization-derived gradients in a given patient was 14.5 mm Hg (IQR 7.5 to 19.3). SVAS severity in WS can be accurately assessed using STJ:An. CFD predicts clinical data well through all SVAS severity levels. STJ:An is independent of physiologic state and has fewer technical limitations than Doppler echocardiography and catheterization. STJ:An could augment traditional methods in guiding surgical management decisions. (C) 2021 Elsevier Inc. All rights reserved.

Click to increase image sizeClick to decrease image sizeThis article refers to:Postponed Withholding: Balanced Decision-Making at the Margins of Viability Additional informationFundingMaternal Child Health Research Institute, Stanford University, Laurie Kraus Lacob Faculty Scholarship.

OBJECTIVES: To describe direct discharge to home from the cardiovascular ICU. DESIGN: Mixed-methods including retrospective Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative data and survey. SETTING: Tertiary pediatric heart center. PATIENTS: Patients less than 25 years old, with a cardiovascular ICU stay of greater than 24 hours and direct discharge to home from January 1, 2016, to December 8, 2020, were included. Select data describing patients discharged from acute care internally and nationally from Pediatric Acute Care Cardiology Collaborative sites were compared with the direct discharge to home cohort. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Encounter- and patient-specific characteristics. Seven-day and 30-day readmission and 30-day mortality served as surrogate safety markers. A survey of cardiovascular ICU frontline providers assessed comfort and skills related to direct discharge to home. There were 364 direct discharge to home encounters that met inclusion criteria. The majority of direct discharge to home encounters were associated with a surgery or procedure (305; 84%). There were 27 encounters (7.4%) for medical technology-dependent patients requiring direct discharge to home. Unplanned 7-day readmissions among direct discharge to home patients was 1.9% compared with 4.6% (p = 0.04) of patients discharged from acute care internally. Readmission among those discharged from acute care internally did not differ from those at Pediatric Acute Care Cardiology Collaborative sites nationally. Frontline cardiovascular ICU providers had mixed levels of confidence in technical aspects and low levels of confidence in logistics of direct discharge to home. CONCLUSIONS: Cardiovascular ICU direct discharge to home was not associated with increased unplanned readmissions compared with patients discharged from acute care and may be safe in select patients. Frontline cardiovascular ICU providers feel time constraints challenge direct discharge to home. Further research is needed to identify patient characteristics associated with safe direct discharge to home and systems needed to support this practice. Summary statistics are described using proportions or medians with interquartile ranges (IQRs) and were performed using Microsoft Excel (Microsoft, Redmond, WA). Two-sample tests of proportions were used to compare readmission frequency of the DDH cohort compared with internal and national PAC3 data using STATA Version 15 (StataCorp, College Station, TX).

Background: Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. Methods: A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus Results: 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. Conclusions: Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

OBJECTIVES:To quantify and describe patient-generated health data.METHODS:This is a retrospective, single-center study of patients hospitalized in the pediatric cardiovascular ICU between February 1, 2020, and February 15, 2020. The number of data points generated over a 24-hour period per patient was collected from the electronic health record. Data were analyzed by type, and frontline provider exposure to data was extrapolated on the basis of patient-to-provider ratios.RESULTS:Thirty patients were eligible for inclusion. Nineteen were hospitalized after cardiac surgery, whereas 11 were medical patients. Patients generated an average of 1460 (SD 509) new data points daily, resulting in frontline providers being presented with an average of 4380 data points during a day shift (7:00 am to 7:00 pm). Overnight, because of a higher patient-to-provider ratio, frontline providers were exposed to an average of 16 060 data points. There was no difference in data generation between medical and surgical patients. Structured data accounted for >80% of the new data generated.CONCLUSIONS:Health care providers face significant generation of new data daily through the contemporary electronic health record, likely contributing to cognitive burden and putting them at risk for cognitive overload. This study represents the first attempt to quantify this volume in the pediatric setting. Most data generated are structured and amenable to data-optimization systems to mitigate the potential for cognitive overload and its deleterious effects on patient safety and health care provider well-being.

Assessment of supravalvar aortic stenosis (SVAS) severity in Williams syndrome (WS) is often complicated by the discrepancy in pressure drops obtained via peak-instantaneous Doppler and peak-to-peak cardiac catheterization measurements. With SVAS, static pressure in the left ventricle is converted to kinetic energy, maximal at the vena contracta, some of which is recovered through pressure energy and some of which is lost through thermal energy and deformation. The phenomenon …

OBJECTIVES:Through improving diagnostics and prognostics genomic sequencing promises to significantly impact clinical decisions for children with critical cardiac disease. Little is known about how families of children with critical cardiac disease perceive the impact of genomic sequencing on clinical care choices. DESIGN:Qualitative interview study. SETTING:A high-volume, tertiary pediatric heart center. SUBJECTS:Families of children with critical cardiac disease. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Thematic analysis of interview response content. Thirty-five families were interviewed. Three themes emerged: 1) benefits versus challenges of having genomic sequencing results, and 2) fears of clinical applications of genomic sequencing, and 3) nonclinical fears related to genomic sequencing. Participants struggled with perceived uses of genomic sequencing-derived knowledge. They described comfort in foreknowledge of their child's likely disease course but articulated significant apprehension around participating in care decisions with limited knowledge of genomic sequencing, genomic sequencing uses to inform clinical resource rationing decisions, and genomic sequencing uses by third parties impacting financial pressures families experience caring for a child with critical cardiac disease. CONCLUSIONS:Families' perceptions of genomic sequencing uses in critical cardiac disease appear to strain their overall trust in the health system. Erosion of trust is concerning because the potential of genomic sequencing in critical cardiac disease will be unrealized if families are unwilling to undergo genomic sequencing, let alone to participate in the ongoing research needed to link genomic sequencing variants to clinical outcomes. Our findings may have implications for genomic sequencing use in children with other critical, high-acuity diseases.

OBJECTIVES To characterize frontline provider perception of clinical text messaging and quantify clinical texting data in a pediatric cardiovascular ICU (CICU). METHODS This is a mixed-methods, retrospective single center study. A survey of frontline CICU providers (pediatric fellows, nurse practitioners, and physician assistants) was conducted to assess attitudes characterizing text messaging on cognitive burden. Text messaging data were abstracted and quantified between January 29, 2020, and April 18, 2020, and the patterns of text messages were analyzed per shift and by provider. RESULTS The survey was completed by 33 of 39 providers (85%). Out of responders, 78% indicated that clinical text messaging frequently or very frequently disrupts critical thinking and workflow. They also felt that the burden of messages was worse during the night shift. Through abstraction, 31 926 text messages were identified. A median of 15 (interquartile range: 12-19) messages per hour were received. A median of 5 messages were received per hour per provider during the day shift and 6 during the night shift. From the entire study period, there were total 2 hours of high-frequency texting (≥15 texts per hour) during the day shift and 68 hours during the night shift. CONCLUSION In our study, providers in the CICU received a large number of texts with a disproportionate burden during the night shift. Text messages are a potential source of cognitive overload for providers. Optimization of text messaging may be needed to mitigate cognitive burden for frontline providers.