Introduction:Pediatric heart centers have advanced quality improvement (QI) work through registries and collaboratives, improving benchmarking and shared learning. However, institutions must also build internal, sustainable QI programs tailored to local needs. We outlined our experience in developing an inclusive QI program that provides a structured framework to drive continuous improvement.Methods:We implemented a 5-step approach: (1) cultivating an environment ready for change, (2) optimizing streams to identify improvement opportunities, (3) building systems to support initiatives, (4) promoting QI work and successes, and (5) sustaining and scaling improvements. This included engaging diverse stakeholders, streamlining data, reducing participation barriers, and applying structured project management. Proposals underwent rigorous review to ensure equitable support.Results:Between 2021 and 2025, the program supported 17 subgroups across cardiology, surgery, anesthesia, and critical care, with 60% of projects led by nonphysicians. It facilitated 21 QI consults (71% progressing to formal projects), 13 publications, more than 30 national presentations, and additional impactful unpublished work, while strengthening leadership and team expertise through QI education. System-level outcomes improved, including surgical mortality and US News & World Report rankings. Performance rounds generated 170 improvement actions to guide systematic change.Conclusions:An inclusive QI program enhances outcomes, and our structure underscores the value of both multidisciplinary collaboration and strategic resource use. By investing in leadership, promoting diversity, and aligning with institutional goals, heart centers can achieve sustained improvement. This framework offers a potential model for institutions seeking robust QI infrastructure.

OBJECTIVES:Unplanned cardiac reinterventions after congenital cardiac surgery may complicate the postoperative course. We sought to identify incidence rates and risk factors for unplanned cardiac reinterventions and associations between unplanned cardiac reinterventions and hospital mortality. METHODS:Patients in the Pediatric Cardiac Critical Care Consortium registry undergoing an index cardiac operation from February 2019 to January 2022 were included. Multivariable logistic regression, adjusted for center effect, was used to evaluate patient risk factors for unplanned cardiac reinterventions and the impact of reintervention on hospital mortality. RESULTS:Included were 34,495 patients from 62 centers. Unplanned cardiac reinterventions occurred in 2635 patients (7.6%) with wide center variation. Risk factors for unplanned cardiac reinterventions included Black race, extracardiac and chromosomal anomalies, younger age, lower weight for age, prior cardiac surgeries, and higher surgical complexity category. The performance of an unplanned cardiac reintervention was associated with higher hospital mortality (16.1%) compared with those who did not undergo reintervention (1.3%) (adjusted odds ratio, 6.45; 95% CI, 5.51-7.56, P < .001). The odds of mortality after unplanned cardiac reinterventions increased with higher Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery category. Mortality was highest in patients who underwent both reoperation and interventional catheterization (31.9%) compared with those who underwent only reoperation (16.3%) or catheterization (9.8%). CONCLUSIONS:Unplanned cardiac reinterventions occur in approximately 1 in 13 patients after congenital cardiac surgery, and approximately 1 in 6 patients with an unplanned cardiac reintervention will die. Patients at greatest risk for unplanned cardiac reinterventions may share patient and disease-specific risk factors. Further investigation is needed to minimize the incidence of residual lesions, understand why Black children have more unplanned cardiac reinterventions, and explore modifiable risk factors for and optimal timing of unplanned cardiac reinterventions.

Objectives: Chylothorax after vascular ring (VR) repair is likely secondary to direct injury to the lymphatic collection system and may benefit from tailored management. We have reviewed the management of patients with chylothorax following VR repair and compared the approaches to chylothorax care after all other cardiac surgeries. Design: Retrospective multicenter cohort. Setting: Ten pediatric cardiac surgical centers in the United States. Patients: Children with chylothorax after VR repair at participating pediatric cardiac surgical centers from 1/1/2021—12/31/2023. Analysis was stratified by chylothorax patients with VR surgery vs all other cardiac surgeries. Results: Overall, 45 patients had chylothorax following VR repair (45/340, 13.2%) in comparison to 384 patients who had chylothorax following all cardiac surgeries (including VR repair and Fontan procedure) (384/8,494, 4.5%). Compared with all other cardiac surgeries, a higher proportion of VR patients, than other cardiac surgical cases, underwent invasive lymphatic intervention including thoracic duct ligation, embolization, and pleurodesis (10/45 vs. 19/314. p = 0.001) and at an earlier median interval from index surgery (3.5 vs. 28 d, p < 0.001). The 10 patients with VR who underwent a lymphatic intervention had higher chest tube output on postoperative days (PODs) 2 (9.2 vs. 2.6 mL/kg/d, p = 0.005) and 3 (4.9 vs. 0.6 mL/kg/d, p = 0.002) compared with those who resolved without an invasive lymphatic intervention. Following lymphatic intervention, chylothorax resolved a median of 1 day later and there were 0 of 10 procedure-related complications. Conclusions: Patients with chylothorax after VR more commonly undergo invasive intervention when compared with those with other surgeries. Chest tube output on PODs 2 and 3 may help differentiate VR patients who will need invasive intervention. Chylothorax resolves soon after invasive intervention in VR patients, and in our cohort of 10 there were no procedural-related complications.

Prolonged pleural drainage and chylothorax are common in postoperative Fontan patients and are associated with increased morbidity and mortality. Multiple medical and interventional treatment strategies exist and vary between centers. This is a retrospective multicenter observational cohort study of pediatric patients who underwent Fontan operation at 8 pediatric cardiac surgical institutions from 1/1/2019 to 12/31/2021. Data were obtained from institutional records and collected from the Pediatric Cardiac Critical Care Consortium (PC4). 185 patients underwent Fontan operation with median age of 3.8 years [IQR 3.2-4.5]. Chest tube drainage for > 14 days occurred in 40 patients (22%). Chylothorax occurred in 33 patients (18%, incidence 9.1-26.2% across centers). Compared to non-chylothorax patients, those with chylothorax had lower preoperative ventricular end diastolic pressures (8 vs. 9 mm Hg, p = 0.019), greater chest tube utilization (13 vs. 7 days, p = < 0.001), ICU LOS (7 vs. 4 days, p = 0.001), hospital LOS (12 vs. 9 days, p < 0.001), and more weight loss (- 2.7% vs. 0.8%, p = 0.019). Using a receiver-operating characteristic curve, chest tube output > 18.8 mL/kg/day on POD 2 predicted chylothorax with an AUC of 0.73. Common chylothorax treatments were diet modification (n = 15, 45%) and sildenafil (n = 14, 52%). Interventional procedures were used in six chylothorax patients (18%). Postoperative chylothorax in Fontan patients was associated with increased chest tube utilization, postoperative interventions, greater weight loss, and longer ICU and hospital LOS. Center level variation suggests outcomes and resource utilization could be improved with further studies and establishment of best practices.

OBJECTIVE:Patients with CHD are at risk for developing necrotising enterocolitis. Currently, no standardised approaches for identification, diagnosis, and treatment of necrotising enterocolitis exists, and there are varying rates and management strategies of necrotising enterocolitis across centres. We used the Paediatric Cardiac Critical Care Consortium to identify high- and low-performing centres based on necrotising enterocolitis rates and convened a necrotising enterocolitis working group. The aims of the group were to understand why variability exists, identify risk factors, and create a foundation for a prospective improvement project. METHODS:Nine centres participated, and collaborative learning sessions were held with multidisciplinary input. REDCap surveys were disseminated to centres to create consensus among site practices and recommendations. RESULTS:The following topics were discussed: diagnosis, risk factors, and management. Diagnosis consensus suggests (1) Diagnosis would benefit from a comprehensive scoring tool, and (2) ultrasound may serve as a highly sensitive diagnostic tool for those at high risk with the absence of other radiologic findings of necrotising enterocolitis. Risk factor consensus suggests (1) those with ductal-dependent systemic blood flow are the highest risk, and (2) vasopressors with splanchnic constriction should be used with caution. Management consensus suggests (1) breastmilk be used first-line for feeding, 2) resume feeds 24-48 hours after a necrotising enterocolitis rule-out, and 3) surgical deference to physical examination and laboratory evaluation above radiographic findings. CONCLUSION:Variability exists in diagnosing necrotising enterocolitis and feeding approaches for at-risk patients. Opportunities exist for collaboration to standardise definitions, compare outcomes, identify risk factors, and create consensus on the management of necrotising enterocolitis.

Chylothorax following pediatric cardiac surgery increases morbidity and mortality. The clinical outcomes of patients with chylothorax with prolonged drainage compared to prompt resolution have not been described. This is a retrospective cohort study across eight United States pediatric cardiac intensive care units (ICU). Patients < 18 years old treated for chylothorax within 30 days of cardiac surgery were included, excluding Fontan palliations. Patients with chest tube duration ≥ 14 days were classified as long chylothorax (LC) vs. < 14 days as short chylothorax (SC). Univariable and multivariable logistic regression modeled patient characteristics associated with LC vs. SC. 134 patients had chylothorax, and 51 (38

ImportanceThe Pediatric Cardiac Critical Care Consortium (PC4) cardiac arrest prevention (CAP) quality improvement (QI) project facilitated a decreased in-hospital cardiac arrest (IHCA) incidence rate across multiple hospitals. The sustainability of this outcome has not been determined.ObjectiveTo examine the IHCA incidence rate at participating hospitals after the QI project ended and discern which factors best aligned with sustained improvement.Design, Setting, and ParticipantsThis observational cohort study compared IHCA data from the CAP era (July 1, 2018, to December 31, 2019) with data from the 2-year follow-up era (March 1, 2020, to February 28, 2022). Data were obtained from pediatric cardiac intensive care units (CICUs) from 17 PC4 CAP–participating hospitals.InterventionThe CAP practice bundle was designed to facilitate local practice integration, with the intention to implement, adapt, and continue CAP processes beyond the CAP era. A web-based survey was administered 2 years after the end of the project to estimate CAP-specific QI work.Main Outcomes and MeasuresRisk-adjusted IHCA incidence rates across all admissions were compared between study eras. The survey generated a novel hospital-specific QI sustainability score, which is generally reflective of the sum of local CAP work performed.ResultsThere were no clinically important differences in demographic and admission characteristics between the 13 082 CAP era admissions and 16 284 follow-up admissions (total mean [SD] age, 5.1 [8.4] years; 56.1% male). Risk-adjusted IHCA incidences were not different between the CAP vs follow-up eras (2.8% vs 2.8%; odds ratio, 1.03; 95% CI, 0.89-1.19), suggesting sustained prevention improvement. There was also no difference between eras in risk-adjusted IHCA incidence within medical, surgical, or high-risk subgroups. A lower hospital QI sustainability score was correlated with higher odds for IHCA in the follow-up vs CAP era (correlation coefficient, −0.58; P = .02). Five hospitals had increases of 1% or greater in risk-adjusted IHCA rates in the follow-up era; these hospitals had significantly lower QI sustainability scores and were less likely to have adopted sustainability elements during the CAP era or report persistent engagement for CAP-related QI processes during follow-up.Conclusions and RelevanceIn this cohort study of all CICU admissions across 17 hospitals, IHCA prevention was feasible and sustainable; the established reduction in risk-adjusted IHCA rate was maintained for at least 2 years after the end of the CAP project. Both implementation strategies and continued engagement in CAP processes during the follow-up era were associated with sustained improvement.

BACKGROUND:Dietary modification is the mainstay of treatment for postoperative chylothorax in children. However, optimal fat-modified diet (FMD) duration to prevent recurrence is unknown. Our aim was to determine the association between FMD duration and chylothorax recurrence. METHODS:Retrospective cohort study conducted across 6 pediatric cardiac intensive care units within the United States. Patients aged <18 years who developed chylothorax within 30 days after cardiac surgery between January 2020 and April 2022 were included. Patients with a Fontan palliation, who died, or were lost to follow-up or within 30 days of resuming a regular diet were excluded. FMD duration was defined as the first day of a FMD when chest tube output was <10 mL/kg/d without increasing until the resumption of a regular diet. Patients were classified into 3 groups (<3 weeks, 3-5 weeks, >5 weeks) based on FMD duration. RESULTS:A total of 105 patients were included: <3 weeks (n = 61) 3-5 weeks (n = 18), and >5 weeks (n = 26). Demographic, surgical, and hospitalization characteristics were not different across groups. In the >5 weeks group, chest tube duration was longer compared with the <3 weeks and 3-5 weeks groups (median, 17.5 days [interquartile range, 9-31] vs 10 and 10.5 days; P = .04). There was no recurrence of chylothorax within 30 days once chylothorax was resolving regardless of FMD duration. CONCLUSIONS:FMD duration was not associated with recurrence of chylothorax, suggesting that FMD duration can safely be shortened to at least <3 weeks from time of resolving chylothorax.

OBJECTIVES: Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with adverse outcomes. Single-center studies suggest that the prevalence of CS-AKI is high after the Norwood procedure, or stage 1 palliation (S1P), but multicenter data are lacking. DESIGN: A secondary analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) multicenter cohort who underwent S1P. Using neonatal modification of Kidney Disease Improving Global Outcomes (KDIGO) criteria, perioperative associations between CS-AKI with morbidity and mortality were examined. Sensitivity analysis, with the exclusion of prophylactic peritoneal dialysis (PD) patients, was performed. SETTING: Twenty-two hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC4) and contributing to NEPHRON. PATIENTS:Three hundred forty-seven neonates (< 30 d old) with S1P managed between September 2015 and January 2018. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS: Of 347 patients, CS-AKI occurred in 231 (67%). The maximum stages were as follows: stage 1, in 141 of 347 (41%); stage 2, in 51 of 347 (15%); and stage 3, in 39 of 347 (11%). Severe CS-AKI (stages 2 and 3) peaked on the first postoperative day. In multivariable analysis, preoperative feeding was associated with lower odds of CS-AKI (odds ratio [OR] 0.48; 95% CI, 0.27-0.86), whereas prophylactic PD was associated with greater odds of severe CS-AKI (OR 3.67 [95% CI, 1.88-7.19]). We failed to identify an association between prophylactic PD and increased creatinine (OR 1.85 [95% CI, 0.82-4.14]) but cannot exclude the possibility of a four-fold increase in odds. Hospital mortality was 5.5% (n = 19). After adjusting for risk covariates and center effect, severe CS-AKI was associated with greater odds of hospital mortality (OR 3.67 [95% CI, 1.11-12.16]). We failed to find associations between severe CS-AKI and respiratory support or length of stay. The sensitivity analysis using PD failed to show associations between severe CS-AKI and outcome. CONCLUSIONS: KDIGO-defined CS-AKI occurred frequently and early postoperatively in this 2015-2018 multicenter PC4/NEPHRON cohort of neonates after S1P. We failed to identify associations between resource utilization and CS-AKI, but there was an association between severe CS-AKI and greater odds of mortality in this high-risk cohort. Improving the precision for defining clinically relevant neonatal CS-AKI remains a priority.

BACKGROUND:Chylothorax after pediatric cardiac surgery is associated with increased morbidity and mortality. Poor understanding exists regarding inflammation within the pleural fluid. Our aim was to determine the relationship between proinflammatory markers and chylothorax. METHODS:This is a single-center prospective observational cohort study. Pediatric patients after cardiac surgery with >20 mL/kg/day of chest tube output were included from January 2022 through January 2023. The pleural fluid was tested for 13 cytokine concentrations using a multiplexed immunoassay and for albumin and C-Reactive Protein (CRP) levels. Bivariable comparisons and Spearman's rank correlations were made. RESULTS:Out of 63 patients, chylothorax occurred in 20 (32 %), of which 10 (50 %) were neonates. Cytokine concentrations, CRP, and albumin levels were not different between chylothorax and non-chylothorax patients. Higher levels of four proinflammatory cytokines (IL-1β, IL-5, IL-8, IL-13) correlated with longer chest tube drainage (r = 0.29, 0.43, 0.28, 0.39 respectively). There were higher concentrations of IL-1β, IL-5, IL-8 and IL-13 in each progressively longer quartile of days to resolution. The longest quartile of days to resolution (12-50 days) showed the highest median cytokine levels. CONCLUSIONS:The 13 cytokines tested were not associated with the diagnosis of chylothorax. However, higher IL-1β, IL-5, IL-8, and IL-13 concentrations were correlated with longer days to resolution. These findings demonstrate an inflammatory component to effusion resolution and may indicate an inflammatory phenotype that is distinct from chylothorax.

Tower, Dana; Glasgow, Sommer; Yost, Christian; Bailly, David; Carter, Camille; Goldstein, Stephanie Author Information

Multicenter early diuretic response (DR) analysis of single furosemide dosing following neonatal cardiac surgery is lacking to inform whether early DR predicts adverse clinical outcomes. We performed a retrospective cohort study utilizing data from the NEPHRON registry. Random forest machine learning generated receiver operating characteristic-area under the curve (ROC-AUC) and odds ratios for mechanical ventilation (MV) and respiratory support (RS). Prolonged MV and RS were defined using ≥ 90th percentile of observed/expected ratios. Secondary outcomes were prolonged CICU and hospital length of stay (LOS) and kidney failure (stage III acute kidney injury (AKI), peritoneal dialysis, and/or continuous kidney replacement therapy on postoperative day three) assessed using covariate-adjusted ROC-AUC curves. A total of 782 children were included. Cumulative urine output (UOP) metrics were lower in prolonged MV and RS patients, but DR poorly predicted prolonged MV (highest AUC 0.611, OR 0.98, sensitivity 0.67, specificity 0.53, p = 0.006, 95

BACKGROUND:Cardiac surgery-associated acute kidney injury (CS-AKI) is common, but its impact on clinical outcomes is variable. Parsing AKI into sub-phenotype(s) and integrating pathologic positive cumulative fluid balance (CFB) may better inform prognosis. We sought to determine whether durational sub-phenotyping of CS-AKI with CFB strengthens association with outcomes among neonates undergoing the Norwood procedure. METHODS:Multicenter, retrospective cohort study from the Neonatal and Pediatric Heart and Renal Outcomes Network. Transient CS-AKI: present only on post-operative day (POD) 1 and/or 2; persistent CS-AKI: continued after POD 2. CFB was evaluated per day and peak CFB during the first 7 postoperative days. Primary and secondary outcomes were mortality, respiratory support-free and hospital-free days (at 28, 60 days, respectively). The primary predictor was persistent CS-AKI, defined by modified neonatal Kidney Disease: Improving Global Outcomes criteria. RESULTS:CS-AKI occurred in 59% (205/347) neonates: 36.6% (127/347) transient and 22.5% (78/347) persistent; CFB > 10% occurred in 18.7% (65/347). Patients with either persistent CS-AKI or peak CFB > 10% had higher mortality. Combined persistent CS-AKI with peak CFB > 10% (n = 21) associated with increased mortality (aOR: 7.8, 95% CI: 1.4, 45.5; p = 0.02), decreased respiratory support-free (predicted mean 12 vs. 19; p < 0.001) and hospital-free days (17 vs. 29; p = 0.048) compared to those with neither. CONCLUSIONS:The combination of persistent CS-AKI and peak CFB > 10% after the Norwood procedure is associated with mortality and hospital resource utilization. Prospective studies targeting intra- and postoperative CS-AKI risk factors and reducing CFB have the potential to improve outcomes.

Earlier diagnosis of chylothorax following pediatric cardiac surgery is associated with decreased duration of chylothorax. Pleural fluid testing is used to diagnosis chylothorax which may delay detection in patients who are not enterally fed at time of chylothorax onset. Our aim was to develop and externally validate a prediction model to detect chylothorax earlier than pleural fluid testing in pediatric patients following cardiac surgery. A multivariable logistic regression model was developed to detect chylothorax using a stepwise approach. The model was developed using data from patients < 18 years following cardiac surgery from Primary Children's Hospital, a tertiary-care academic center, between 2017 and 2020. External validation used a contemporary cohort (n = 171) from Lucille Packard Children's Hospital. A total of 763 encounters (735 patients) were analyzed, of which 72 had chylothorax. The final variables selected were chest tube output (CTO) the day after sternal closure (dichotomized at 15.6 mL/kg/day, and as a continuous variable) and delayed sternal closure. The highest odds of chylothorax were associated with CTO on post-sternal closure day 1 > 15.6 mL/kg/day (odds ratio 11.3, 95% CI 6,3, 21.3). The c-statistic for the internal and external validation datasets using the dichotomized CTO variable were 0.78 (95% CI 0.73, 0.82) and 0.84 (95% CI, 0.78, 0.9) and performance improved when using CTO as a continuous variable (OR 0.84, CI: 95% CI 0.80, 0.87). Using the models described, chylothorax after pediatric cardiac surgery may be detected earlier and without reliance on enteral feeds.

BACKGROUND: In refractory respiratory failure, extracorporeal membrane oxygenation (ECMO) is a rescue therapy to prevent ventilator-induced lung injury. Optimal ventilator parameters during ECMO remain unknown. Our objective was to describe the association between mortality and ventilator parameters during ECMO for neonatal and pediatric respiratory failure. METHODS: We performed a secondary analysis of the Bleeding and Thrombosis on ECMO dataset. Ventilator parameters included breathing frequency, tidal volume, peak inspiratory pressure, PEEP, dynamic driving pressure, pressure support, mean airway pressure, and FIO2. Parameters were evaluated before cannulation, on the calendar day of ECMO initiation (ECMO day 1), and the day before ECMO separation. RESULTS: Of 237 included subjects analyzed, 64% were neonates, of whom 36% had a congenital diaphragmatic hernia. Of all the subjects, 67% were supported on venoarterial ECMO. Overall in-hospital mortality was 35% (n = 83). The median (interquartile range) PEEP on ECMO day 1 was 8 (5.0–10.0) cm H2O for neonates and 10 (8.0–10.0) cm H2O for pediatric subjects. By multivariable analysis, higher PEEP on ECMO day 1 in neonates was associated with lower odds of in-hospital mortality (odds ratio 0.77, 95% CI 0.62–0.92; P = .01), with a further amplified effect in neonates with congenital diaphragmatic hernia (odds ratio 0.59, 95% CI 0.41–0.86; P = .005). No ventilator type or parameter was associated with mortality in pediatric subjects. CONCLUSIONS: Avoiding low PEEP on ECMO day 1 for neonates on ECMO may be beneficial, particularly those with a congenital diaphragmatic hernia. No additional ventilator parameters were associated with mortality in either neonatal or pediatric subjects. PEEP is a modifiable parameter that may improve neonatal survival during ECMO and requires further investigation.

To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.

Background: The ideal extracorporeal membrane oxygenation (ECMO) modality choice (venoarterial [VA] versus venovenous [VV]) for a primary respiratory reason is complex and multifactorial. There is an increasing need to identify the ideal (VV vs. VA) support modality in this population. The objective of this study was to compare survival outcomes of subjects with respiratory failure who could have received VV or VA ECMO. Subjects and Methods: Children ≤20 kg requiring ECMO for respiratory indications from January 2015 to December 2019 were identified retrospectively from the Extracorporeal Life Support Organization registry. To identify a cohort eligible for VV, we excluded subjects receiving cardiac support therapies and included only those receiving mechanical ventilation with a positive end expiratory pressure ≥10 or high frequency oscillatory ventilation or had a PaO2/FiO2 ratio ≤200 or an oxygenation index ≥16. Subjects were grouped by initial cannulation strategy. Statistical approach utilized doubly robust propensity weighted logistic regression and primary outcome was survival to hospital discharge. Results: Of 1686 VV candidates, 871 underwent VV and 815 VA ECMO for a respiratory indication. VV ECMO was associated with higher survival (odds ratio: 1.57; confidence interval: 1.22–2.03, P < 0.001). Conclusions: VV ECMO selection for subjects with respiratory failure was associated with lower mortality in small pediatric and neonatal patients.

Objective:Children with heart disease may require inpatient care for many reasons, but ultimately have a final reason for hospitalisation prior to discharge. Factors influencing length of stay in paediatric cardiac acute care units have been described but the last reason for hospitalisation has not been studied. Our aim was to describe Final Hospital Need as a novel measure, determine Final Hospital Need in our patients, and describe factors associated with this Need. Methods:Single-centre survey design. Discharging providers selected a Final Hospital Need from the following categories: cardiovascular, respiratory, feeding/fluid, haematology/ID, pain/sedation, systems issues, and other/wound issues. Univariable and multivariable analyses were performed separately for outcomes "cardiovascular" and "feeding/fluid." Measurements and Results:Survey response rate was 99% (624 encounters). The most frequent Final Hospital Needs were cardiovascular (36%), feeding/fluid (24%) and systems issues (13%). Probability of Final Hospital Need "cardiovascular" decreased as length of stay increased. Multivariate analysis showed Final Hospital Need "cardiovascular" was negatively associated with aortic arch repair, Norwood procedure, and Final ICU Need "respiratory" and "other." Final Hospital Need "feeding/fluid" was negatively associated with left-sided valve procedure, but positively associated with final ICU need "respiratory," and tube feeding at discharge. Conclusions:Final Hospital Need is a novel measure that can be predicted by clinical factors including age, Final ICU Need, and type of surgery. Final Hospital Need may be utilised to track changes in clinical care over time and as a target for improvement work.