Skip to main content
SpringerLink
Log in

Surgical Quality Predicts Length of Stay in Patients with Congenital Heart Disease

  • Original Article
  • Published:
Pediatric Cardiology Aims and scope Submit manuscript

Abstract

Historically, the primary marker of quality for congenital cardiac surgery has been postoperative mortality. The purpose of this study was to determine whether additional markers (10 surgical metrics) independently predict length of stay (LOS), thereby providing specific targets for quality improvement. Ten metrics (unplanned ECMO, unplanned cardiac catheterization, revision of primary repair, delayed closure, mediastinitis, reexploration for bleeding, complete heart block, vocal cord paralysis, diaphragm paralysis, and change in preoperative diagnosis) were defined in 2008 and subsequently collected from 1024 consecutive index congenital cardiac cases, yielding 990 cases. Four patient characteristics and 22 case characteristics were used for risk adjustment. Univariate and multivariable analyses were used to determine independent associations between each metric and postoperative LOS. Increased LOS was independently associated with revision of the primary repair (p = 0.014), postoperative complete heart block requiring a permanent pacemaker (p = 0.001), diaphragm paralysis requiring plication (p < 0.001), and unplanned postoperative cardiac catheterization (p < 0.001). Compared with patients without each metric, LOS was 1.6 (95 % CI 1.1–2.2, p = 0.014), 1.7 (95 % CI 1.2–2.3, p = 0.001), 1.8 (95 % CI 1.4–2.3, p < 0.001), and 2.0 (95 % CI 1.7–2.4, p < 0.001) times as long, respectively. These effects equated to an additional 4.5–7.8 days in hospital, depending on the metric. The other 6 metrics were not independently associated with increased LOS. The quality of surgery during repair of congenital heart disease affects outcomes. Reducing the incidence of these 4 specific surgical metrics may significantly decrease LOS in this population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Agarwal HS, Wolfram KB, Saville BR, Donahue BS, Bichell DP (2014) Postoperative complications and association with outcomes in pediatric cardiac surgery. J Thorac Cardiovasc Surg 148:609–616

    Article  PubMed  Google Scholar 

  2. Anderson JB, Czosek RJ, Knilans TK, Meganathan K, Heaton P (2012) Postoperative heart block in children with common forms of congenital heart disease: results from the KID Database. J Cardiovasc Electrophysiol 23:1349–1354

    Article  PubMed  Google Scholar 

  3. Asoh K, Hickey E, Dorostkar PC, Chaturvedi R, van Arsdell G, Humpl T et al (2009) Outcomes of emergent cardiac catheterization following pediatric cardiac surgery. Catheter Cardiovasc Interv 73:933–940

    Article  PubMed  Google Scholar 

  4. Birkmeyer JD, Dimick JB, Birkmeyer NJO (2004) Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg 198:626–632

    Article  PubMed  Google Scholar 

  5. Brown KL, Ridout DA, Goldman AP, Hoskote A, Penny DJ (2003) Risk factors for long intensive care unit stay after cardiopulmonary bypass in children. Crit Care Med 31:28–33

    Article  PubMed  Google Scholar 

  6. Dunteman GH (1989) Principal components analysis. SAGE, Newbury Park

    Google Scholar 

  7. Grant SW, Hickey GJ, Cosgriff R (2013) Creating transparency in UK adult cardiac surgery data. Heart 99:1067–1068

    Article  PubMed  Google Scholar 

  8. Jenkins KJ, Gauvreau K, Newburger JW, Spray TL, Moller JH, Iezzoni LI (2002) Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 123:110–118

    Article  PubMed  Google Scholar 

  9. Larrazabal LA, del Nido PJ, Jenkins KJ, Gauvreau K, Lacro R, Colan S et al (2007) Measurement of technical performance in congenital heart surgery: a pilot study. Ann Thorac Surg 83:179–184

    Article  PubMed  Google Scholar 

  10. Mainz J (2003) Developing evidence-based clinical indicators: a state of the art methods primer. Int J Qual Health Care 15:i5–i11

    Article  PubMed  Google Scholar 

  11. Mainz J (2003) Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 15:523–530

    Article  PubMed  Google Scholar 

  12. Nathan M, Karamichalis J, Liu H, Gauvreau K, Colan S, Saia M et al (2014) Technical Performance Scores are strongly associated with early mortality, postoperative adverse events, and intensive care unit length of stay-analysis of consecutive discharges for 2 years. J Thorac Cardiovasc Surg 147:389–396

    Article  PubMed  Google Scholar 

  13. Newburger JW, Wypij D, Bellinger DC, Du Plessis AJ, Kuban KC, Rappaport LA et al (2003) Length of stay after infant heart surgery is related to cognitive outcome at age 8 years. J Pediatr 143:67–73

    Article  PubMed  Google Scholar 

  14. O’Brien SM, Clarke DR, Jacobs JP, Jacobs ML, Lacour-Gayet FG, Pizarro C et al (2009) An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg 138:1139–1153

    Article  PubMed  Google Scholar 

  15. Pagowska-Klimek I, Pychynska-Pokorska M, Krajewski W, Moll JJ (2011) Predictors of long intensive care unit stay following cardiac surgery in children. Eur J Cardiothorac Surg 40:179–184

    Article  PubMed  Google Scholar 

  16. Schwarz GH (1978) Estimating the dimension of a model. Ann Stat 6:461–464

    Article  Google Scholar 

  17. Searle SR, Speed FM, Milliken GA (1980) Population marginal means in the linear model: an alternative to least squares means. Am Stat 34:216–221

    Google Scholar 

  18. Shahian DM, Edwards FH, Ferraris VA, Haan CK, Rich JB, Normand ST et al (2007) Quality measurement in adult cardiac surgery: part 1—conceptual framework and measure selection. Ann Thorac Surg 83:S3–S12

    Article  PubMed  Google Scholar 

  19. Siehr SL, Martin MH, Axelrod D, Efron B, Peng L, Roth SJ et al (2014) Outcomes following cardiac catheterization after congenital heart surgery. Catheter Cardiovasc Interv 84:622–628

    Article  PubMed  Google Scholar 

  20. Sinzobahamvya N, Weber T, Sata S, Haun C, Arenz C, Photiadis J et al (2013) Quantification of morbidity associated with congenital heart surgery. Thorac Cardiovasc Surg 61:278–285

    PubMed  Google Scholar 

  21. STS Congenital Heart Surgery Database Data Specifications, Version 3.22 (2013) The society of thoracic surgeons. http://www.sts.org/sites/default/files/documents/CongenitalDataSpecsV3_22.pdf. Accessed 14 Nov 2014

  22. STS Congenital Heart Surgery Executive Summary, All Patients, Period Ending 12/31/2013 (2014) Duke clinical research institute. http://www.sts.org/sites/default/files/documents/CongenitalSTSExecSummary_AllPatients_Update.pdf. Accessed 16 Dec 2014

  23. Szekely A, Erzsebet E, Kiraly L, Szatmari A, Dinya E (2006) Intraoperative and postoperative risk factors for prolonged mechanical ventilation after pediatric cardiac surgery. Pediatr Anesth 16:1166–1175

    Google Scholar 

  24. Welke KF, Karamlou T, Ungerleider RM, Diggs BS (2010) Mortality rate is not a valid indicator of quality differences between pediatric cardiac surgical programs. Ann Thorac Surg 89:139–146

    Article  PubMed  Google Scholar 

  25. Welsby IJ, Bennett-Guerrero E, Atwell D, White WD, Newman MF, Smith PK et al (2002) The association of complication type with mortality and prolonged stay after cardiac surgery with cardiopulmonary bypass. Anesth Analg 94:1072–1078

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Pediatric Cardiology, Doernbecher Children’s Hospital, Oregon Health & Science University (OHSU), 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA

    Eric A. Johnson, Laurie R. Armsby & Grant H. Burch

  2. Division of Pediatric Cardiothoracic Surgery, Doernbecher Children’s Hospital, Oregon Health & Science University (OHSU), 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA

    M. Mujeeb Zubair, Milon K. Good, Ashok Muralidaran & Stephen M. Langley

  3. Oregon Institute of Occupational Health Sciences, Oregon Health & Science University (OHSU), 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA

    Michael R. Lasarev

  4. Division of Perinatology, Oregon Health & Science University (OHSU), 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA

    A. Roger Hohimer

Authors
  1. Eric A. Johnson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Mujeeb Zubair
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Laurie R. Armsby
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Grant H. Burch
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Milon K. Good
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael R. Lasarev
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. A. Roger Hohimer
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ashok Muralidaran
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Stephen M. Langley
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eric A. Johnson.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 41 kb)

Supplementary material 2 (DOCX 21 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Johnson, E.A., Zubair, M.M., Armsby, L.R. et al. Surgical Quality Predicts Length of Stay in Patients with Congenital Heart Disease. Pediatr Cardiol 37, 593–600 (2016). https://doi.org/10.1007/s00246-015-1319-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-015-1319-x

Keywords

Search

Navigation