O1012: Implementation of target-based care is associated with a reduction of intensive care and overall post-operative length of stay

Background: A clinical pathway is an effective tool to reduce practice variability after pediatric cardiovascular surgery, however, development of such is time-consuming and oftentimes lacking in evidence. Target-based care (TBC) is a relatively simple concept that employs local historical data for a specific cardiac operation. The median is calculated for post-surgical milestones, and then this data is displayed transparently for the medical team and patient/family, thereby providing a shared mental model. We hypothesize that TBC will lead to a relative decrease in post-operative ICU and overall hospital length of stay (LOS).

Methods: This is a single-institution quality improvement study with a retrospective arm and an ongoing prospective arm. Post-operative data from the previous 4 years (2018-2022) were collected and reviewed for the following operations: VSD closure, AV septal defect, tetralogy of Fallot, arterial switch with/without VSD closure, ASD closure, arch repair thoracotomy, Norwood, Glenn, Fontan, and BT shunt. For each operation, the median (50th percentile) was calculated from the retrospective cohort for 5 post-operative targets: extubation, chest tube removal, central line removal, ICU transfer, and discharge. Readmission at 7 days was assessed as a balancing measure. Surgical mortalities were excluded. All patients undergoing the aforementioned operations were included, regardless of comorbidities. The number of days observed (O) for each target was divided by the expected (E) (median) to derive O/E ratio, where O/E = 1.0 indicates a met target, < 1.0 beat target, and >1.0 exceeding target. Variables are expressed as median [inter-quartile range] or mean ± standard deviation, and compared using Wilcoxon rank sum, student’s t, or Chi-square tests where appropriate.

Results: There were 684 patients included in the retrospective cohort, and 102 patients enrolled in TBC cohort to date. There was no significant difference in proportion of operations performed over the 2 time-periods. The TBC cohort had a significant reduction in median O/E ratios for all 5 clinical targets (Table 1). In addition, the TBC cohort was significantly more likely to beat (55% vs. 42%) and achieve target discharge (72% vs. 56%). TBC patients were less likely to be a discharge outlier (O/E > 2.0, 7% vs. 19%). Interestingly, all 7 outlier patients required post-operative gastrostomy tube placement, and 3 were transferred back to ICU. There was no difference in 7-day readmission after implementation of TBC (3.9% vs. 4.0%, p = 1.0).

Conclusion: Initial implementation of TBC is associated with a decreased ICU and overall hospital LOS without concomitant increase in rate of readmission. TBC provides a shared mental model for heart center teams and may lead to improved patient care efficiency and outcomes after surgery.