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Clinical pathway for the Fontan patient to standardise care and improve outcomes

Published online by Cambridge University Press:  14 July 2020

Sarah M. Lagergren Open the ORCID record for Sarah M. Lagergren [Opens in a new window] ,
Megan Jensen ,
Bryan Beaven  and
Suma Goudar Open the ORCID record for Suma Goudar [Opens in a new window]
Sarah M. Lagergren*
Affiliation:
Children’s Mercy Hospital, Ward Family Heart Center, Kansas City, MO, USA
Megan Jensen
Affiliation:
Children’s Mercy Hospital, Ward Family Heart Center, Kansas City, MO, USA
Bryan Beaven
Affiliation:
Children’s Mercy Hospital, Ward Family Heart Center, Kansas City, MO, USA
Suma Goudar
Affiliation:
Children’s Mercy Hospital, Ward Family Heart Center, Kansas City, MO, USA
*
Author for correspondence: Sarah M. Lagergren, Children’s Mercy Hospital, Ward Family Heart Center, Kansas City, 6318 N. Bell Street, MO 64151, USA. Tel: +1 (816) 520-0571, +1 (816) 234-3255; Fax +1 (816) 302-9877. E-mail: smlagergren@cmh.edu
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Abstract

Introduction:

The Fontan procedure is the final stage of surgical palliation for the children with functionally single ventricle anatomy. The post-operative medical management of this patient population can be variable and hospital length of stay prolonged. The purpose of this quality improvement project was to determine if the implementation of an evidence-based clinical pathway for post-operative management of the Fontan patient at a large Midwestern academic paediatric medical centre would standardise care and decrease length of stay.

Materials and methods:

The clinical pathway was developed using key components from three published pathways for the Fontan procedure from other paediatric institutions across the United States. Components of the clinical pathway included (1) supplemental oxygen until pleural drainage tubes are removed, (2) fluid restriction to 80% daily maintenance and a prescribed low-fat diet, (3) aggressive and standardised diuretic therapy while inpatient and (4) central venous access. The pathway was trialed using Plan-Do-Study-Act cycles in 2016, implemented in 2017 and sustained in 2018–2019. A retrospective electronic medical record review was performed to compare key outcomes from pre-pathway (2014–2015, 37 patients) with post-pathway implementation (2017–2018, 30 patients).

Results:

Adherence to the pathway was nearly 100% with a statistically significant decrease in length of stay from 12 to 9 days (p = 0.007) and no increase in readmissions.

Conclusion:

Standardising care can improve clinical and financial outcomes for the Fontan patient population without negatively impacting quality of care, thus providing a positive benefit to the healthcare institution, industry and patient.

Keywords

Fontan pathwaystandardisation of careclinical pathwaylength of stay
Type
Original Article
Information
Cardiology in the Young , Volume 30 , Issue 9 , September 2020 , pp. 1247 - 1252
Copyright
© The Author(s), 2020. Published by Cambridge University Press

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References

May, LE.Pediatric Heart Surgery: A Ready Reference for Professionals, 5th ed. maxiSHARE, Milwaukee, WI, 2012.Google Scholar
Dean, PN, Hillman, DG.Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011; 128: e1181–e1186. doi: 10.1542/peds.2010-3742CrossRefGoogle ScholarPubMed
Cava, JR, Bevandic, SM.A medical strategy to reduce persistent chest tube drainage after the Fontan operation. Am J Cardiol 2005; 96: 130–133. doi: 10.1016/j.amjcard.2005.03.034CrossRefGoogle ScholarPubMed
Sunstrom, RE, Muralidaran, A, Gerrah, R, et al.A defined management strategy improves early outcomes after the Fontan procedure: the portland protocol. Soc Thor Surg 2015; 99: 148–155. doi: 10.1016/j.athoracsur.2014.06.121CrossRefGoogle ScholarPubMed
d’Udekem, Y, Iyengar, AJ, Galati, JC, et al.Redefining expectations of long-term survival after the Fontan procedure: twenty-five years of follow-up from entire population of Australia and New Zealand. Circulation 2014; 130 (11 Suppl 1): S32–S38. doi: 10.1161/CIRCULATIONAHA.113.007764CrossRefGoogle ScholarPubMed
Mannion, R, Exworthy, M. (Re)Making the procrustean bed? Standardization and customization as competing logics in healthcare. Int J Health Policy M 2017; 6: 301–304. doi: 10.15171/ijhpm.2017.35CrossRefGoogle Scholar
Uzark, K, Frederick, C, Lamberti, JJ, et al.Changing practice patterns for children with heart disease: a clinical pathway approach. Am J Crit Care 1998; 7: 101–105.CrossRefGoogle ScholarPubMed
Allen, HD, Davis, JT.Standardizing care delivery for infants and children with common congenital cardiac lesions. Curr Opin Pediatr 1995; 7: 601–605.CrossRefGoogle ScholarPubMed
Pike, NA, Okuhara, CA.Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol. J Thor Cardiovasc Surg 2015; 150: 481–487. doi: 10.1016/j.jtcvs.2015.06.042CrossRefGoogle ScholarPubMed
Gupta, A, Daggett, C, Behera, S, et al.Risk factors for persistent pleural effusions after the extracardiac Fontan procedure. J Thor Cardiovasc Surg 2014; 127: 1664–1669. doi: 10.1016/j.jtcvs.2003.09.011CrossRefGoogle Scholar
O’Mathuna, DP. Ethical considerations for evidence implementation and evidence generation. In: Melnyk, BM, Fineout-Overholt, E (eds). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice, 3rd edn. Wolters Kluwer Health, Philadelphia, 2015: 515–530.Google Scholar
O’Brien, J. Surgical outcomes and dashboards: 2014–2018. Results from the Society of Thoracic Surgeons Congenital Heart Surgery Database [PowerPoint presentation]. 2019.Google Scholar
Jacobs, JP, Shahaian, DM, Prager, RL, et al.The society of thoracic surgeons national database 2016 annual report. Soc Thor Surg 2016; 102: 1790–1797.CrossRefGoogle Scholar
Jacobs, JP, Shahaian, DM, D’Agostino, RS, et al.The society of thoracic surgeons national database 2018 annual report. Soc Thor Surg 2018; 106: 1603–1611.CrossRefGoogle Scholar
Napolene, CP, Oppido, G, Angeli, Eet al.Results of the modified Fontan procedure are not related to age at operative. Eur J Cardiothorac Surg 2010; 37: 645–650. doi: 10.1016/j.ejcts.2009.09.003CrossRefGoogle Scholar