243: INTENSIVE CARE IN CHILDREN WITH HLHS IN DEVELOPING COUNTRIES BUT TO WHAT EXTENT?

Abstract

Learning Objectives: Many hospitals aim to extubate children early after cardiac surgery, yet it remains unclear whether this practice is associated with extubation failure (EF). We evaluated adjusted EF rates and duration of postoperative mechanical ventilation (POMV) across hospitals and assessed cardiac intensive care unit (CICU) organizational factors associated with EF. Methods: We calculated hospital-level case-mix adjusted EF rates for cardiac surgical patients in the Pediatric Cardiac Critical Care Consortium (PC4) registry. EF was defined as reintubation <48 hours after the first planned postoperative extubation. The EF model was derived using multivariable logistic regression and validated through bootstrap resampling (1000 samples). Adjusted POMV was calculated from a previously published PC4 case-mix adjustment model. Observed-to-expected (O/E) ratios for EF and POMV were measured at each hospital; outliers were those with a 95% confidence interval around the O/E not including 1. Hierarchical logistic regression was used to assess the association between CICU factors (e.g. staffing, resources) and EF. Results: There were 16,453 hospitalizations (25 hospitals) from 8/2014–6/2017. Overall EF rate was 5.3%. Predictors of EF (p<0.05 in final model) included younger age, underweight, greater surgical complexity, airway anomaly, chromosomal anomaly/syndrome, longer bypass time, and other preoperative comorbidities. Three hospitals were lower-than-expected outliers (O/E <1) and three hospitals were higher-than-expected outliers (O/E>1) for EF. Two hospitals were low outliers for both EF and POMV and three were high outliers for both. No hospital was an outlier in opposite directions across EF and POMV. Greater nursing hours per patient day and % nursing staff with critical care certification were associated with lower odds of EF. Lower % nurses with <2 years of experience, greater % critical care trained attendings, CICUdedicated respiratory therapists, and fewer patients per CICU attending were not associated with lower odds of EF. Conclusions: We saw no evidence that hospitals trade greater EF rates for shorter duration of POMV after pediatric cardiac surgery. On the contrary, we identified high performing hospitals with both low EF rates and duration of POMV. Increasing specialized critical care nurse staffing may achieve better extubation outcomes and mitigate effects of inexperienced nurses. CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MD CCM