Jean Anne Connor

Factors Associated With Increased Resource Utilization for Congenital Heart Disease

Objective. To identify patient, institutional, and regional factors that are associated with high resource utilization for congenital heart surgery. Methods. We used hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) year 2000 (data from 27 states). Patients who had congenital heart surgery and were younger than 18 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. High resource utilization admissions were defined as those in the highest decile for total hospital charges. Univariate and multivariate analyses with and without deaths were used to determine demographic and hospital predictors for cases of high resource use. Case-mix severity was approximated using Risk Adjustment for Congenital Heart Surgery risk groups. Regional and state differences were also examined. Results. Among 10569 cases of congenital heart surgery identified, median total hospital charges were

The meaning of cost for families of children with congenital heart disease.

53828. Statewide differences in the number of high resource use admissions were present; California, Colorado, Florida, Hawaii, Pennsylvania, and Texas were more likely to have high resource use cases, and Maine and South Carolina were less likely. Subsequent analyses were performed adjusting for baseline state effects. Multivariate analyses using generalized estimating equations models revealed Risk Adjustment for Congenital Heart Surgery risk category (odds ratio [OR]: 1.66–14.1), age (OR: 3.81), prematurity (OR: 4.85), the presence of other major noncardiac structural anomalies (OR: 2.53), Medicaid insurance (OR: 1.48), and admission during a weekend (OR: 1.62) to be independent predictors of a higher odds of high cost cases. Although some institutional differences were noted in univariate analyses, gender, race, bed size, teaching and children’s hospital status, hospital ownership, and hospital volume of cardiac cases were not independently associated with greater odds of high resource utilization. Conclusions. States varied in the frequency of high resource utilization for congenital heart surgery. Patients who had greater disease complexity, younger age, prematurity, other anomalies, and Medicaid and were admitted during a weekend were more likely to result in high resource utilization. Institutions of various types did not differ in high cost admissions, regardless of children’s hospital or teaching status.

The relationship of nurse staffing, skill mix, and Magnet recognition to institutional volume and mortality for congenital heart surgery.

INTRODUCTION The purpose of this study was to describe the cost burden of congenital heart disease (CHD) and the associated social impact as experienced by families. METHOD Qualitative methods were used to collect and interpret data. Semi-structured interviews were conducted with parents of children with various degrees of CHD complexity and socioeconomic status currently admitted for congenital heart surgery at a large tertiary care regional center. RESULTS The meaning of cost burden as defined by participants resulted in the emergence of two major categories, lifestyle change and uncertainty. Cost was described beyond monetary terms and as a result, data in each category were further clustered into three underlying subcategories labeled financial, emotional, and family burden. The childs disease complexity and parents socioeconomic status seem to be linked to higher levels of stress experienced in terms of finances, emotional drain, and family member burden. Prenatal diagnosis was noted to trigger early discussion of financial uncertainty, often resulting in altered personal spending prior to birth. DISCUSSION The cost experienced by parents of children with complex CHD was described as both life-changing and uncertain. Informing families of these types of additional stressors may allow issues of finances to be considered early in the overall preparation of caring for a child with complex CHD.

Variation in Preoperative and Intraoperative Care for First‐stage Palliation of Single‐ventricle Heart Disease: A Report from the Joint Council on Congenital Heart Disease National Quality Improvement Collaborative

Objective: The aim of this study was to examine the relationship of nurse staffing, skill mix, and Magnet® recognition to institutional volume and mortality for congenital heart surgery at childrens hospitals. Background: Little is known about how nurse staffing, skill mix, and Magnet recognition influence outcomes in childrens hospitals. Methods: Cases of congenital heart surgery were identified from the 2005-2006 Pediatric Health Information System Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The National Association of Childrens Hospitals and Related Institution database was used for staffing data and verified by chief nursing officers; Magnet recognition was obtained from the American Nurses Credentialing Center Web site. Relationships among nursing characteristics, volume, and mortality were examined. Results: Among children undergoing congenital heart surgery at major childrens hospitals, there was marked variation in intensive care unit (ICU) nursing hours per patient day (14.96-32.31). Variation in ICU nursing skill mix was less extreme (80%-100%); 20 hospitals had 100% registered nurse staffing in ICUs. There was a significant difference in median nursing skill mix between Magnet and non-Magnet hospitals (P = .02). None of the nursing characteristics was associated with mortality. However, higher nursing worked hours was significantly associated with higher volume (rs = 0.39, P = .027). Hospital volume was significantly associated with risk-adjusted mortality. Conclusion: Nursing characteristics varied in ICUs in childrens hospitals treating congenital heart surgery but were not associated with mortality. There was a significant relationship between ICU nursing worked hours and institutional volume. Nursing skill mix was lower in Magnet hospitals.

Hypoplastic left heart syndrome.

BACKGROUND AND METHODS As the first multicenter quality improvement collaborative in pediatric cardiology, the Joint Council on Congenital Heart Disease National Pediatric Cardiology Quality Improvement Collaborative registry collects information on the clinical care and outcomes of infants discharged home after first-stage palliation of single-ventricle heart disease, the Norwood operation, and variants. We sought to describe the preoperative and intraoperative characteristics of the first 100 patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry. RESULTS From 21 contributing centers, 59% of infants were male, with median birth weight of 3.1 kg (1.9-5.0 kg); the majority had hypoplastic left heart syndrome (71%). A prenatal diagnosis of congenital heart disease was made in 75%; only one had fetal cardiac intervention. Chromosomal anomalies were present in 8%, and major noncardiac organ system anomalies were present in 9%. Preoperative risk factors were common (55%) but less frequent in those with prenatal cardiac diagnosis (P= .001). Four patients underwent a preoperative transcatheter intervention. Substantial variation across participating sites was demonstrated for choice of initial palliation for the 93 patients requiring a full first-stage approach, with 50% of sites performing stage I with right ventricle to pulmonary artery conduit as the preferred operation; 89% of hybrid procedures were performed at a single center. Significant intraoperative variation by site was noted for the 83 patients who underwent traditional surgical stage I palliation, particularly with use of regional perfusion and depth of hypothermia. CONCLUSIONS In summary, there is substantial variation across surgical centers in the successful initial palliation of infants with single-ventricle heart disease, particularly with regard to choice of palliation strategy, and intraoperative techniques including use of regional perfusion and depth of hypothermia. Further exploration of the relationship of such variables to subsequent outcomes after hospital discharge may help reduce variability and improve long-term outcomes.

The Cardiac Children's Hospital Early Warning Score (C-CHEWS).

Hypoplastic left heart syndrome(HLHS) refers to the abnormal development of the left-sided cardiac structures, resulting in obstruction to blood flow from the left ventricular outflow tract. In addition, the syndrome includes underdevelopment of the left ventricle, aorta, and aortic arch, as well as mitral atresia or stenosis. HLHS has been reported to occur in approximately 0.016 to 0.036% of all live births. Newborn infants with the condition generally are born at full term and initially appear healthy. As the arterial duct closes, the systemic perfusion becomes decreased, resulting in hypoxemia, acidosis, and shock. Usually, no heart murmur, or a non-specific heart murmur, may be detected. The second heart sound is loud and single because of aortic atresia. Often the liver is enlarged secondary to congestive heart failure. The embryologic cause of the disease, as in the case of most congenital cardiac defects, is not fully known. The most useful diagnostic modality is the echocardiogram. The syndrome can be diagnosed by fetal echocardiography between 18 and 22 weeks of gestation. Differential diagnosis includes other left-sided obstructive lesions where the systemic circulation is dependent on ductal flow (critical aortic stenosis, coarctation of the aorta, interrupted aortic arch). Children with the syndrome require surgery as neonates, as they have duct-dependent systemic circulation. Currently, there are two major modalities, primary cardiac transplantation or a series of staged functionally univentricular palliations. The treatment chosen is dependent on the preference of the institution, its experience, and also preference. Although survival following initial surgical intervention has improved significantly over the last 20 years, significant mortality and morbidity are present for both surgical strategies. As a result pediatric cardiologists continue to be challenged by discussions with families regarding initial decision relative to treatment, and long-term prognosis as information on long-term survival and quality of life for those born with the syndrome is limited.

The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States.

Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other hospitalized children. Pediatric early warning scoring tools have helped to provide early identification and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring. However, the tools have rarely been used and have not been validated in the pediatric cardiac population. This paper describes the modification of a pediatric early warning scoring system for cardiovascular patients, the implementation of the tool, and its companion escalation of care algorithm on an inpatient pediatric cardiovascular unit.

Clopidogrel in a Pediatric Population: Prescribing Practice and Outcomes from a Single Center

OBJECTIVE: This study explored pediatric critical care nursing and organizational factors that impact in-hospital mortality for cardiac surgery patients across children’s hospitals in the United States. BACKGROUND: Congenital heart disease is the most common birth defect and the no. 1 cause of death for infants with a congenital defect. Little is known about the impact of pediatric critical care nursing and organizational factors on pediatric mortality. METHODS: Nursing leaders from 38 children’s hospitals that contribute data to the Pediatric Health Information System data set completed an organizational assessment for years 2009 and 2010. These data were linked with patient-level data. The Risk Adjustment for Congenital Heart Surgery method was used to adjust for baseline patient differences in patients younger than 18 years. RESULTS: The odds of death increased as the institutional percentage of pediatric critical care unit nurses with 2 years’ clinical experience or less increased. The odds of mortality were highest when the percentage of RNs with 2 years’ clinical experience or less was 20% or greater. The odds of death decreased as the institutional percentage of critical care nurses with 11 years’ clinical experience or more increased and for hospitals participating in national quality metric benchmarking. Clinical experience was independently associated with in-hospital mortality. CONCLUSIONS: These data are the 1st to link clinical nursing experience with pediatric patient outcomes. A cut point of 20% RNs or greater with 2 years’ clinical experience or less was determined to significantly affect inpatient mortality. Participation in national quality metric benchmarking programs was significantly associated with improved mortality.

The use of large administrative data sets in nursing research 1

Background This study aimed to provide descriptive information about off-label treatment practice with clopidogrel in a pediatric population. Methods Patients less than 18 years of age prescribed clopidogrel between March 2002 and August 2005 were retrospectively identified at Children’s Hospital, Boston. Data from the time of first documented clopidogrel use to the most recent follow-up assessment were collected. Adverse events were classified according to seriousness and relationship to clopidogrel. Results Of the 90 patients in the study, 53% were boys. The median age of the patients was 6.7 years, and their median weight was 23.6 kg at first clopidogrel use. Prescriptions were predominantly for cardiac indications (96%), with a few for neurologic indications (4%). Common cardiac indications were history of thrombosis involving a conduit or shunt, abnormal vasculature with potential for low flow, and device placement. The median total dose was 1.3 mg/kg/day, and the duration of therapy varied from less than 1 day to 4 years (median, 45 days). Three patients experienced minor bleeding, all of whom were receiving concomitant acetylsalicylic acid. Another patient experienced catastrophic bleeding after vessel tear during catheterization. One patient with a fenestrated Fontan and poor ventricular function had baffle thrombosis and subsequent stroke while receiving clopidogrel and acetylsalicylic acid. Conclusions Clopidogrel was prescribed most often to prevent thrombosis in patients with cardiac disease. Patients with neurologic conditions also were treated. Bruising and bleeding events occurred rarely.

Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative.

A NALYSIS OF large administrative data sets has been a method used primarily by health services researchers to examine issues such as access, regional differences in care, and health outcomes. Most administrative data sets were first developed in the 1970s for the collection of data regarding health plans, health system utilization, and claims data. Although they were not originally intended for conducting research, administrative data sets were found to be an attractive avenue for health services research studies. Technologic advances in personal computers, modern statistical analysis software, and uniform International Classification of Diseases, Ninth Revision nomenclature have widened the horizons for researchers. In the past, investigations using national or state data sets required access to mainframe computer resources, but today, analyses of this type may be conducted using one’s personal computer. The purpose of this article is to discuss the use of large administrative data sets as a tool in nursing research. As early as 1985, the limited use of secondary data analysis in nursing research was noted (McArt & McDougal, 1985). Jacobson et al.,1993 conducted a Medline search (1986-1992) for nursing citations using the key words secondary data analysis and identified 11 citations, 3 of which appeared in nursing journals. We conducted a similar literature search (1997-2003) using PUBMED with the key words secondary data analysis and nursing and identified 82 nursing studies using secondary data analysis. Of those, only 15 used existing administrative data sets. Fourteen of the 15 were published in nursing journals. Although the use of secondary analysis as a research method has increased in nursing, the use of administrative data sets has not kept equal tempo. Large administrative data sets embody information about groups of people and often describe entire populations at either state and/or national levels, thus enhancing generalizability of research findings. The data are representative of care delivered in many settings and can be useful to examine patterns of health service and resource utilization. Longitudinal administrative data sets, which collect person-level information, can be used to track subjects both over time and across settings of care. Finally, these data sets already exist, can be obtained inexpensively, and are easily adapted for use with analytical software. Various types of administrative data sets are available. Thirty-six states presently are legislatively mandated as part of public health law to collect discharge information on all hospitalized patients. Patient identifiers are removed from the data to protect patient confidentiality, and most state hospital inpatient data sets lack identifiers to track recurrent hospitalizations. Two examples of state data sets are the New York State Department