Session VII: PEDx Talks
By Matthew DiGiusto, MD and Sean S. Barnes, MD, MBA
Public Reporting and US News: Where is the Data Coming from and How is it Being Used?
David F. Vener, MD (Texas Children’s Hospital, Houston)
The “transparency movement” is driven by multiple forces to include headline seekers (investigative journalists), information/publicity sales (US News), dollar savers (insurers), and information advocates (parent support groups). Public reporting has been shown to make a difference as people who know they are being observed tend to perform better. One problem with data reporting is that risk adjustment is critical. The Leeds Congenital Heart Program in the UK was temporarily suspended when a number of perceived poor outcomes were not risk-adjusted. Several surgeries were delayed, and mothers had to be transferred for delivery before the program was subsequently reinstated.
Dr. Vener described how cardiac data comes from several different sources. The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database is a voluntary database but with nearly 100% participation in the United States. There have been some recent changes to STS public reporting of data including no longer utilizing star ratings (despite all the data still being present) and reporting benchmark surgical outcomes including risk adjustment for ten defined procedures.
A new model for risk adjustment is now under investigation and analysis, which appears to be improved, however, there continue to be issues. STS risk adjustment is purely surgical procedure based and not diagnosis based. Other risk factors cannot be accounted for including socioeconomic status, which may double the mortality risk, as well as tracheal surgery not being included even if it is the primary operation and it significantly increases morbidity and mortality.
Additional sources of data include the American College of Cardiology IMPACT Registry (captures interventional cardiology and EP data), and the Pediatric Cardiac Critical Care Consortium (PC4) database. The PC4 can leverage their databases to examine both surgical and medical mortality but this data is not available to the public. The entire premise of PC4 is built on transparency and collaborative learning.
US News Pediatric Cardiology and Cardiac Surgery does not obtain data directly from STS or IMPACT but rather relies on honest and accurate completion of their survey. They then apply numeric rankings to programs that, while statistically and clinically meaningless, are easily digestible for the lay public and widely disseminated. They look at overall outcomes from STS which uses the most recent four-year data, which may be as old as five years, and does not take into account changes in surgeons over that time frame. Additionally, approximately 50% of the scores come from hospital-wide metrics to include commitment to best practices, nursing Magnet status, various accreditations, and the presence of support services.
While public reporting is important, an unintended consequence is elevated stress levels for surgeons. It is important to minimize risk aversion in an age of transparency which can be achieved through optimization of data source, risk models, and performance measures.
Sedation for Non-invasive Cardiac Imaging: What are My Options?
Joanna Rosing Paquin, MD (Cincinnati Children’s Hospital)
Current sedation practices for non-invasive cardiac imaging vary. One reason for this variation is the different cardiac imaging modalities required. It is important to keep the sedation goal in mind when looking at echocardiogram versus MRI. Dr. Paquin advocates the utility of dexmedetomidine in patients with congenital heart disease for sedation. Dexmedetomidine is a highly selective central alpha2-adrenergic receptor agonist that allows for cooperative sedation with minimal respiratory depression. Dexmedetomidine has previously been demonstrated to be equivocal to chloral hydrate and barbiturates for transthoracic echocardiogram (TTE) sedation by Miller J et al. in Pediatric Anesthesiology. Intranasal (IN) dexmedetomidine administration provides adequate plasma concentration for sedation in children as it has >80% bioavailability. There are some concerns with IN dexmedetomidine as it can cause bradycardia as well as alterations in blood pressure (both hypertension and hypotension).
A meta-analysis by Poonai N et al. in Pediatrics of IN dexmedetomidine for procedural distress in children (1 month - 14 years) looked at a total of over 2000 patients. A dose of 2.5 mcg/kg had a time of onset of 7-20.6 minutes with a duration of sedation ranging from 41-91.5 minutes. Cincinnati Children’s Hospital has initiated a TTE sedation protocol with RN sedation using IN dexmedetomidine ± IN midazolam as part of a research consortium looking at sedation for non-painful procedures. Initial unpublished results from the Cincinnati Children’s TTE sedation protocol is demonstrating adequate sedation with minimal side effects.
Improving Team Performance Through In-Situ Simulations of Critical Events
Christopher S. Nichols, MD (Children’s Hospital Colorado, Aurora)
Dr. Nichols is the Simulation Medical Director at Children’s Hospital Colorado. He discussed that several professionals spend time in deliberate practice. The Federal Aviation Administration (FAA) and airline pilots are famous for the amount of simulation that is required in their training and maintenance of certification. Opera singers and NFL football players both spend an exorbitant amount of time in practice when compared to the amount of time they are performing. Often NFL players spend 30 minutes per week in deliberate practice for each minute of game time. The NASA astronauts not only spend significant hours in deliberate practice but they also simulate contingencies to the point they will simulate the death of an astronaut and not allow him/her to return home to their family for several days.
Dr. Nicholas discussed the Society for Simulation in Healthcare (SSH). The SSH’s mission is to serve a global community of practice enhancing the quality of healthcare. Through leveraging simulation, the SSH seeks to improve performance and reduce errors in patient care. The SSH was established in 2004 and has a diverse membership that includes physicians, nurses, allied health and paramedical personnel, researchers, educators, and developers from around the globe.
Malcolm Gladwell famously coined that an individual needs 10,000 hours of deliberate practice before they become an expert. Dr. Nicholas argues that it is a part of the Hippocratic oath that medical simulation is performed as our daily work includes high-risk endeavors and there is the potential for a patient crisis event. Medical simulation leads to improved participant retention. Dr. Nicholas finds it best to have a pre-test, simulation, and post-test in line with adult learning theories to improve retention. It is best for a team to go through in-situ simulation. It helps to identify gaps not only in individual team members but also the limitations of the environment.