Abstract 16413: The Development of Care Curves Following the Stage 1 Palliation: A Comparison of Intensive Care Among Five Centers

Abstract

Introduction: Comparisons of care among centers is currently limited to major endpoints, such as mortality, length of stay, or complication rates. Hypothesis: We hypothesized that comparing individual elements of intensive care over time using classical statistics and “care curves” may highlight important modifiable differences among centers. Methods: We retrospectively reviewed data of key elements of postoperative care after stage-1-palliation (S1P) among 5 US centers during 2009-2018. Minimum mandatory ventilation rate (MMVR), opioid total daily dose (TDD) and fluid balance (FB) were computed from postoperative day (POD) 0 to 28. Cox regression, mixed random effect models and growth chart-like care curves were used to analyze data variability and trajectory over time. Results: During the study period, 502 patients underwent S1P (median age 5 [IQR 3-6] days). Patients were weaned from MMV by POD 8 (IQR 5-16), with significant differences among centers (P<0.001). Opioid administration peaked on POD 2 (3.7 [IQR 1.5-7.5] mg morphine equivalents/kg/day), and freedom from opioids was achieved in a median of 13 (IQR 8-25) days (P<0.001 among centers). After adjusting for patient-level characteristics, center affiliation was independently predictive of time to freedom from MMV and from opioids. The median daily FB per patient was +23 (IQR -3 to +39) ml/kg/day (P<0.001 among centers). Center affiliation was independently predictive of both trajectories over time and daily variation in MMVR, opioid TDD, and FB. Growth chart-like care curves can be used to visualize variation in elements over time (Fig1). Conclusions: Both “care curves” and classical statistics highlighted important modifiable differences in the elements of care among centers. MMVR, opioid TDD, and FB following S1P significantly differ even after adjusting for patient and operative factors. Care curves may be used to guide collaborative quality improvement initiatives in the intensive care unit.