The state of the unit: variable care models in paediatric acute care cardiology units documented by the fourth iteration of the Paediatric Acute Care Cardiology Collaborative (PAC3) Hospital Survey.

Central venous catheter use is not standardised in paediatric cardiology, yet it is associated with additional morbidity. We aimed to characterise variation in central venous catheter use and complications across paediatric acute care cardiology units. This retrospective, multi-centre, and registry-based study examined all unique acute care cardiology encounters from February 2019 through September 2021 in the Paediatric Acute Care Cardiology Collaborative registry. Descriptive and comparative statistics were assessed for differences based on central venous catheter use. Multivariate logistic regression identified factors associated with increased line duration and use frequency. About 35,379 encounters from 24 institutions were assessed. About one in five encounters had at least one central venous catheter (n = 7,524, 21.3%). Neonates and post-operative cardiothoracic surgery patients were more likely to have central venous catheters than not (28.9% of neonates with, versus 11.4% without; 58.4% of post-operative patients with, versus 35.7% without; p < 0.001). Most patients after STAT 4 procedures retained central venous access for over half of the acute care cardiology stay. Institutions with overall "low" central venous catheter utilisation rates (<20%) also used central venous access most often on STAT 4 patients (p < 0.0001). Complication rates for venous thrombus and central line-associated bloodstream infection were low (1.9% and 0.2%). There is variable utilisation of central venous catheters across participating acute care cardiology units, though overall they are common vascular access modalities. Acute care cardiology units use central venous catheters more often in neonates, those after cardiac surgery, and in their higher-risk patients (i.e. after STAT 4 procedures).

Introduction: Disparities in healthcare outcomes are well described among patients of different races and ethnicities including pediatric cardiology. Multicenter studies examining these outcomes are lacking in pediatric acute care cardiology. We hypothesize that Black and Hispanic patients admitted to pediatric acute care cardiology units have increased hospital and acute care encounter length of stay (LOS) and complication rates compared to their White and non-Hispanic peers. Methods: Utilizing the Pediatric Acute Care Cardiology Collaborative registry, we examined all acute care cardiology unit encounters from 2/1/2019 to 7/30/2021 ending in discharge to home or death. Hospitalizations were categorized by race and ethnicity. In-hospital complications included health-care acquired infections, iatrogenic incidents, pneumonia, sepsis, seizures and stroke. Data were analyzed for differences in LOS and complication rates using chi-square and ANOVA testing. We used Bonferroni correction to establish a significance threshold of 0.007. Results: Analysis included 30,404 hospitalizations from 29 centers. There were 16,233 White (70%), 4,533 Black (19%), 919 Asian (4%) and 1,629 other races (7%) encounters. There were 23,592 (78%) non-Hispanic and 4,583 (15%) Hispanic encounters. Black patients had higher rates of premature birth (21.4%) and low birth weight (10.7%), compared to White patients (15.6% and 5.9% respectively, p&lt;0.0001). Both non-Hispanic Black and Hispanic patients had longer total hospital and acute care LOS than non-Hispanic White patients. Complication rates analyzed by race trended towards significance between Black and White patients, and Hispanic patients had a higher complication rate than non-Hispanics. ( Table 1 ) Conclusions: Despite improved outcomes for patients with congenital and acquired heart disease, significant racial and ethnic disparities continue to exist. Directed efforts are needed to achieve equitable results.

We utilized the multicenter Pediatric Acute Care Cardiology Collaborative (PAC3) 2017 and 2019 surveys to describe practice variation in therapy availability and changes over a 2-year period. A high acuity therapies (ATs) score was derived (1 point per positive response) from 44 survey questions and scores were compared to center surgical volume. Of 31 centers that completed the 2017 survey, 26 also completed the 2019 survey. Scores ranged from 11 to 34 in 2017 and 11 to 35 in 2019. AT scores in 2019 were not statistically different from 2017 scores (29/44, IQR 27–32.5 vs. 29.5/44, IQR 27–31, p = 0.9). In 2019, more centers reported initiation of continuous positive airway pressure (CPAP) and Bi-level positive airway pressure (BiPAP) in Acute Care Cardiology Unit (ACCU) (19/26 vs. 4/26, p < 0.001) and permitting continuous CPAP/BiPAP (22/26 vs. 14/26, p = 0.034) compared to 2017. Scores in both survey years were significantly higher in the highest surgical volume group compared to the lowest, 33 ± 1.5 versus 25 ± 8.5, p = 0.046 and 32 ± 1.7 versus 23 ± 5.5, p = 0.009, respectively. Variation in therapy within the ACCUs participating in PAC3 presents an opportunity for shared learning across the collaborative. Experience with PAC3 was associated with increasing available respiratory therapies from 2017 to 2019. Whether AT scores impact the quality and outcomes of pediatric acute cardiac care will be the subject of further investigation using a comprehensive registry launched in early 2019.

The Pediatric Acute Care Cardiology Collaborative (PAC3 ) was established in 2014 to improve the quality, value, and experience of hospital-based cardiac acute care outside of the intensive care unit. An initial PAC3 project was a comprehensive survey to understand unit structure, practices, and resource utilization across the collaborative. This report aims to describe the previously unknown degree of practice variation across member institutions. A 126-stem question survey was developed with a total of 412 possible response fields across nine domains including demographics, staffing, available resources and therapies, and standard care practices. Five supplemental questions addressed surgical case volume and number of cardiac acute care unit (CACU) admissions. Responses were recorded and stored in Research Electronic Data Capture (REDCap). Surveys were completed by 31 out of 34 centers (91%) with minimal incomplete fields. A majority (61%) of centers have a single dedicated CACU, which is contiguous or adjacent to the intensive care unit in 48%. A nurse staffing ratio of 3:1 is most common (71%) and most (84%) centers employed a resource nurse. Centralized wireless rhythm monitoring is used in 84% of centers with 54% staffed continuously. There was significant variation in the use of noninvasive respiratory support, vasoactive infusions, and ventricular assist devices across the collaborative. Approximately half of the surveyed centers had lesion-specific postoperative pathways and approximately two-thirds had protocols for single-ventricle patients. The PAC3 hospital survey is the most comprehensive description of systems and care practices unique to CACUs to date. There exists considerable heterogeneity among unit composition and variation in care practices. These variations may allow for identification of best practices and improved quality of care for patients.

Collaborative quality improvement and learning networks have amended healthcare quality and value across specialities. Motivated by these successes, the Pediatric Acute Care Cardiology Collaborative (PAC3) was founded in late 2014 with an emphasis on improving outcomes of paediatric cardiology patients within cardiac acute care units; acute care encompasses all hospital-based inpatient non-intensive care. PAC3 aims to deliver higher quality and greater value care by facilitating the sharing of ideas and building alignment among its member institutions. These aims are intentionally aligned with the work of other national clinical collaborations, registries, and parent advocacy organisations. The mission and early work of PAC3 is exemplified by the formal partnership with the Pediatric Cardiac Critical Care Consortium (PC4), as well as the creation of a clinical registry, which links with the PC4 registry to track practices and outcomes across the entire inpatient encounter from admission to discharge. Capturing the full inpatient experience allows detection of outcome differences related to variation in care delivered outside the cardiac ICU and development of benchmarks for cardiac acute care. We aspire to improve patient outcomes such as morbidity, hospital length of stay, and re-admission rates, while working to advance patient and family satisfaction. We will use quality improvement methodologies consistent with the Model for Improvement to achieve these aims. Membership currently includes 36 centres across North America, out of which 26 are also members of PC4. In this report, we describe the development of PAC3, including the philosophical, organisational, and infrastructural elements that will enable a paediatric acute care cardiology learning network.

Introduction: Arrhythmias are common in pediatric cardiology patients, yet prevalence during hospitalizations and treatments are poorly defined. This descriptive study reports arrhythmia prevalence and medical management from Pediatric Acute Care Cardiology Collaborative (PAC 3 ) centers. Aims Our primary aim is to describe prevalence and outcomes of treated arrhythmias among acute care cardiology units (ACCU). Secondary aims include comparison of medical vs. post-operative admissions and selection of antiarrhythmics. Methods: We performed a multi-center retrospective review of the PAC 3 registry limited to hospitalized patients with an arrhythmia treated from 2/2019-2/2023 among 33 centers. Arrhythmias are classified in the registry as Atrial Tachycardia/Supraventricular Tachycardia (AT/SVT), Junctional Tachycardia (JT), or Ventricular Tachycardia (VT). Descriptive statistics, Wilcoxon-Mann-Whitney, and χ2 testing were used. Results: Prevalence of treated arrhythmia in the cohort (n=38,396) was 5.4% (n=2,090 patients) over 2291 hospitalizations. AT /SVT (68.3%) were more frequent than VT (21.5%) or JT (2.8%) (p&lt;0.01). Bradyarrhythmias (7.5%) were infrequent. Of 8,733 CICU transfers, 513 (5.9 %) transfers of 257 patients (2.0 transfers/patient) were due to arrhythmia. Medical and Surgical patients varied in demographics and outcomes (Table). For AT/SVT, propranolol was the most prescribed antiarrhythmic, followed by sotalol. (Figure). Conclusions: Treated arrhythmias are prevalent in ACCU patients and are a relatively frequent cause of ICU transfers. Arrhythmia treatment patterns warrant further investigation and could be the subject of QI.

ACC/AHA/AAP RECOMMENDATIONS FOR TRAINING IN PEDIATRIC CARDIOLOGY

Advanced practice providers (APPs) are being employed at increasing rates in order to meet new in-hospital care demands. Utilising the Paediatric Acute Care Cardiology Collaborative (PAC3) hospital survey, we evaluated variations in staffing models regarding first-line providers and assessed associations with programme volume, acuity of care, and post-operative length of stay (LOS). The PAC3 hospital survey defined staffing models and resource availability across member institutions. A resource acuity score was derived for each participating acute care cardiology unit. Surgical volume was obtained from The Society of Thoracic Surgeons database. Pearson's correlation coefficients were used to evaluate the relationship between staffing models and centre volume as well as unit acuity. A previously developed case-mix adjustment model for total post-operative LOS was utilised in a multinomial regression model to evaluate the association of APP patient coverage with observed-to-expected post-operative LOS. Surveys were completed by 31 (91%) PAC3 centres in 2017. Nearly all centres (94%) employ APPs, with a mean of 1.7 (range 0-5) APPs present on weekday rounds. The number of APPs present has a positive correlation with surgical volume (r = 0.49, p < 0.01) and increased acuity (r = 0.39, p = 0.03). In the multivariate model, as coverage by APPs increased from low to moderate or high, there was greater likelihood of having a shorter-than-expected post-operative LOS (p < 0.001). The incorporation of paediatric acute care cardiology APPs is associated with reduced post-operative LOS. Future studies are necessary to understand how APPs impact these patient-specific outcomes.

Introduction: Necrotizing enterocolitis (NEC) is a life-threatening condition of compromised gastrointestinal mucosa with risk of progression to ischemia, necrosis and perforation. The incidence and outcomes of NEC in infants with congenital heart disease (CHD) are incompletely understood. Hypothesis: Patients who develop NEC in the acute care cardiology unit (ACCU) are likely to have different patient characteristics and worse clinical outcomes than those who do not develop NEC. Aims: Describe differences in baseline characteristics and clinical outcomes in infants &lt;6 months of age with CHD in the ACCU who suffered NEC compared to those who did not. Methods: Data were analyzed from the Pediatric Acute Care Cardiology Collaborative (PAC3) database. All patients &lt;6 months were included. Patients who had NEC (Bell’s stage ≥2) on the ACCU were compared to those who did not. Results: In 29041 patient encounters from 16770 unique patients across 33 centers, the incidence of NEC was 1.5%. Patients with NEC were more likely to have extracardiac abnormalities, antenatal diagnosis and have undergone procedural intervention (Table 1). Patients who developed NEC had longer lengths of stay and higher rates of mortality, CICU transfer and readmission (Table 2). In addition, patients who developed NEC had lower rates of oral feeding at encounter end. Of 14823 patients in their post-surgical encounter, those who developed NEC were significantly more likely to have undergone a more complex index procedure and to be younger, lower weight and on prostaglandin at the time of surgery. Patients who developed NEC were more likely to be on anticoagulation, ACE-inhibitors, anti-reflux medications, milrinone, diuretics and anticonvulsants. Conclusion: In this original multicenter analysis, patients who developed NEC on the ACCU had different characteristics and significantly worse clinical outcomes. Further study is warranted to identify risk factors for NEC in this vulnerable population.

Hospital readmissions are costly, often preventable, and associated with both medical and socioeconomic factors. The primary objective of this study was to evaluate the relationship between social determinants of health (SDOH) and readmission to a pediatric acute care cardiology unit. Secondary objectives included assessing the incidence of preventable or urgent readmissions and suggesting interventions to address common causes of these readmissions. This single-center, retrospective analysis reviewed readmissions to the acute care cardiology unit at Cincinnati Children's Hospital within 7days of discharge from 2019 to 2022. A preventability score and urgency metrics were assigned to each readmission, and multivariable logistic regression was used to obtain odds ratios and 95% confidence intervals according to individual and community-level measures of SDOH. Out of 265 readmission encounters, 27 (10%) were preventable and 74 (28%) were urgent. Readmission length of stay was significantly longer for preventable or urgent readmissions. Birth weight, gestational age, English-speaking status, race/ethnicity, sex, insurance category, deprivation index, and single ventricle status were not significantly associated with preventable or urgent readmissions. The most common reason identified for preventable readmission was insufficient discharge education, and the most common reason identified for urgent readmission was advancement of chronic disease. Measured SDOH were not associated with preventable or urgent readmissions, which may be partially due to our institution's multidisciplinary approach to address SDOH. However, as insufficient discharge education was a common reason for preventable readmission, clearly more work is needed to delineate what specific strategies are most effective for mitigating adverse SDOH.

Hospital discharge delays can negatively affect patient flow and hospital charges. Our primary aim was to increase the percentage of acute care cardiology patients discharged within 2 hours of meeting standardized medically ready (MedR) discharge criteria. Secondary aims were to reduce length of stay (LOS) and lower hospital charges. A multidisciplinary team used quality improvement methods to implement and study MedR discharge criteria in our hospital electronic health record. The criteria were ordered on admission and modified on daily rounds. Bedside nurses documented the time when all MedR discharge criteria were met. A statistical process control chart measured interventions over time. Discharge before noon and 30-day readmissions were also tracked. Average LOS was examined, comparing the first 6 months of the intervention period to the last 6 months. Inpatient charges were reviewed for patients with >2 hours MedR discharge delay. The mean percentage of patients discharged within 2 hours of meeting MedR discharge criteria increased from 20% to 78% over 22 months, with more patients discharged before noon (19%-32%). Median LOS decreased from 11 days (interquartile range: 6-21) to 10 days (interquartile range: 5-19) (P = .047), whereas 30-day readmission remained stable at 16.3%. A total of 265 delayed MedR discharges beyond 2 hours occurred. The sum of inpatient charges from care provided after meeting MedR criteria was $332 038 (average $1253 per delayed discharge). Discharge timeliness in pediatric acute care cardiology patients can be improved by standardizing medical discharge criteria, which may shorten LOS and decrease medical charges.

Specialised training opportunities in paediatric cardiology are rare for advanced practice providers, creating an educational gap for novice practitioners. Standardised curricula have been cited as a beneficial intervention to optimally prepare these providers for highly specialised fields. We sought to understand the current onboarding practices of advanced practice providers in paediatric acute care cardiology to identify opportunities for curricular improvement. A survey developed by a task force by the Pediatric Acute Care Cardiology Collaborative (PAC3) was distributed across PAC3 programmes in May 2023 to evaluate the onboarding practices of advanced practice providers at paediatric heart centres nationwide. Survey responses reflected orienting practices at 19 paediatric heart centres representing varying programme and team sizes. Of the respondents, 32% felt their current model does not meet all the needs of the new team member. Key successful onboarding elements included a structured curriculum with goals and objectives, dedicated education time and materials, standardised assessments, and individualised learning in the presence of a supportive team. All respondents agreed that an online curriculum would be beneficial. There is no national standardised educational pathway for advanced practice providers entering paediatric acute care cardiology practice. There are opportunities to develop a formalised curriculum with structured learner assessment at a national level, which could be modified at the institution or learner level to enhance current onboarding practices.

Background: Improved survival and healthcare system changes have led to increasing complexity of the typical hospitalized pediatric patient. This has led to the development of inpatient specialists such as Pediatric Hospitalists with resultant improved clinical outcomes. Similar trends in pediatric cardiology have catalyzed the creation of acute care cardiology (ACC). Yet, the broad impact on pediatric cardiology clinical outcomes secondary to the ACC inpatient model has not been previously studied prospectively. Hypothesis: Adoption of an ACC model will improve clinical outcomes. Methods: This was a QI initiative at a tertiary care children’s hospital focused on a redesign of the care model for inpatients with cardiac disease requiring non-ICU level of care through adoption of an ACC model. We selected complication rate and back transfer to ICU as outcome measures, discharge time as a process measure, and 7-day unplanned readmissions and length of stay (LOS) as balancing measures. Baseline data was gathered for 6 months and measures were prospectively studied using statistical process control charts for 12 months post-transition. Standard rules for identifying special cause variation (SCV) were applied. We compared patient and family experience scores (PFE) pre- and post-transition using an independent t-test. There were no changes in surgical or nursing staffing, beds, or average daily census between baseline and post-transition periods suggesting any changes in measures could be attributed to the ACC model and not external factors. Results: All outcome and process measures significantly improved from baseline to post-transition periods showing SCV following adoption of the ACC model (complications: 23.6% vs 16.0%; back transfer to ICU: 11.4% vs 6.9%; patient discharge time: 15:22 vs 14:26) (Figure 1). LOS and 7-day unplanned readmissions were unchanged post-transition suggesting no major inadvertent negative consequences of the ACC model (Figure 2). PFE improved post-transition ( p =0.04) (Figure 3). Conclusions: Adoption of an ACC model significantly improved outcomes and PFE without evidence of impactful negative effects. Though ACC has been widely adopted nationally, this is the first report documenting the prospectively measured impact of such a change in the established model of care. Ongoing evaluation of resource utilization, sustainability of improvement, and newly embedded improvement efforts is underway.

Dr. Katarina Hanséus is the focus of our fourth in a series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Dr. Hanséus was born in Malmö, Sweden. She attended undergraduate school in her home town in Malmö, Sweden, graduating in 1974. Dr. Hanséus then went on to complete medical school at University of Lund in Lund, Sweden, graduating in 1980, where additionally she completed a Doctoral Dissertation in the evaluation of cardiac function and chamber size in children using Doppler and cross-sectional echocardiography. Under the Swedish Board of National Welfare, Dr. Hanséus completed her authorisation as a paediatrician in 1986, followed by her authorisation as a paediatric cardiologist in 1988, at University of Lund. She was appointed head of Paediatric Cardiology in 2000 at the Children's Heart Center, Skane University Hospital, Lund, Sweden. The programme at Lund serves as one of the two national referral centres for comprehensive paediatric and congenital cardiac care, including paediatric cardiac surgery, in Sweden. From 2006 to 2013, she served as the clinical and administrative head of the Department of Neonatology, Paediatric Surgery, Paediatric Intensive Care, Paediatric Cardiology, and Paediatric Cardiac Surgery, returning as the head of Paediatric Cardiology in 2013, for which she currently holds the position.Dr. Hanséus is a recognised leader in the field of Paediatric Cardiology and has been involved in leadership within the Swedish Pediatric Society, the Swedish Association for Pediatric Cardiology, and the Association for European Paediatric and Congenital Cardiology throughout her career. Within the Association for European Paediatric and Congenital Cardiology, she served as the Secretary General from 2011 to 2016, the President Elect in 2018, and is the current President serving from 2019 until 2022. This article presents our interview with Dr. Hanséus, an interview that covers her experience as a leader in the field of Paediatric Cardiology, including the history and goals of the Association for European Paediatric and Congenital Cardiology, and her role and vision as their current President.

RESEARCH Purpose:Oxygen delivery via nasal cannula is a standard therapy in hospitalized pediatric patients; however, it can have adverse effects in certain populations, such as infants with cardiac shunting physiology1,2. An oxygen-air blender can be used via standard nasal cannula to provide the lowest amount of fraction of inspired oxygen (FiO2) in order to reduce harm2. A recent Pediatric Acute Care Cardiology Collaborative (PAC3) Hospital Survey indicates that 88% of participating acute care cardiology units (ACCU) provide blended oxygen to patients, however, indications for use are not well-established3,4. A local ACCU nursing staff survey revealed mixed use of blended oxygen and variable understanding of current oxygen weaning orders and protocols. A literature search did not provide sufficient guidance on oxygen use best practices in patients with congenital heart disease. We sought to evaluate the current practice of oxygen administration in our ACCU. Project Design:Data extraction from PAC3 registry for local ACCU encounters on oxygen use for patient encounters since October 2021. Multidisciplinary group convened to outline patient and data field inclusion criteria. Data evaluated for all ACCU encounters for patients on supplemental oxygen via nasal cannula. A gap analysis and a process map were utilized to better understand the current state. Results::ACCU patient encounters used supplemental oxygen, of which 14.6% utilized blended oxygen. Analysis revealed confusion of electronic medical record (EMR) oxygen weaning led to varying approaches for choosing amount of flow versus amount of concentrated oxygen (FiO2) as the weaning mechanism. Additional causes included standard use of blenders in the cardiovascular intensive care unit, a knowledge gap of the proper indication for blended oxygen, and lack of guidelines for weaning oxygen. Conclusion:Best practice guidelines nor standard oxygen weaning protocol exist for blended oxygen use in patients with congenital heart disease. Future steps include analysis of patient-specific factors related to the use of blended oxygen to establish best practice guidelines.