Heart Center Performance Rounds: reviewing the flight paths of patients

1. Heart Center Performance Rounds: reviewing the flight paths of patients

2. Objectives • Examine the idea behind Performance Rounds • Demonstrate how the slides are created, the language used, and the content of the slides • Identify common themes or issues noticed in the flight paths of patients that can be addressed to improve quality of care. • Appraise what the Heart Center has learned from Performance Rounds and what changes were madeto systems practices.

3. What are Performance Rounds? • Based off of NASA flight paths and Line Operations Safety Assessments (LOSA) • A weekly quality review • Multidisciplinary • Follows the path of the surgical or cath lab patient through the Heart Center • Looks for events/errors/commonalities (threat and error management)

4. Performance Rounds

5. What goes on the slide? • Patient event data entered into an excel sheet that is uploaded to an IDEA AP and yields a time graph with different threat levels. • Add in echo results, safety scoops, pertinent events, CVOR events (bypass times) • Incorporate data from Society of Thoracic Surgeons (STS) and Pediatric Cardiac Critical Care Consortium (PC4)

6. Definitions of terms Hickey, E. et al (February 2015) National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: error cycle precede ~ 85% of patient deaths. The Journal of Thoracic and Cardiovascular Surgery. 496-507

7. Surgeon/Cardiologist Fellow This information is privileged and confidential pursuant to Texas Health and Safety code sections 161.031-161.033 and Texas occupations code section160.007 and/or T.R.C.P. Wt Age Name Anes Kg Patient name Diagnosis 07/24/2019 autologous pericardial patch closure of ASD ASD 6 day LOS Previous surgeries or procedures 04/17/2019 cath w/ partial test occlusion of the ASD Other medical history 7/26 echo: no residual ASD, mild mitral stenosis, peak velocity ~1.8 m/s. upper mild MR, trivial TR peak velocity 3.5m/s. RV mod depressed, normal LV sys fxn. Possible coronary fistula vs coronary flow in atypical projection into LVOT Echo to evaluate left side d/t pulm edema and S4 CPB 45 mins AXC 17 mins 7/30 echo: mildly depressed RV fxn, improved. Normal LV fxn. Suture material seen extending into atrial septum. No MR or stenosis. 7/24 post op TEE: no residual ASD, mild MR w, no stenosis. No evidence of aortic stenosis or insufficiency. Mild RV sys dysfunction. Normal LV sys fxn 7/30 pt<10% weight/length for age and no nutrition risk referral placed during nursing admission history.

8. Surgeon/Cardiologist Fellow This information is privileged and confidential pursuant to Texas Health and Safety code sections 161.031-161.033 and Texas occupations code section160.007 and/or T.R.C.P. Wt Age Name Anes 2.8 Kg 6 days Diagnosis 04/15/2019 Norwood with 3.5 mm Gore Tex R subclavian to RPA shunt and de Vega tricuspid annuplasty 04/15/2019 VA ECMO cannulation (ECPR) 04/17/2019 norwood take down, arch reconstruction, tricuspid and aortic valvuloplasty and PA banding 04/19/2019 PAB tightening and decannulation from VA ECMO 04/22/2019 delayed sternal closure and PAB loosening 28 days 5/7 DORV, TGA, mid muscular VSD, arch hypoplasia w discrete coarctation, prominent elongated subaortic conus, mitral valve hypoplasia w/ possible supravalvar membrane, small secundum ASD 4/22 mod TR, RV with mildly depressed sys fxn, LV low normal fxn, MPA band with flow acceleraton of 3.2m/s and peak gradient of 40 mmHg VACTERL, horseshoe kidney 4/17 post op echo: improved TR, trivial MR, mildly depressed RV sys fxn. Mod. Depressed LV sys fxn 4/19 post op echo: mod to severe TR (worse), PAB w/ peak velocity of 3.5 m/s, RV mildly depressed, LV mildly depressed 4/16 echo: severe TR and AR. BiV severely depressed 2 days 2 hours 4/15 post op echo: mild PV regurg, mild to mod TR, mildly depressed RV sys fxn, normal LV sys fxn PAB tightening & decannulation from ECMO Delayed sternal closure and PAB loosening Sternal wound dehiscence -> wound vac. Norwood and tricuspid annuplasty CPB 201 mins XC 12 mins ACP 69 mins Circ. A 15 mins BT shunt clipped Pt w/ desaturation unresponsive to increased Fio2 and bagging, had low ETCO2 Norwood takedown, arch reconstruction, tricuspid and aortic valvuloplasty and PA banding ECPR. Time from call to circuit: 33 minutes 4/19 non functional PD catheter replaced CPB 297 mins AXC 108 +74 mins ACB 69+40+18 mins Circ arrest 22 mins Intubated for poor cardiac output hydrocortisone JET 4/22 LLE US showed focal occlusion of L ext. iliac artery. Also found incidence of NEC Concern for circular shunt. Required flows of ~250% and inflow cannula has mixed venous saturation of 100%

9. Performance Rounds and Quality Feedback Weekly Performance Rounds Weekly Quality Review and Feedback

10. Changes in our practice • Tuesday mornings: successfully review 25-30 cases per week (combined cath and surgical patients) • Median of 30 issues identified per week • Major themes: • Heart Center opportunities • PA care • Lymphatic disease • Communication across units • NICU to CICU • CICU to CPCU • Adhering to SPS guidelines • VTE prophylaxis • Temporary Pacemaker boxes • ECMO clamp trial