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Introduction:We previously found variation across congenital heart centers in postoperative chest tube (CT) management including one ?model? center with shorter CT duration and length of stay (LOS). It was unknown whether the model center?s approach of removing CTs earlier with higher volumes of output could be spread to other centers to reduce variation in CT management and improve outcomes. Using collaborative learning, we conducted a multicenter quality improvement (QI) project to decrease postoperative CT duration and LOS.Methods:PAC3and PC4data were collected on patients undergoing the 10 STS benchmark operations during the baseline phase (6/2017-6/2018) and intervention phase (7/2018-3/2019). Collaborative learning methods included review of best practices from the model site, regular data feedback on practices and outcomes, monthly webinars, and QI coaching, with an overall goal to reduce CT duration by 20%. Sites adapted CT removal practices (e.g. timing, volume criteria) from the model site to their local resources, practices, and setting. Statistical process control and traditional statistics were used to evaluate CT duration and LOS over time.Results:Overall 1767 patients from 9 centers were included. Patient characteristics did not differ between eras. Median CT duration decreased from 88.8 [IQR 48.1, 138.5] to 68.9 [IQR 44.5, 114.0] hours (p<0.0001). Median postoperative LOS decreased from 8 [IQR 5,14] to 7 [IQR 5, 11.5] days (p=0.0001). SPC analysis showed a decrease in CT duration and LOS in conjunction with the intervention phase, reported as mean per SPC standards (Figure). Rates of CT replacement (1.9% vs 2.1%, p = 0.40) and readmission for effusion did not change (1.2% vs 1.2%, p = 0.79).Conclusions:We successfully lowered postoperative CT duration and LOS across 9 centers using collaborative learning methodology. We plan to spread this project to other PAC3-PC4centers and will monitor for sustained improvement.

Introduction:Cardiac arrest (CA) rates vary substantially across pediatric cardiac ICUs (CICU), however it remains unknown whether CA prevention can be improved. The Pediatric Cardiac Critical Care Consortium (PC4) initiated a Cardiac Arrest Prevention (CAP) quality improvement (QI) project across 19 CICUs.Hypothesis:CAP would reduce CA rate by 25% across CICUs within 1 year.Methods:CAP is a translatable 5 element bundle aimed at CA prevention in high-risk patients implemented at participating CICUs starting in 5/2018. Bundle included multidisciplinary safety huddles to foster a shared model of CA risk, patient-specific early deterioration signs with strict vital sign limits and mitigation plans, pre-sedation discussion, bedside epinephrine, and CA event review. We employed statistical process control (SPC) to evaluate improvement after CAP initiation only at the 15 CICUs that reliably submitted bundle compliance data; 1043 audits were performed across these centers. We used mixed-effects logistic regression, accounting for case mix and clustering within hospitals, to evaluate CA rates pre- vs. post-CAP stratified by surgical or medical patient in all CICUs.Results:Cohort included 36,723 CICU encounters pre-CAP, 4047 post-CAP (58% surgical). There was no evidence of improvement across CICUs during the pre-CAP period. SPC showed significant improvement post-CAP with 45% decrease in CA rate from 5.1 to 2.8/1000 CICU days (figure). Of 1043 audits, 42% successfully completed all 5 bundle elements. Compliance with individual elements varied, with safety huddle compliance 78%. Regression analysis confirmed significant reduction in adjusted CA rate post-CAP for surgical, OR 0.67(CI 0.5-0.89), but not medical encounters, OR 0.88(CI 0.63-1.22).Conclusions:Implementation of the PC4 CAP bundle led to significant improvement in CA prevention across CICUs. Identifying the key elements driving improvement is crucial for dissemination and spread of CAP.