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Inside Pediatrics, Neonatology

Marking a Milestone: RNICU Goes More Than One Year Without Central Line Associated Bloodstream Infections

Three hundred and ninety days.That’s how long the Regional Neonatal Intensive Care Unit (RNICU) at the University of Alabama at Birmingham (UAB) has gone without a central line associated bloodstream infection (CLABSI). And that, in the world of tiny, sick babies, is huge.

Healthcare-acquired infections (HAI) are a major problem in all hospitals, said Lindy Winter, M.D., Medical Director, but particularly for premature babies. “They are more vulnerable to infections because their immune systems are immature,” she said, “and they can’t fight off bacteria in the same way that adults are able to.”

Ideally, the rate of CLABSIs in a NICU should be zero, she said. Buta few years ago UAB’s rate was higher than national benchmarks, a rate determined through a formula based on the number of days patients have an IV line and how often infections occur. It’s also a major quality indicator for hospitals, reported to the Centers for Disease Control and Prevention and required for US News & World Report’s Best Hospitals ranking.

Thus, in 2013, UAB NICU leadership launched a major initiative to bring down the rate of CLABSIs. It was not an easy task, Winter said. “It required a huge culture change,” she said, “because NICU clinicians around the country believed such infections were inevitable, a natural outcome because these infants were immunocompromised anyway and nothing could be done to prevent it.”

She and her team set out to prove them wrong. They started with operational changes in how the central line was inserted and accessed, working closely with materials management to try different products to improve sterility. They changed how the skin and devices were prepped, and moved from having a single nurse insert, access, and manage the line, including changing dressings, to a buddy system in which at least one nurse is PICC (peripherally inserted central catheter) certified.

They studied their data to see which babies were more likely to get an infection. They discovered it was those who had umbilical lines that had been inserted at birth and remained longer than five days. “We did a lot of education with providers about switching from the umbilical to a PICC line to move closer to that five-day goal,” Winter said.

They also added central lines to the list of 10 things clinicians discuss during their daily patient rounds. This, Winter said, reminds staff to think about central lines and if they were needed as part of their daily routine.

Their efforts paid off. By 2016, the NICU started seeing a steady reduction in CLABSIs. And then, starting in the summer of 2019, there were none for more than a year.  “We held our breath all year,” said Winter. When they reached the 365-day mark they celebrated, ordering in food from the staff’s favorite restaurants.

The streak eventually broke when a critically ill baby developed an infection. After the emergency was over, the team instituted a “swarm,” a rapid cycle debrief to figure out what happened. “He was very sick and we had to access the line frequently for medications,” said Winter. “We think that was the issue.”

 Since that one infection, there have been no others tied to central lines.

“It was such a team effort,” said Winter. It’s not just the doctors and nurses, but the respiratory therapists, housekeeping staff, even materials management, all working together to reach the goal of zero.

Editor’s Note: The UAB Department of Pediatrics Neonatology Division and its 23 board-certified neonatologists works in collaboration with the Regional Neonatal Intensive Care Unit (RNICU) at UAB and the Neonatology Intensive Care Unit (NICU) at Children’s of Alabama. The RNICU provides care for infants with varying diagnoses, including extreme prematurity and cardiac defects, in an environment equipped with the latest patient care technology. The RNICU is housed in UAB’s new Women and Infants Center. The NICU at Children’s of Alabama is a Level IV unit with 48 private rooms available for neonates and infants and provides care for patients similar to the RNICU in addition to surgical procedures, ECMO and specialized dialysis (Aquadex) for the neonatal population.

Inside Pediatrics, Neonatology

Addressing COVID-19 in the NICU

When you are responsible for the tiniest, sickest babies in the state and a global pandemic hits, there is no time to waste. That’s the approach Hannah Hightower, M.D., a neonatologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB), and her team took in early March 2020, when normal life seemed to cease overnight. The state started shutting down March 13, and by March 19 she and her team released their first set of guidelines for COVID-19-related maternal and infant care.

“I realized this would have a great effect on how the Neonatal Intensive Care Unit (NICU) and infant nurseries operated,” Hightower said. “The virus was a great unknown and very little published guidance was available. There was also a lot of fear among the staff. I felt an urgency to provide our NICU staff a framework of how to safely handle patients and families in the midst of the emerging virus.”

So she took what little information was available from other regions and countries and sought guidance from her pediatric infectious disease colleagues to develop Guidelines of Care for COVID-19-exposed mothers and infants.

Those first guidelines would form the foundation of numerous iterations over the following year as the virus spread and more data on its effects in pregnant women and their babies emerged. “As time went by, the protocols changed pretty frequently because of the speed of the emerging data,” she said.

Early policy changes limited visitors to the NICU to only the mother and one support person in order to reduce possible exposure of infants and staff in the NICU. They also followed national recommendations to briefly separate COVID-positive mothers from their babies after delivery in order to prevent transmission to the infant. That changed over the summer as evidence emerged that as long as the mother was not severely ill and used proper precautions, including wearing a mask and performing hand hygiene, the risk of transmission to her infant was low.

The more the NICU team learned, the more they reached out to share their knowledge, Hightower said. “I coordinated with nursing leadership and other neonatologists around the state to share our experiences with each other,” she said. “It was a big collaborative effort.” She also spent a lot of time on Zoom and national conference calls with other pediatric and neonatal physicians, as well as the hospital’s own infectious disease specialists. In addition, there was also ongoing education for the staff about how to protect themselves and others.

A big part of their effort was educating the families about safety protocols and helping them get COVID tested when necessary, and then explaining the need to quarantine or isolate. After a year of living with the pandemic, Hightower now says, “We are more comfortable handling infants and families dealing with COVID-19. Even though vaccines are becoming available, it will remain important to continue masking throughout the year. For now, limiting visitors is also going to continue,” she said, and they still encourage families to limit their interactions outside the hospital.

Inside Pediatrics, Nephrology

Becoming the Leaders in Treating Congenital Nephrotic Syndrome

It is one of the most challenging congenital kidney conditions pediatric nephrologists see. Called  congenital nephrotic syndrome (CNS), it is an extremely rare genetic disease that affects the glomerular filtration system of the kidneys, leading to tremendous loss of protein through the urine. The result is extensive edema, skin breakdown and impaired respiration.

And that’s just the beginning, said Daniel Feig, M.D., Ph.D., the Margaret M. Porter Endowed Chair in Pediatric Nephology at Children’s of Alabama and the University of Alabama at Birmingham (UAB).“These kids are very susceptible to infections because so many immune chemicals are lost in the urine,” he said. They are also prone to blood clots because of low water volume and poor circulation, which can severely damage other organs, leading to bowel infarction and stroke. “They also become very malnourished because they can’t take in enough protein to keep up with the losses through the urine,” he said.

Symptoms usually appear by 2 months of age. “But because this is a structural problem in the kidney filters, there is no medicine that stops it,” he said. Early management involves trying to replace lost protein, “but that’s usually not enough.” Second-line management includes medications to slow kidney function, “but now we’re walking a tightrope of impaired kidney function to reduce protein losses.”

Eventually, the kidneys need to be removed so the child can receive enough nourishment. That means dialysis until they can receive a transplant.

“They’re a challenge,” he said. “But over the years, we’ve had very good success in moving down the pathway and getting them transplanted and they do well.” Because the condition is so rare, most pediatric nephrologists only see one or two patients their entire career. But word of Children’s program has spread, and today the team is treating patients from throughout the south.

“As a program we are happy to take care of these kids and share our expertise with other programs,” Feig said. One challenge has been reimbursement since health insurance may not cover out-of-state care. “We’re negotiating with other states and our own internal services to accept what we can get and then just take care of the kids, he said, adding, “A big shout out to the flexibility of the institution to allow us to do this.”

The goal is to build a center of excellence for children with CNS that demonstrates not only superior outcomes, he said, but cost savings.  

Becoming a referral center also allows greater clinical research into the disease, Feig said. Clinical trials for new therapies are difficult to conduct because there are so few children with the disease. But Children’s is slowly building a repository of biometric information and tissue for future research. “We don’t have a faculty researcher right now who is focused on CNS, but as we continue to recruit faculty that’s an untapped opportunity.” All the challenges of caring for these kids, he said, is worth it once they get a transplant. “They grow and develop and play just like all other small children. It’s a boon to these families who go through this terrible neonatal course and then get their kids back.”

Inside Pediatrics, Nephrology

Managing COVID-19 in the Dialysis Unit

When COVID-19 hit in early March, hospitals, including Children’s of Alabama, pivoted to telehealth appointments and canceled non-urgent procedures. But that’s not an option for children who need dialysis, particularly since Children’s is the only hospital in Alabama providing pediatric dialysis.

“We were running at full staff and operating as usual,” said Suzanne White, dialysis director at Children’s renal care center. That meant seeing hemodialysis patients three times a week, home dialysis patients once a month, and implementing protocols to reduce the risk of infection to patients and staff. It also meant that even if a patient tested positive for COVID-19, they still had to come to the hospital for dialysis. “You can’t reschedule dialysis if you have COVID,” said Sahar Fathallah-Shaykh, M.D., a pediatric nephrologist at Children’s and the University of Alabama at Birmingham (UAB). The task was made more challenging as with kidney transplants on hold, the dialysis center was seeing twice as many patients.

Among the changes the unit implemented:

  • Moving hemodialysis patients to peritoneal (home) dialysis whenever possible to limit visits to the hospital. This posed its own challenges, including training family members and coordinating with surgeons. “We did more peritoneal dialysis surgeries in those early months than we had done in years,” Fathallah-Shaykh said.
  • Limiting visitors in the unit. “We could accommodate eight patients at one time but we couldn’t have people gathering,” White said.” That meant families calling from the parking lot when they arrived, mask wearing, initial screening when they entered the hospital, and more advanced screening before they entered the dialysis unit. We drilled down to avoid screening fatigue,” she said.
  • Extensive education with families about COVID-19 and risk mitigation. “We had to make sure they realized the impact of this illness,” Fathallah-Shaykh said.
  • Treating COVID-positive patients in an isolation room when the unit was empty and implementing a special deep cleaning process.

“We were diligent because we knew what the illness could cause,” White said. The team was particularly concerned about the staff. Dialysis nurses require extensive training, and there are few available if one becomes sick. “If several got sick, it would be a disaster,” Fathallah-Shaykh said. In the end, just four staff and four patients tested positive, all community acquired. And, Fathallah-Shaykh stressed, “We never relaxed our standards. We added COVID to our high standard of care; we didn’t adjust our standard of care for COVID.”

Inside Pediatrics, Nephrology

Improving Renal Transplant Outcomes

Blood pressure is one of the most basic biometrics, taken nearly every time someone visits a health care provider. It’s also one of the most important indicators of kidney problems in both native and transplanted kidneys, with studies suggesting a direct benefit of maintaining normal blood pressures on transplant outcomes.

But taking a child’s blood pressure when they’re seen in clinic provides just a snapshot in time in a non-standard environment that can be associated with high anxiety, said Michael E. Seifert, M.D., a pediatric nephrologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB). That’s why the gold standard for assessing blood pressure control is a 24-hour ambulatory blood pressure monitor, which the Pediatric Kidney Transplant Program strives to perform at least once a year in each eligible patient. The device takes and records blood pressure every 30-60 minutes, providing a slew of important information for clinicians. In fact, studies suggest that ambulatory blood pressures are a better predictor of long-term cardiovascular outcomes than clinic blood pressures.

It can also highlight unique blood pressure patterns in children with transplants that can’t be detected with the occasional clinic visit, such as masked hypertension, when blood pressure is normal in the clinic but high the rest of the day. Or nocturnal hypertension, in which it is only high at night or when the patient is asleep. A normal pattern for blood pressure over a 24-hour period is called nocturnal dipping, where the blood pressure is lower during the nighttime and sleep periods than when patients are awake.

However, when the staff dug into its data, they found that only about 20% to 25% of their eligible patients had had an ambulatory blood pressure monitor in the past year. So they launched a quality improvement project as part of the Improving Renal Outcomes Collaborative (IROC), a learning health system of 32 pediatric kidney transplant centers in the U.S. that share data and best practices in an effort to improve transplant outcomes. The quality improvement project was supported by a Quality Improvement Award from the Kaul Pediatric Research Institute at Children’s of Alabama.

The team already had a weekly pre-visit planning meeting in place that helped prepare for each patient’s needs during the next week of clinics. They used that opportunity to generate lists of patients who had not had the ambulatory blood pressure monitor, and systematically made it a part of the transplant anniversary visits. After just six months, placement rates jumped to over 40%, even throughout the pandemic and telehealth visits.

“We are really proud of our team for being able to improve and sustain that during some pretty challenging conditions,” Seifert said.

Even more important, in about three-fourths of the patients, the ambulatory blood pressures turned up a problem that required intervention.

“We assumed we were doing a great job with this because we’re nephrologists and we have hypertension clinics focused on proper blood pressure measurement and control,” Seifert said. “But until you start looking hard at your data, you can’t presume you’re doing as well as you think you are. We didn’t know we needed to improve until we turned the lens on it.” The project has been so successful other solid organ transplant programs at Children’s are also considering implementing it as part of their cardiovascular risk assessments.

Inside Pediatrics, Neurology & Neurosurgery

Pediatric Neurosurgeon Launches Interactive Website Fostering Global Collaboration

Having partnered over the years with neurosurgeons in Vietnam and Ghana, James Johnston, Jr., M.D., a pediatric neurosurgeon at Children’s of Alabama and the University of Alabama at Birmingham (UAB), knew many in his field who craved this type of global collaboration but didn’t know where to start. That’s why he co-founded an interactive website designed to bring specialists and organizations together to improve the care of surgical patients worldwide.

Known as InterSurgeon (https://intersurgeon.org), the effort is the joint vision of Johnston and British pediatric neurosurgeon William Harkness, M.D., who focused on the stark fact that 80% of the world’s population lacks access to safe, timely and affordable surgical care. The pair, with support from multiple international organizations and Dean Vickers at the University of Alabama at Birmingham (UAB), raised funds to build InterSurgeon to help fill this void. It matches surgeons from disparate locations to not only collaborate, but form a supportive global community of like-minded professionals.

Initially launched with pediatric neurosurgeons in mind, InterSurgeon now also includes members from many other surgical specialties. The free service empowers surgeons, anesthesiologists, allied health professionals and equipment providers to partner on training, education and clinical care as well as share equipment and other resources.

“We’ve tried to create a stand-alone nexus for all players in global surgery to be able to join with others to better collaborate,” said Johnston, also an associate professor of pediatric neurosurgery at UAB.

“The World Health Organization passed a resolution in 2016 that put new emphasis on global surgery training as a major priority for global health,” he said. “We focus so much on infectious diseases, but what’s ended up happening is that the annual morbidity and mortality from surgery worldwide dwarfs all of that. It’s stunning.”

Key partnerships between InterSurgeon and other organizations over the past several years have driven opportunities for collaboration as well as access to surgical education with specialized technology. In addition to the United Nations Institute for Training and Research (UNITAR), partners include the G4 Alliance, which advocates for increased access to safe surgical care; and Ohana One, which has sent “smart glasses” loaded with augmented reality software from Birmingham-based HelpLightning to various sites around the world. This enabled mentor surgeons in developed healthcare systems to virtually interact in real time with mentees performing surgery for training purposes.

 With procedural competence integral to the specialty, surgery requires “a certain amount of infrastructure, and a lot of that has lagged worldwide,” Johnston noted. “But even in places with equipment, the quality of surgical training is not always as good as it could be.”

 With more than 600 members in 95 countries and growing, InterSurgeon aims to “shore up” that gap.            

“It’s a very difficult problem, and no one thing will solve it,” Johnston said. “But in surgery, it’s very important to connect experts and institutions with learners to bring them up to speed and improve the quality of the surgery they’re doing.”     

Inside Pediatrics, Neurology & Neurosurgery

Probing the Molecular Underpinnings of Undiagnosed Muscle Disorders

The Jerry Lewis fundraising telethons of yore educated many people about myopathies, the most famous of which – muscular dystrophy – highlights the often-progressive and disabling muscle weakness afflicting these children. But up to 10% of myopathy cases seen by Michael Lopez, M.D., Ph.D., a Children’s of Alabama pediatric neuromuscular physician-scientist, are undiagnosable, despite comprehensive evaluation.

This dilemma has driven Lopez, also an assistant professor of pediatric neurology at the University of Alabama at Birmingham (UAB), to collaborate with colleagues to use whole genome and RNA-Seq sequencing to potentially solve such cases. Lopez has enrolled 10 patients and their families into innovative clinical research aiming to reveal the molecular basis of undiagnosed myopathies in hopes of offering affected patients a prognosis and steering them toward effective treatments.

“In a small sliver of patients, I’m convinced they have a myopathy but am unable to refine their diagnosis and give clarity on what type,” Lopez explained. “In that group of kids, in which I’m pretty sure the cause is genetic and everything else is ruled out, we end up in this diagnostic odyssey.”

To tackle this problem, Lopez joined with UAB’s Liz Worthey, Ph.D., director of the Center for Genomic Data Sciences, and Matthew Alexander, Ph.D., an assistant professor of pediatric neurology. Using simple blood draws from parents and children and next-generation gene sequencing techniques, the trio hope to identify new genes responsible for muscle disorders or previously unreported variants of uncertain significance, dubbed VUS, in genes already known to cause myopathies. These mutations can be inserted into animal models to build evidence that a specific VUS triggers the condition.

“This allows us to get a snapshot of all the mutations possible in the genome, not excluding places that turn genes on and off,” Lopez said. “Data can help us support or refute a disease-causing mechanism for the VUS.”

Lopez is well aware the project won’t produce quick answers, and participating families also understand the findings may not benefit them personally.

“But it is possible to come back with a molecular diagnosis,” he said. “If we find something that’s already well-understood, that would offer them some treatment options if they’re already available.”

 Longer-term, Lopez hopes the research will point toward targeted treatments for these muscle disorders, some of which might be derived by repurposing old drugs in “off-the-shelf libraries.”            

“Treatment is just one goal, a second is resolving the diagnosis and solving the case,” he said. “That’s a huge burden relieved for both family and patient. And another piece is the science – to improve our understanding of how these diseases occur and how the muscle functions.”

Inside Pediatrics, Pulmonology

Study Shows Long-Term Effectiveness of Ivacaftor in Children and Adults with Cystic Fibrosis

The world of cystic fibrosis was radically changed in 2012 with the approval of the first cystic fibrosis transmembrane conductance regulator (CFTR) modulator, ivacaftor, which targets certain genetic mutations responsible for the disease. Now, a recently published study by the Cystic Fibrosis Foundation’s multi-center Observational Study in People with CF with the G551D Mutation (GOAL) trial (conducted through the Therapeutics Development Network and funded through the Cystic Fibrosis Foundation) finds that ivacaftor remains effective for at least 5.5 years. Study investigators included Children’s of Alabama pediatric pulmonologist Jennifer S. Guimbellot, M.D., Ph.D, Scott Sagel, M.D., Ph.D., at the University of Colorado, and Steven M. Rowe M.D., who directs the Gregory Fleming James Cystic Fibrosis Research Center at the University of Alabama Birmingham (UAB), as well as other GOAL investigators,

The study followed patients who participated in the drug’s original six-month study. Although a small study with 96 participants, 81% continued as throughout the study duration. “To follow them over five years is a big feat,” said Guimbellot. But it allowed the team to understand whether ivacaftor is helpful with long-term use.

While the study found the drug remained effective overall, with clinically important improvements in lung function, pulmonary exacerbations, quality of life, weight gain, and P. aeruginosa infection, there were some differences based on age and baseline lung function. Adults and those with lower baseline lung function experienced greater improvements in lung function at 5.5 years than children and those with higher baseline lung function. As might be expected, quality-of-life improvement was greater in and more sustained in adults who had lower baseline quality of life scores. Importantly, this was the first study to show quality-of-life improvement beyond 2 years.

Another important finding is that while the overall cohort maintained an average lung function above the pre-ivacaftor level, some continued to experience lung function decline, particularly children. Some also continued to experience infections and remained underweight.

This suggests that “there’s something going on that we need to understand better,” Guimbellot said. “It doesn’t mean that ivacaftor doesn’t work for children; it definitely does work for children. It’s just something we don’t understand and there’s still room for improving care.”

One interesting observation is that while most participants gained weight (in part because they didn’t spend as much metabolic energy fighting the lung disease and attendant infections), some gained an unhealthy amount of weight. “This is something we have to pay attention to,” Guimbellot said. This may include revising the typical high-calorie, high-protein, high-fat diet recommended for certain people with CF to a more balanced diet.

The study is important not only because it shows the long-term effects of ivacaftor, she said, but because it can, hopefully, be extrapolated to the newest approved CTFR, a combination of elexacaftor, ivacaftor, and tezacaftor. Unlike ivacaftor, which is effective for just 4% or 5% of the CF population, this combination, approved in 2019, works in up to 90% of people with the disease.

“As a physician who helps diagnose newborns with cystic fibrosis, I am often asked what parents can expect the child’s lifespan to be,” Guimbellot said. Today the median age of survival is 47, but that doesn’t take into account the effect of the CTFR modulators. “With the new drugs,” she said, “we may see a population of children who don’t have the typical findings of cystic fibrosis as long as they adhere to their therapies.”

Inside Pediatrics, Pulmonology

Pulmonology Telehealth Gets Good Reviews

When the pandemic hit in March 2020, most clinics at Children’s of Alabama pivoted to telehealth visits, including pulmonology. Although things have primarily returned to normal with in-person visits, telehealth still has a presence in the outpatient setting.

Given that, an interprofessional team of Pediatric Pulmonary Trainees at the University of Alabama at Birmingham led by Valerie Tarn, MS, RD, LD, training director of the Pediatric Pulmonary Center (PPC), launched a survey to assess how families and clinicians felt about televisits in the pulmonary clinic. “We wanted to evaluate our services and get feedback from our families since many have children with special healthcare needs that require multiple visits per year,” she said. “We wondered if we could do telehealth for every other visit in some populations.”

They surveyed families that had already had a televisit (most used their phones) and those that hadn’t, as well as clinicians who participated in the televisits, to see what, if any, barriers existed as well as collect demographic information.

Most families who had participated in telehealth said they would like to continue for some, but not all, visits. The greatest advantages were avoiding COVID-19 infection and not having to drive to the hospital. The latter is particularly important, Tarn said, since many families drive an hour or more to the clinic. As one parent commented, “This has been wonderful experience! I don’t have to worry about exposing her to COVID or the flu, which is very dangerous for my child. Hope to be able to continue this service in the future!”

About 90 percent of families that hadn’t had a pulmonary televisit reported having Internet access. When asked about potential disadvantages to such visits, they noted the inability to conduct a physical exam. As one parent wrote,  “Please allow the patient to have a choice as to whether or not the appointment is to be in-person or a telehealth appointment.”

Clinicians agreed that telehealth was probably here to stay, Tarn said, but they wanted a more consistent structure. That included prescreening families and finding ways to incorporate other members of the health care team into the visit. “A lot of our patients need to see other health professionals,” she said. “How do you get them to talk with the pharmacist or social worker or nutritionist?” In the spring, the doctors were typically emailing other clinicians or leaving a message in the patient’s secure medical record about the need for follow up.

In the cystic fibrosis clinic, however, nutritionists, social workers, and other allied health professionals rotatedthrough the visit, each taking turns with the iPad. “That worked fairly smoothly,” Tarn said, and could provide a model for other pulmonary clinics.

In the future, the clinicians noted, it would be helpful if patients had home equipment available, such as spirometers, peak flow meters, and weight scales.

But overall, Tarn said, families and healthcare professionals liked telehealth. Now that the surveys have been collected, the PPC trainees plan to present the research results to an interprofessional audience at a local or regional conference.

Cardiology, Inside Pediatrics

Comparing Delayed Sternal Closure Results Reinforces Success at Children’s of Alabama

Leaving the chest open for a day or two after complex neonatal heart surgery has been standard procedure at Children’s of Alabama for about a dozen years. The practice is believed to be a “safety mechanism” that lessens compression on the heart and lungs as swollen babies begin to recover from their operations, according to Robert Dabal, M.D., chief of pediatric cardiothoracic surgery at Children’s and an associate professor of surgery at the University of Alabama at Birmingham (UAB).

But does the approach, known as delayed sternal closure, actually produce better outcomes than closing a newborn’s chest at the conclusion of surgery? The Pediatric Cardiac Critical Care Consortium (PC4) recently invited Children’s and University of Michigan’s C.S. Mott Children’s Hospital to debate the question by comparing each hospital’s outcomes. Unlike standard practice at Children’s, C.S. Mott cardiothoracic surgeons “tend to close a lot of complex neonates,” Dabal explained.

Children’s has been a member of PC4 – which aims to improve the quality of care to patients in North America and beyond with critical pediatric and congenital cardiovascular disease – since the group’s inception about 12 years ago. The head-to-head comparison of outcomes between Children’s and C.S. Mott showed survival rates to be higher at Children’s, though the gap was not statistically significant, Dabal said.

“We found that delayed sternal closure doesn’t really negatively impact patients in any way, either in length of stay or rate of complications, but it does make them a little easier to manage in the immediate postoperative period,” he said.

Mortality rates at Children’s for complex neonatal heart surgeries are consistently far lower than the U.S. average, he noted. For example, for the Norwood procedure – a three-step heart surgery for hypoplastic left heart syndrome – Children’s mortality rate has been about 5.5% over the last five years, compared with a national average of about 15%.

Possible complications from leaving the chest open after surgery include slightly higher odds of infection, “though we haven’t really seen that here,” Dabal said. The practice also requires greater sedation to prevent patients from “moving around a lot” in the days after surgery and a slight delay in removing ventilators.

But the PC4 debate results essentially reinforce Children’s approach, and Dabal expects delayed sternal closure to continue here as the standard of care. “I don’t think we’ll be making major changes, though we’re always interested in continuing to improve our results,” he said.