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Online Resource 1
Title
Surgical Quality Predicts Length of Stay in Patients with Congenital Heart Disease
Journal Name
Pediatric Cardiology
Authors
Eric A. Johnson, MD1, M. Mujeeb Zubair, MD2, Laurie R. Armsby, MD1, Grant H. Burch, MD1, Milon K. Good,
MPH 2, Michael R. Lasarev, MS3, A. Roger Hohimer, PhD4, Ashok Muralidaran, MD 2, and Stephen M. Langley,
MD FRCS (CTh)2
Institution and affiliations
Oregon Health & Science University (OHSU)
3181 S.W. Sam Jackson Park Rd.
Portland, OR 97239-3098
1 Division of Pediatric Cardiology, Doernbecher Children's Hospital, OHSU
2 Division of Pediatric Cardiothoracic Surgery, Doernbecher Children's Hospital, OHSU
3 Oregon Institute of Occupational Health Sciences, OHSU
4 Division of Perinatology, OHSU
Corresponding Author
Eric A. Johnson, MD
Oregon Health & Science University
707 SW Gaines St., CDRCP
Portland, OR 97239
Telephone: 503-418-5750
Fax: 503-494-2824
Email: johnseri@ohsu.edu
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Online Resource 1
Congenital Cardiac Surgical Metrics
We sought to develop metrics, beyond measurements of postoperative mortality, as additional tools to assess the
quality of the care we provide.
The 10 Metrics:
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Unplanned postoperative extracorporeal membrane oxygenation
Unplanned postoperative cardiac catheterization
Revision of the primary repair
Delayed sternal closure
Mediastinitis
Reexploration for bleeding
Postoperative complete heart block requiring a permanent pacemaker
Vocal cord paralysis
Diaphragm paralysis requiring plication
Change in the preoperative diagnosis
Definitions:
Unplanned postoperative extracorporeal membrane oxygenation (ECMO):
This is an assessment of the health of the myocardium, and the quality of surgical repair immediately after surgery.
Definition: The patient is placed on ECMO (with oxygenator) or a ventricular assist device (VAD, without
oxygenator) support during the same hospitalization following cardiac surgery, and:
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the preoperative plan did not include postoperative ECMO/VAD support as part of the strategy for
postoperative care.
For clarification, ask: Was ECMO/VAD planned to be part of the postoperative management?
Appropriate: John Smith underwent arterial switch operation, he could not be weaned from cardiopulmonary
bypass and was placed on VAD support in the operating room (OR) or within two hours of leaving the OR.
Inappropriate: Jill Smith underwent repair of total anomalous pulmonary venous connection, she was converted
from cardiopulmonary bypass to ECMO in the operating room, as planned, for two days of support to allow her
pulmonary vascular resistance to drop.
Unplanned postoperative cardiac catheterization:
This is an assessment of the quality of the surgical repair.
Definition: The patient undergoes cardiac catheterization (hemodynamic or interventional; not electrophysiology)
during the same hospitalization following cardiac surgery, and:
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the preoperative discussions did not plan for a cardiac catheterization to follow the surgery.
For clarification, ask: Was the plan to stage the procedure with surgery followed by a catheterization?
Appropriate: John Smith underwent truncus repair, his postoperative day 3 echo showed probable left pulmonary
artery (LPA) stenosis, so he underwent cardiac catheterization for assessment and possible LPA stent.
Inappropriate: Jill Smith underwent truncus repair, on postoperative day 5, as planned, she underwent stenting of
the distal LPA which was felt preoperatively to be too distal for surgical augmentation.
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Revision of the primary repair:
This is an assessment of the quality of the primary repair.
Definition: The primary operation requires revision (improvement or correction) during the same hospitalization.
This does not include:
 revisions or modifications or improvements performed during the primary operation (while still in the OR).
 staged procedures.
 a second operation to address lesions identified after surgery, which do not involve the primary site of surgery
(i.e. missed or evolving lesions).
For clarification, ask: Was the second surgery an attempt to repair something wrong with the primary surgery?
Appropriate: John Smith underwent placement of a right modified Blalock-Taussig shunt (RMBTS), on
postoperative day 3 a catheterization revealed severe distal shunt stenosis. He returned to the OR for revision of the
shunt insertion.
Inappropriate: Jill Smith underwent placement of a RMBTS, on postoperative night 1 the shunt thrombosed due to
insufficient heparin dosing, so she underwent urgent thrombectomy.
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Appropriate: John Smith underwent a bidirectional Glenn, he underwent a catheterization on postoperative day 2
secondary to severe cyanosis which showed stenosis of the Glenn. He returned to the operating room for revision of
the cavopulmonary anastomosis.
Inappropriate: Jill Smith underwent a bidirectional Glenn, she underwent a catheterization on postoperative day 2
secondary to severe cyanosis which showed a previously undiagnosed left superior vena cava. She returned to the
operating room for a left bidirectional Glenn.
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Appropriate: John Smith underwent total anomalous pulmonary venous connection (TAPVC) repair on day of life
6. On postoperative day 18, his left pulmonary veins were still stenotic and he returned to the OR for revision of the
left pulmonary vein anastomosis and a Stage I Norwood.
Inappropriate: Jill Smith underwent TAPVC repair on day of life 6. On postoperative day 18 (after her pulmonary
vascular resistance decreased), she underwent the Stage I Norwood operation.
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Appropriate: John Smith underwent a Stage I Norwood. On postoperative day 14, he underwent revision of the
arch secondary to residual stenosis and inability to extubate.
Inappropriate: Jill Smith underwent a Stage I Norwood. On postoperative day 14, she underwent tricuspid
valvuloplasty secondary to inability to extubate.
Delayed sternal closure:
This is an assessment of the stability of the patient in the early postoperative period as a measure of the quality of
surgical repair.
Definition: The patient is leaves the operating room with an open chest, or the chest is opened in the postoperative
period due to instability or bleeding, and later closed.
For clarification, ask: Was the sternum left open or reopened to make the patient more stable after surgery?
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Appropriate: John Smith underwent truncus repair. His chest was left open for 3 days and closed on postoperative
day 4.
Inappropriate: Jill Smith underwent truncus repair. On postoperative day 6, she developed cellulitis, and the
incision was opened above the sternum for drainage. After 7 days, the incision was closed.
Mediastinitis:
This is an assessment of perioperative infection control measures.
Definition: The patient develops a mediastinitis involving the deep tissues of the chest (as opposed to cellulitis),
during the same hospitalization following cardiac repair.
Reexploration for bleeding:
This is an assessment of the quality of hemostatic stability after surgery.
Definition: The chest is opened, or Esmarch removed, due to excessive bleeding within the thorax.
For clarification, ask: Was the indication for the procedure to control bleeding?
Appropriate: John Smith underwent arterial switch operation, several hours postoperatively he became hypotensive
and an echo showed pericardial effusion. His chest was emergently opened, 45 mL of blood was removed, and a
bleeding area around a suture was repaired.
Inappropriate: Jill Smith underwent arterial switch operation followed by 5 days of ECMO support. On
postoperative day 5 she was decannulated, 25 mL of bloody fluid was removed from the posterior mediastinum, and
her chest was closed.
Postoperative complete heart block requiring a permanent pacemaker:
This is an assessment of surgical technique resulting in permanent injury to the AV conduction system.
Definition: Following heart surgery, the patient develops complete heart block which does not resolve, thus
requiring placement of a permanent pacemaker.
For clarification, ask: Is the postoperative indication for pacemaker new, complete heart block?
Appropriate: John Smith underwent complete atrioventricular canal repair, and he came off cardiopulmonary
bypass in complete heart block and remained so for 10 days, after which a permanent pacer was placed.
Inappropriate: Jill Smith underwent the Fontan operation, and she came off bypass in an accelerated junctional
rhythm. Over the next 14 days her sinus rhythm remained in the 50s with a junctional rhythm greater than 60,
leading to AV discordance and poor cardiac output. A permanent pacemaker was placed on postoperative day 14.
Vocal cord paralysis:
This is an assessment of surgical technique resulting in injury to the recurrent laryngeal nerve.
Definition: Diagnostic studies show paralysis of a vocal cord (either temporary or permanent) following surgery.
Diaphragm paralysis requiring plication:
This is an assessment of surgical technique resulting in injury to the phrenic nerve which requires plication.
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Definition: Diagnostic studies show paralysis of the diaphragm following surgery for which the patient requires
plication. (The requirement of plication produces a more accurate metric as patients who tolerate diaphragm
hemiparesis may never have the condition diagnosed.)
Change in the preoperative diagnosis:
This is an assessment of the quality of preoperative diagnosis and discussion.
Definition: The preoperative diagnosis is found to be different than what is seen under direct visualization in the
OR. Whether or not this leads to a change in the operative procedure, this will be noted.