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Extubation Failure Rates After Pediatric Cardiac Surgery Vary Across Hospitals*

Rooney, Sydney R., BS1,2; Donohue, Janet E., MPH2; Bush, Lauren B., MPH2; Zhang, Wenying, MS3; Banerjee, Mousumi, PhD3,4; Pasquali, Sara K., MD, MHS2,3,5; Gaies, Michael G., MD, MPH, MSc2,3,5

Pediatric Critical Care Medicine: May 2019 - Volume 20 - Issue 5 - p 450–456
doi: 10.1097/PCC.0000000000001877
Cardiac Intensive Care
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Objectives: Many hospitals aim to extubate children early after cardiac surgery, yet it remains unclear how this practice associates with extubation failure. We evaluated adjusted extubation failure rates and duration of postoperative mechanical ventilation across hospitals and assessed cardiac ICU organizational factors associated with extubation failure.

Design: Secondary analysis of the Pediatric Cardiac Critical Care Consortium clinical registry.

Setting: Pediatric Cardiac Critical Care Consortium cardiac ICUs.

Patients: Patients with qualifying index surgical procedures from August 2014 to June 2017.

Interventions: None.

Measurements and Main Results: We modeled hospital-level adjusted extubation failure rates using multivariable logistic regression. A previously validated Pediatric Cardiac Critical Care Consortium model was used to calculate adjusted postoperative mechanical ventilation. Observed-to-expected ratios for both metrics were derived for each hospital to assess performance. Hierarchical logistic regression was used to assess the association between cardiac ICU factors and extubation failure. Overall, 16,052 surgical hospitalizations were analyzed. Predictors of extubation failure (p < 0.05 in final case-mix adjustment model) included younger age, underweight, greater surgical complexity, airway anomaly, chromosomal anomaly/syndrome, longer cardiopulmonary bypass time, and other preoperative comorbidities. Three hospitals were better-than-expected outliers for extubation failure (95% CI around observed-to-expected < 1), and three hospitals were worse-than-expected (95% CI around observed-to-expected > 1). Two hospitals were better-than-expected outliers for both extubation failure and postoperative mechanical ventilation, and three were worse-than-expected for both. No hospital was an outlier in opposite directions. Greater nursing hours per patient day and percent nursing staff with critical care certification were associated with lower odds of extubation failure. Cardiac ICU factors such as fewer inexperienced nurses, greater percent critical care trained attendings, cardiac ICU–dedicated respiratory therapists, and fewer patients per cardiac ICU attending were not associated with lower odds of extubation failure.

Conclusions: We saw no evidence that hospitals trade higher extubation failure rates for shorter duration of postoperative mechanical ventilation after pediatric cardiac surgery. Increasing specialized cardiac ICU nursing hours per patient day may achieve better extubation outcomes and mitigate the impact of inexperienced nurses.

1Vanderbilt University School of Medicine, Nashville, TN.

2Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor, MI.

3Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.

4Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI.

5Department of Pediatrics, Division of Cardiology, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI.

*See also p. 495.

This work was performed at University of Michigan, Ann Arbor, MI.

Supported, in part, by funding from the University of Michigan Congenital Heart Center, Champs for Mott, and the Michigan Institute for Clinical & Health Research (National Institutes of Health/National Center for Advancing Translational Sciences UL1TR002240).

Ms. Rooney’s and Dr. Gaies’ institutions received funding from the National Institutes of Health (NIH). Ms. Rooney received funding from Sarnoff Cardiovascular Research Foundation. Drs. Pasquali and Gaies received support for article research from the NIH. Ms. Zhang disclosed work for hire. Dr. Pasquali’s institution received funding from the National Heart, Lung, and Blood Institute, and she receives funding from the National Heart, Lung, and Blood Institute (R01HL12226; principal investigator Dr. Pasquali). Dr. Gaies is supported by a career development award from the U.S. National Institutes of Health, National Heart, Lung, and Blood Institute (K08-HL116639). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Michael Gaies, MD, C.S. Mott Children’s Hospital, 1540 E Hospital Drive, Ann Arbor, MI 48109. E-mail: sydney.r.rooney@vanderbilt.edu

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies