Andrew Young Shin

All Publications

• Recommendations for Centers Performing Pediatric Heart Surgery in the United States. The Annals of thoracic surgery Backer, C. L., Overman, D. M., Dearani, J. A., Romano, J. C., Tweddell, J. S., Kumar, S. R., Marino, B. S., Bacha, E. A., Jaquiss, R. D., Zaidi, A. N., Gurvitz, M., Costello, J. M., Pierick, T. A., Ravekes, W. J., Reagor, J. A., St Louis, J. D., Spaeth, J., Mahle, W. T., Shin, A. Y., Lopez, K. N., Karamlou, T., Welke, K. F., Bryant, R., Husain, S. A., Chen, J. M., Kaza, A., Wells, W. J., Glatz, A. C., Cohen, M. I., McElhinney, D. B., Parra, D. A., Pasquali, S. K. 2023

  Abstract

  Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

  View details for DOI 10.1016/j.athoracsur.2023.08.016

  View details for PubMedID 37777933

• Recommendations for Centers Performing Pediatric Heart Surgery in the United States. World journal for pediatric & congenital heart surgery Backer, C. L., Overman, D. M., Dearani, J. A., Romano, J. C., Tweddell, J. S., Ram Kumar, S., Marino, B. S., Bacha, E. A., Jaquiss, R. D., Zaidi, A. N., Gurvitz, M., Costello, J. M., Pierick, T. A., Ravekes, W. J., Reagor, J. A., St Louis, J. D., Spaeth, J., Mahle, W. T., Shin, A. Y., Lopez, K. N., Karamlou, T., Welke, K. F., Bryant, R., Adil Husain, S., Chen, J. M., Kaza, A., Wells, W. J., Glatz, A. C., Cohen, M. I., McElhinney, D. B., Parra, D. A., Pasquali, S. K. 2023; 14 (5): 642-679

  Abstract

  Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

  View details for DOI 10.1177/21501351231190353

  View details for PubMedID 37737602

• The Association Between Central Line-Associated Bloodstream Infection and Central Line Access. Critical care medicine Ward, A., Chemparathy, A., Seneviratne, M., Gaskari, S., Mathew, R., Wood, M., Donnelly, L. F., Lee, G. M., Scheinker, D., Shin, A. Y. 2023

  Abstract

  OBJECTIVES: Identifying modifiable risk factors associated with central line-associated bloodstream infections (CLABSIs) may lead to modifications to central line (CL) management. We hypothesize that the number of CL accesses per day is associated with an increased risk for CLABSI and that a significant fraction of CL access may be substituted with non-CL routes.DESIGN: We conducted a retrospective cohort study of patients with at least one CL device day from January 1, 2015, to December 31, 2019. A multivariate mixed-effects logistic regression model was used to estimate the association between the number of CL accesses in a given CL device day and prevalence of CLABSI within the following 3 days.SETTING: A 395-bed pediatric academic medical center.PATIENTS: Patients with at least one CL device day from January 1, 2015, to December 31, 2019.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: There were 138,411 eligible CL device days across 6,543 patients, with 639 device days within 3 days of a CLABSI (a total of 217 CLABSIs). The number of per-day CL accesses was independently associated with risk of CLABSI in the next 3 days (adjusted odds ratio, 1.007; 95% CI, 1.003-1.012; p = 0.002). Of medications administered through CLs, 88% were candidates for delivery through a peripheral line. On average, these accesses contributed a 6.3% increase in daily risk for CLABSI.CONCLUSIONS: The number of daily CL accesses is independently associated with risk of CLABSI in the next 3 days. In the pediatric population examined, most medications delivered through CLs could be safely administered peripherally. Efforts to reduce CL access may be an important strategy to include in contemporary CLABSI-prevention bundles.

  View details for DOI 10.1097/CCM.0000000000005838

  View details for PubMedID 36920081

• WAVES - The Lucile Packard Children's Hospital Pediatric Physiological Waveforms Dataset. Scientific data Miller, D. R., Dhillon, G. S., Bambos, N., Shin, A. Y., Scheinker, D. 2023; 10 (1): 124

  Abstract

  WAVES is a large, single-center dataset comprising 9 years of high-frequency physiological waveform data from patients in intensive and acute care units at a large academic, pediatric medical center. The data comprise approximately 10.6 million hours of 1 to 20 concurrent waveforms over approximately 50,364 distinct patient encounters. The data have been de-identified, cleaned, and organized to facilitate research. Initial analyses demonstrate the potential of the data for clinical applications such as non-invasive blood pressure monitoring and methodological applications such as waveform-agnostic data imputation. WAVES is the largest pediatric-focused and second largest physiological waveform dataset available for research.

  View details for DOI 10.1038/s41597-023-02037-x

  View details for PubMedID 36882443

  View details for PubMedCentralID 3609896

• Target Based Care: An Intervention to Reduce Variation in Postoperative Length of Stay. The Journal of pediatrics Shin, A. Y., Rao, I. J., Bassett, H. K., Chadwick, W., Kim, J., Kipps, A. K., Komra, K., Loh, L., Maeda, K., Mafla, M., Presnell, L., Sharek, P. J., Steffen, K. M., Scheinker, D., Algaze, C. A. 2020

  Abstract

  OBJECTIVES: To derive care targets and evaluate the impact of displaying them at the point of care on postoperative length of stay (LOS).STUDY DESIGN: A prospective cohort study using 2 years of historical controls within a freestanding, academic children's hospital. Patients undergoing benchmark cardiac surgery between May 4, 2014 and August 15, 2016 (preintervention) and September 6, 2016 to September 30, 2018 (postintervention) were included. The intervention consisted of displaying at the point of care targets for the timing of extubation, transfer from the intensive care unit (ICU), and hospital discharge. Family satisfaction, reintubation, and readmission rates were tracked.RESULTS: The postintervention cohort consisted of 219 consecutive patients. There was a reduction in variation for ICU (difference in SD -2.56, p < 0.01), and total LOS (difference in SD -2.84, P < .001). Patients stayed on average 0.97 fewer days (p<0.001) in the ICU (median -1.01 [IQR -2.15,-0.39], 0.7 fewer days (p<0.001) on mechanical ventilation (median -0.54 [IQR -0.77,-0.50], and 1.18 fewer days (p<0.001) for the total LOS (median -2.25 [IQR -3.69,-0.15]. Log transformed multivariable linear regression demonstrated the intervention to be associated with shorter ICU LOS (beta coefficient -0.19, SE 0.059, p<0.001), total postoperative LOS (beta coefficient -0.12, SE 0.052, p=0.02), and ventilator duration (beta coefficient -0.21, SE 0.048, p<0.001). Balancing metrics did not differ after the intervention.CONCLUSIONS: Target based care is a simple, novel intervention associated with reduced variation in LOS and absolute LOS across a diverse spectrum of complex cardiac surgeries.

  View details for DOI 10.1016/j.jpeds.2020.09.017

  View details for PubMedID 32920104

• Differences in Central Line-Associated Bloodstream Infection Rates Based on the Criteria Used to Count Central Line Days. JAMA Scheinker, D., Ward, A., Shin, A. Y., Lee, G. M., Mathew, R., Donnelly, L. F. 2020; 323 (2): 183–85

  View details for DOI 10.1001/jama.2019.18616

  View details for PubMedID 31935018

• Cost-effectiveness of Humanitarian Pediatric Cardiac Surgery Programs in Low- and Middle-Income Countries. JAMA network open Cardarelli, M., Vaikunth, S., Mills, K., DiSessa, T., Molloy, F., Sauter, E., Bowtell, K., Rivera, R., Shin, A. Y., Novick, W. 2018; 1 (7): e184707

  Abstract

  Endorsement of global humanitarian interventions is based on either proven cost-effectiveness or perceived public health benefits. The cost-effectiveness and long-term benefits of global humanitarian pediatric cardiac surgery are unknown, and funding for this intervention is insufficient.To determine the cost-effectiveness of the intervention (multiple 2-week-long humanitarian pediatric cardiac surgery program assistance trips to various low- and middle-income countries [LMICs]) and to produce a measure of the long-lasting effects of global humanitarian programs.International, multicenter cost-effectiveness analysis of a cohort of children (aged <16 years) undergoing surgical treatment of congenital heart disease during 2015 in LMICs, including China, Macedonia, Honduras, Iran, Iraq, Libya, Nigeria, Pakistan, Russia, and Ukraine. The study also assessed estimated improvement in the United Nations Human Development Indicators (life expectancy, years of schooling, and gross national income) for each individual survivor, as a proxy for long-term benefits of the intervention.The primary outcome was cost-effectiveness of the intervention. The secondary outcomes were potential gains in life expectancy, years of schooling, and gross national income per capita for each survivor.During 2015, 446 patients (192 [43%] female; mean [SD] age, 3.7 [5.4] years) were served in 10 LMICs at an overall cost of $3 210 873. Of them, 424 were children. The cost-effectiveness of the intervention was $171 per disability-adjusted life-year averted. Each survivor in the cohort (390 of 424) potentially gained 39.9 disability-adjusted life-years averted, 3.5 years of schooling, and $159 533 in gross national income per capita during his or her extended lifetime at purchasing power parity and 3% discounting.Humanitarian pediatric cardiac surgery in LMICs is highly cost-effective. It also leaves behind a lasting humanitarian footprint by potentially improving individual development indices.

  View details for DOI 10.1001/jamanetworkopen.2018.4707

  View details for PubMedID 30646368

  View details for PubMedCentralID PMC6324367

• Changes in Efficiency and Safety Culture After Integration of an I-PASS-Supported Handoff Process. Pediatrics Sheth, S., McCarthy, E., Kipps, A. K., Wood, M., Roth, S. J., Sharek, P. J., Shin, A. Y. 2016; 137 (2): 1-9

  Abstract

  Recent publications have shown improved outcomes associated with resident-to-resident handoff processes. However, the implementation of similar handoff processes for patients moving between units and teams with expansive responsibilities presents unique challenges. We sought to determine the impact of a multidisciplinary standardized handoff process on efficiency, safety culture, and satisfaction.A prospective improvement initiative to standardize handoffs during patient transitions from the cardiovascular ICU to the acute care unit was implemented in a university-affiliated children's hospital.Time between verbal handoff and patient transfer decreased from baseline (397 ± 167 minutes) to the postintervention period (24 ± 21 minutes) (P < .01). Percentage positive scores for the handoff/transitions domain of a national culture of safety survey improved (39.8% vs 15.2% and 38.8% vs 19.6%; P = .005 and 0.03, respectively). Provider satisfaction improved related to the information conveyed (34% to 41%; P = .03), time to transfer (5% to 34%; P < .01), and overall experience (3% to 24%; P < .01). Family satisfaction improved for several questions, including: "satisfaction with the information conveyed" (42% to 70%; P = .02), "opportunities to ask questions" (46% to 74%; P < .01), and "Acute Care team's knowledgeabout my child's issues" (50% to 73%; P = .04). No differences in rates of readmission, rapid response team calls, or mortality were observed.Implementation of a multidisciplinary I-PASS-supported handoff process for patients transferring from the cardiovascular ICU to the acute care unit resulted in improved transfer efficiency, safety culture scores, and satisfaction of providers and families.

  View details for DOI 10.1542/peds.2015-0166

  View details for PubMedID 26743818

• Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost. Pediatrics Algaze, C. A., Wood, M., Pageler, N. M., Sharek, P. J., Longhurst, C. A., Shin, A. Y. 2016; 137 (1): 1-8

  Abstract

  We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs.We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay.We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was $717, 538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7-1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods.Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.

  View details for DOI 10.1542/peds.2014-3019

  View details for PubMedID 26681782

• Exploring Value in Congenital Heart Disease: An Evaluation of Inpatient Admissions. Congenital heart disease Shin, A. Y., Hu, Z., Jin, B., Lal, S., Rosenthal, D. N., Efron, B., Sharek, P. J., Sutherland, S. M., Cohen, H. J., McElhinney, D. B., Roth, S. J., Ling, X. B. 2015; 10 (6): E278-87

  Abstract

  Understanding value provides an important context for improvement. However, most health care models fail to measure value. Our objective was to categorize inpatient encounters within an academic congenital heart program based on clinical outcome and the cost to achieve the outcome (value). We aimed to describe clinical and nonclinical features associated with value.We defined hospital encounters based on outcome per resource utilized. We performed principal component and cluster analysis to classify encounters based on mortality, length of stay, hospital cost and revenue into six classes. We used nearest shrunken centroid to identify discriminant features associated with the cluster-derived classes. These features underwent hierarchical clustering and multivariate analysis to identify features associated with each class.We analyzed all patients admitted to an academic congenital heart program between September 1, 2009, and December 31, 2012.A total of 2658 encounters occurred during the study period. Six classes were categorized by value. Low-performing value classes were associated with greater institutional reward; however, encounters with higher-performing value were associated with a loss in profitability. Encounters that included insertion of a pediatric ventricular assist device (log OR 2.5 [95% CI, 1.78 to 3.43]) and acquisition of a hospital-acquired infection (log OR 1.42 [95% CI, 0.99 to 1.87]) were risk factors for inferior health care value.Among the patients in our study, institutional reward was not associated with value. We describe a framework to target quality improvement and resource management efforts that can benefit patients, institutions, and payers alike.

  View details for DOI 10.1111/chd.12290

  View details for PubMedID 26219731

• Hyponatremia among runners in the Boston Marathon NEW ENGLAND JOURNAL OF MEDICINE Almond, C. S., Shin, A. Y., Fortescue, E. B., Mannix, R. C., Wypij, D., Binstadt, B. A., Duncan, C. N., Olson, D. P., Salerno, A. E., Newburger, J. W., Greenes, D. S. 2005; 352 (15): 1550-1556

  Abstract

  Hyponatremia has emerged as an important cause of race-related death and life-threatening illness among marathon runners. We studied a cohort of marathon runners to estimate the incidence of hyponatremia and to identify the principal risk factors.Participants in the 2002 Boston Marathon were recruited one or two days before the race. Subjects completed a survey describing demographic information and training history. After the race, runners provided a blood sample and completed a questionnaire detailing their fluid consumption and urine output during the race. Prerace and postrace weights were recorded. Multivariate regression analyses were performed to identify risk factors associated with hyponatremia.Of 766 runners enrolled, 488 runners (64 percent) provided a usable blood sample at the finish line. Thirteen percent had hyponatremia (a serum sodium concentration of 135 mmol per liter or less); 0.6 percent had critical hyponatremia (120 mmol per liter or less). On univariate analyses, hyponatremia was associated with substantial weight gain, consumption of more than 3 liters of fluids during the race, consumption of fluids every mile, a racing time of >4:00 hours, female sex, and low body-mass index. On multivariate analysis, hyponatremia was associated with weight gain (odds ratio, 4.2; 95 percent confidence interval, 2.2 to 8.2), a racing time of >4:00 hours (odds ratio for the comparison with a time of <3:30 hours, 7.4; 95 percent confidence interval, 2.9 to 23.1), and body-mass-index extremes.Hyponatremia occurs in a substantial fraction of nonelite marathon runners and can be severe. Considerable weight gain while running, a long racing time, and body-mass-index extremes were associated with hyponatremia, whereas female sex, composition of fluids ingested, and use of nonsteroidal antiinflammatory drugs were not.

  View details for Web of Science ID 000228324200007

  View details for PubMedID 15829535

• Recommendations for centers performing pediatric heart surgery in the United States. The Journal of thoracic and cardiovascular surgery Backer, C. L., Overman, D. M., Dearani, J. A., Romano, J. C., Tweddell, J. S., Kumar, S. R., Marino, B. S., Bacha, E. A., Jaquiss, R. D., Zaidi, A. N., Gurvitz, M., Costello, J. M., Pierick, T. A., Ravekes, W. J., Reagor, J. A., St Louis, J. D., Spaeth, J., Mahle, W. T., Shin, A. Y., Lopez, K. N., Karamlou, T., Welke, K. F., Bryant, R., Husain, S. A., Chen, J. M., Kaza, A., Wells, W. J., Glatz, A. C., Cohen, M. I., McElhinney, D. B., Parra, D. A., Pasquali, S. K. 2023

  Abstract

  Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

  View details for DOI 10.1016/j.jtcvs.2023.09.001

  View details for PubMedID 37777958

• Surgical scheduling via optimization and machine learning with long-tailed data : Health care management science, in press. Health care management science Shi, Y., Mahdian, S., Blanchet, J., Glynn, P., Shin, A. Y., Scheinker, D. 2023

  Abstract

  Using data from cardiovascular surgery patients with long and highly variable post-surgical lengths of stay (LOS), we develop a modeling framework to reduce recovery unit congestion. We estimate the LOS and its probability distribution using machine learning models, schedule procedures on a rolling basis using a variety of optimization models, and estimate performance with simulation. The machine learning models achieved only modest LOS prediction accuracy, despite access to a very rich set of patient characteristics. Compared to the current paper-based system used in the hospital, most optimization models failed to reduce congestion without increasing wait times for surgery. A conservative stochastic optimization with sufficient sampling to capture the long tail of the LOS distribution outperformed the current manual process and other stochastic and robust optimization approaches. These results highlight the perils of using oversimplified distributional models of LOS for scheduling procedures and the importance of using optimization methods well-suited to dealing with long-tailed behavior.

  View details for DOI 10.1007/s10729-023-09649-0

  View details for PubMedID 37665543

• Team Communication and Expectations Following Pediatric Cardiac Surgery: A Multi-Disciplinary Survey. Pediatric cardiology Bushnell, J., Connelly, C., Algaze, C. A., Bailly, D. K., Koth, A., Mafla, M., Presnell, L., Shin, A. Y., McCammond, A. N. 2022

  Abstract

  Patients and families desire an accurate understanding of the expected recovery following congenital cardiac surgery. Variation in knowledge and expectations within the care team may be under-recognized and impact communication and care delivery. Our objective was to assess knowledge of common postoperative milestones and perceived efficacy of communication with patients and families and within the care team. An 18-question survey measuring knowledge of expected milestones for recovery after four index operations and team communication in the postoperative period was distributed electronically to multidisciplinary care team members at 16 academic pediatric heart centers. Answers were compared to local median data for each respondent's heart center to assess accuracy and stratified by heart center role and years of experience. We obtained 874 responses with broad representation of disciplines. More than half of all respondent predictions (55.3%) did not match their local median data. Percent matching did not vary by care team role but improved with increasing experience (35.8%<2years vs. 46.4%>10years, p=0.2133). Of all respondents, 62.7% expressed confidence discussing the anticipated postoperative course, 78.6% denoted confidence discussing postoperative complications, and 55.3% conveyed that not all members of their care team share a common expectation for typical postoperative recovery. Most respondents (94.6%) stated that increased knowledge of local data would positively impact communication. Confidence in communication exceeded accuracy in predicting the timing of postoperative milestones. Important variation in knowledge and expectations for postoperative recovery in pediatric cardiac surgery exists and may impact communication and clinical effectiveness.

  View details for DOI 10.1007/s00246-022-03059-9

  View details for PubMedID 36436004

• Criteria for Early Pacemaker Implantation in Patients With Postoperative Heart Block After Congenital Heart Surgery. Circulation. Arrhythmia and electrophysiology Duong, S. Q., Shi, Y., Giacone, H., Navarre, B., Gal, D., Han, B., Sganga, D., Ma, M., Reddy, C. D., Shin, A., Kwiatkowski, D. M., Dubin, A. M., Scheinker, D., Algaze, C. A. 2022: e011145

  Abstract

  Guidelines recommend observation for atrioventricular node recovery until postoperative days (POD) 7 to 10 before permanent pacemaker placement (PPM) in patients with heart block after congenital cardiac surgery. To aid in surgical decision-making for early PPM, we established criteria to identify patients at high risk of requiring PPM.We reviewed all cases of second degree and complete heart block (CHB) on POD 0 from August 2009 through December 2018. A decision tree model was trained to predict the need for PPM amongst patients with persistent CHB and prospectively validated from January 2019 through March 2021. Separate models were developed for all patients on POD 0 and those without recovery by POD 4.Of the 139 patients with postoperative heart block, 68 required PPM. PPM was associated with older age (3.2 versus 1.0 years; P=0.018) and persistent CHB on POD 0 (versus intermittent CHB or second degree heart block; 87% versus 58%; P=0.001). Median days [IQR] to atrioventricular node recovery was 2 [0-5] and PPM was 9 [6-11]. Of the 100 cases of persistent CHB (21 in the validation cohort), 59 (59%) required PPM. A decision tree model identified 4 risk factors for PPM in patients with persistent CHB: (1) aortic valve replacement, subaortic stenosis repair, or Konno procedure; (2) ventricular L-looping; (3) atrioventricular valve replacement; (4) and absence of preoperative antiarrhythmic agent (in POD 0 model only). The POD 4 model specificity was 0.89 [0.67-0.99] and positive predictive value was 0.94 [95% CI 0.81-0.98], which was stable in prospective validation (positive predictive value 1.0).A data-driven analysis led to actionable criteria to identify patients requiring PPM. Patients with left ventricular outflow tract surgery, atrioventricular valve replacement, or ventricular L-Looping could be considered for PPM on POD 4 to reduce risks of temporary pacing and improve care efficiency.

  View details for DOI 10.1161/CIRCEP.122.011145

  View details for PubMedID 36306332

• Predictive Ability of the Braden QD Scale for Hospital-Acquired Venous Thromboembolism in Hospitalized Children JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Gonzalez, A., Mulet, Y., Song, N., Loh, L., Scheinker, D., Shin, A. Y., Donnelly, L. F. 2022; 48 (10): 513-520

  Abstract

  Hospital-acquired venous thromboembolisms (HA-VTEs) are increasingly common in pediatric inpatients and associated with significant morbidity and cost. The Braden QD Scale was created to predict the risk of hospital-acquired pressure injury (HAPI) and is used broadly in children's hospitals. This study evaluated the ability of the Braden QD Total score to predict risk of HA-VTE at a quaternary children's hospital.To analyze the predictive potential of the Braden QD Total score and subscores for HA-VTEs, the researchers performed univariate logistic regressions. The increase in a patient's odds of developing an HA-VTE for every 1-point increase in each Braden QD score was evaluated. Each model was evaluated using a 5-fold cross-validated area-under-the-curve of the corresponding receiver operating characteristic curve (AUROC).This study analyzed 27,689 pediatric inpatients. HA-VTE occurred in 135 patients. The odds of HA-VTE incidence increased by 29% (odds ratio 1.29, 95% confidence interval [CI] 1.25-1.34, p < 0.001) for every 1-point increase in a patient's Braden QD Total score. The AUROC was 0.81 (95% CI 0.77-0.85).The Braden QD Scale is a predictor for HA-VTE, outperforming its original intended use for predicting HAPI and performing similarly to other HA-VTE predictive models. As the Braden QD Total score is currently recorded in the electronic health records of many children's hospitals, it could be practically and easily implemented as a tool to predict which patients are at risk for HA-VTE.

  View details for DOI 10.1016/j.jcjq.2022.05.007

  View details for Web of Science ID 000873971100004

  View details for PubMedID 35963770

• Age at surgery and outcomes following neonatal cardiac surgery: An analysis from the Pediatric Cardiac Critical Care Consortium. The Journal of thoracic and cardiovascular surgery Smith, A. H., Shin, A. Y., Tabbutt, S., Banerjee, M., Zhang, W., Borasino, S., Elhoff, J. J., Gaynor, J. W., Ghanayem, N. S., Pasquali, S. K., St Louis, J. D., Shashidharan, S., Ruppe, M., Schumacher, K. R., Gaies, M., Costello, J. M. 2022

  Abstract

  The optimal timing for neonatal cardiac surgery is a potentially modifiable factor that may affect outcomes. We studied the relationship between age at surgery (AAS) and outcomes across multiple hospitals, focusing on neonatal operations where timing appears is not emergency.We studied neonates ≥37 weeks' gestation and ≥2.5 kg admitted to a treating hospital on or before day of life 2 undergoing selected index cardiac operations. The impact of AAS on outcomes was evaluated across the entire cohort and a standard risk subgroup (ie, free of preoperative mechanical ventilation, mechanical circulatory support, or other organ failure). Outcomes included mortality, major morbidity (ie, cardiac arrest, mechanical circulatory support, unplanned cardiac reintervention, or neurologic complication), and postoperative cardiac intensive care unit and hospital length of stay. Post hoc analyses focused on operations undertaken between day of life 2 and 7.We studied 2536 neonates from 47 hospitals. AAS from day of life 2 through 7 was not associated with risk adjusted mortality or major morbidity among the entire cohort and the standard risk subgroup. Older AAS, although associated with modest increases in postoperative cardiac intensive care unit and hospital length of stay in the entire cohort, was not associated with hospital length of stay in the standard risk subgroup.Among select nonemergency neonatal cardiac operations, AAS between day of life 2 and 7 was not found to be associated with risk adjusted mortality or major morbidity. Although delays in surgical timing may modestly increase preoperative resource use, studies of AAS and outcomes not evident at the time of discharge are needed.

  View details for DOI 10.1016/j.jtcvs.2022.05.029

  View details for PubMedID 35760618

• Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard. Applied clinical informatics Safranek, C. W., Feitzinger, L., Joyner, A. K., Woo, N., Smith, V., Souza, E. D., Vasilakis, C., Anderson, T. A., Fehr, J., Shin, A. Y., Scheinker, D., Wang, E., Xie, J. 2022; 13 (2): 370-379

  Abstract

  BACKGROUND: Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers.OBJECTIVES: This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data.METHODS: We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation.RESULTS: The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data.CONCLUSION: A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

  View details for DOI 10.1055/s-0042-1744387

  View details for PubMedID 35322398

• Performance of a Commonly Used Pressure Injury Risk Model Under Changing Incidence JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Fleming, S., McFarlane, K., Thapa, I., Johnson, A. K., Kruger, J. F., Shin, A. Y., Scheinker, D., Donnelly, L. F. 2022; 48 (3): 131-138

  Abstract

  Hospital-acquired pressure injuries (HAPIs) cause patient harm and increase health care costs. We sought to evaluate the performance of the Braden QD Scale-associated changes in HAPI incidence.Using electronic health records data from a quaternary children's hospital, we evaluated the association between Braden QD scores and patient risk of HAPI. We analyzed how this relationship changed during a hospitalwide quality HAPI reduction initiative.Of 23,532 unique patients, 108 (0.46%, 95% confidence interval [CI] = 0.38%-0.55%) experienced a HAPI. Every 1-point increase in the Braden QD score was associated with a 41% increase in the patient's odds of developing a HAPI (odds ratio [OR] = 1.41, 95% CI = 1.36-1.46, p < 0.001). HAPI incidence declined significantly following implementation of a HAPI-reduction initiative (β = -0.09, 95% CI = -0.11 - -0.07, p < 0.001), as did Braden QD positive predictive value (β = -0.29, 95% CI = -0.44 - -0.14, p < 0.001) and specificity (β = -0.28, 95% CI = -0.43 - -0.14, p < 0.001), while sensitivity (β = 0.93, 95% CI = 0.30-1.75, p = 0.01) and the concordance statistic (β = 0.18, 95% CI = 0.15-0.21, p < 0.001) increased significantly.Decreases in HAPI incidence following a quality improvement initiative were associated with (1) significant deterioration in threshold-dependent performance measures such as specificity and precision and (2) significant improvements in threshold-independent performance measures such as the concordance statistic. The performance of the Braden QD Scale is more stable as a tool that continuously measures risk than as a prediction tool.

  View details for DOI 10.1016/j.jcjq.2021.10.008

  View details for Web of Science ID 000763291600002

  View details for PubMedID 34866024

• Post-operative Morbidity and Mortality After Fontan Procedure in Patients with Heterotaxy and Other Situs Anomalies. Pediatric cardiology Duong, S. Q., Zaniletti, I., Lopez, L., Sutherland, S. M., Shin, A. Y., Collins, R. T. 1800

  Abstract

  Heterotaxy is a complex, multisystem disorder associated with single ventricle heart disease and decreased survival. Ciliary dysfunction is common in heterotaxy and other situs abnormalities (H/SA) and may increase post-operative complications. We hypothesized that patients with H/SA have increased respiratory and renal morbidities and increased in-hospital mortality after Fontan procedure. We queried the Pediatric Health Information System database for hospitalizations with ICD-9/10 codes for Fontan procedure in patients aged 1 through 11years from 2004 to 2019. H/SA was identified by codes for dextrocardia, situs inversus, asplenia/polysplenia, or atrial isomerism and compared to non-H/SA controls. Outcomes were in-hospital mortality or heart transplantation, ECMO, hemodialysis, length of stay (LOS), and mechanical ventilation or vasoactive medication use≥4days. We adjusted estimates with multivariable logistic regression. Of 7897 patients at 50 centers, 1366 (17%) met criteria for H/SA. H/SA had worse outcomes for all study measures: death/transplantation (1.9 vs 1.1%, OR 1.74 (95% CI 1.01-3.03); p=0.047), ECMO (3.7 vs 2.3%, OR 1.74 (1.28-2.35); p<0.001), hemodialysis (2.1 vs 1.2%, OR 1.66 (1.06-2.59); p=0.026), prolonged mechanical ventilation (13.2% vs 7.6%, OR 1.85 (1.53-2.25); p<0.001) and vasoactive medication use (29.4 vs 19.7%, OR 1.65 (1.43-1.90), and longer LOS (11 (8-17) vs 9 (7-14) days; p<0.001). H/SA is associated with increased cardiovascular, renal, and respiratory morbidity, as well as in-hospital mortality after Fontan procedure. Attention to renal and respiratory needs may improve outcomes in this difficult population. The relationship between ciliary dysfunction and lung and renal morbidity should be explored further.

  View details for DOI 10.1007/s00246-021-02804-w

  View details for PubMedID 35064275

• Leadership and professional development: Creating a culture of collaboration and growth JOURNAL OF HOSPITAL MEDICINE Patel, M. D., Shin, A. 2022

  View details for DOI 10.1002/jhm.2729

  View details for Web of Science ID 000742207600001

• Leadership & professional development: Creating a culture of collaboration and growth. Journal of hospital medicine Patel, M. D., Shin, A. 2022; 17 (1): 42-43

  View details for DOI 10.1002/jhm.2729

  View details for PubMedID 35504495

• Workforce demographics and unit structure in paediatric cardiac critical care in the United States. Cardiology in the young Horak, R. V., Bai, S., Marino, B. S., Werho, D. K., Rhodes, L. A., Costello, J. M., Cabrera, A. G., Cooper, D. S., Tan, Y., Tabbutt, S., Krawczeski, C. D. 2021: 1-5

  Abstract

  OBJECTIVE: To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States.DESIGN: REDCap surveys were sent by email from May till August 2019 to medical directors ("directors") of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure.MEASUREMENTS AND MAIN RESULTS: Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%).CONCLUSIONS: Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

  View details for DOI 10.1017/S1047951121004753

  View details for PubMedID 34857058

• Early Functional Status After Surgery for Congenital Heart Disease: A Single-Center Retrospective Study. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Han, B., Yang, J. K., Ling, A. Y., Ma, M., Kipps, A. K., Shin, A. Y., Beshish, A. G. 2021

  Abstract

  OBJECTIVES: The objective of this study is to investigate the change in functional status in infants, children, and adolescents undergoing congenital heart surgery using the Functional Status Scale.DESIGN: A single-center retrospective study.SETTING: A 26-bed cardiac ICU in a free-standing university-affiliated tertiary children's hospital.PATIENTS: All patients 0-18 years who underwent congenital heart surgery from January 1, 2014, to December 31, 2017.INTERVENTIONS: None.MEASUREMENTS AND MIN RESULTS: The primary outcome variable was change in Functional Status Scale scores from admission to discharge. Additionally, two binary outcomes were derived from the primary outcome: new morbidity (change in Functional Status Scale ≥ 3) and unfavorable functional outcome (change in Functional Status Scale ≥ 5); their association with risk factors was assessed using modified Poisson regression. Out of 1,398 eligible surgical encounters, 65 (4.6%) and 15 (1.0%) had evidence of new morbidity and unfavorable functional outcomes, respectively. Higher Surgeons Society of Thoracic and the European Association for Cardio-Thoracic Surgery score, single-ventricle physiology, and longer cardiopulmonary bypass time were associated with new morbidity. Longer hospital length of stay was associated with both new morbidity and unfavorable outcome.CONCLUSIONS: This study demonstrates the novel application of the Functional Status Scale on patients undergoing congenital heart surgery. New morbidity was noted in 4.6%, whereas unfavorable outcome in 1%. There was a small change in the total Functional Status Scale score that was largely attributed to changes in the feeding domain. Higher Society of Thoracic and the European Association for Cardio-Thoracic Surgery score, single-ventricle physiology, and longer cardiopulmonary bypass times were associated with new morbidity, whereas longer hospital length of stay was associated with both new morbidity and unfavorable outcome. Further studies with larger sample size will need to be done to confirm our findings and to better ascertain the utility of Functional Status Scale on this patient population.

  View details for DOI 10.1097/PCC.0000000000002838

  View details for PubMedID 34593740

• Standardized Training for Physicians Practicing Pediatric Cardiac Critical Care. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Tabbutt, S., Krawczeski, C., McBride, M., Amirnovin, R., Owens, G., Smith, A., Wolf, M., Rhodes, L., Hehir, D., Asija, R., Teele, S. A., Ghanayem, N., Zyblewski, S., Thiagarajan, R., Yeh, J., Shin, A. Y., Schwartz, S. M., Schuette, J., Scahill, C., Roth, S. J., Hoffman, T. M., Cooper, D. S., Byrnes, J., Bergstrom, C., Vesel, T., Scott, J. P., Rossi, A., Kwiatkowski, D., DiPietro, L. M., Connor, C., Chen, J., Charpie, J., Bochkoris, M., Affolter, J., Bronicki, R. A. 2021

  Abstract

  OBJECTIVES: In the vast majority of Children's Hospitals, the critically ill patient can be found in one of three locations: the PICU, the neonatal ICU, and the cardiac ICU. Training, certification, and maintenance of certification for neonatology and critical care medicine are over seen by the Accreditation Council for Graduate Medical Education and American Board of Pediatrics. There is no standardization of training or oversight of certification and maintenance of certification for pediatric cardiac critical care.DATA SOURCES: The curricula from the twenty 4th year pediatric cardiac critical care training programs were collated, along with the learning objectives from the Pediatric Cardiac Intensive Care Society published "Curriculum for Pediatric Cardiac Critical Care Medicine."STUDY SELECTION: This initiative is endorsed by the Pediatric Cardiac Intensive Care Society as a first step toward Accreditation Council for Graduate Medical Education oversight of training and American Board of Pediatrics oversight of maintenance of certification.DATA EXTRACTION: A taskforce was established of cardiac intensivists, including the directors of all 4th year pediatric cardiac critical care training programs.DATA SYNTHESIS: Using modified Delphi methodology, learning objectives, rotational requirements, and institutional requirements for providing training were developed.CONCLUSIONS: In the current era of increasing specialized care in pediatric cardiac critical care, standardized training for pediatric cardiac critical care is paramount to optimizing outcomes.

  View details for DOI 10.1097/PCC.0000000000002815

  View details for PubMedID 34554132

• Role of Texting as a Source of Cognitive Burden in a Pediatric Cardiovascular ICU. Hospital pediatrics Han, B., Gal, D. B., Mafla, M., Sacks, L. D., Singh, A. T., Shin, A. Y. 2021

  Abstract

  OBJECTIVES: To characterize frontline provider perception of clinical text messaging and quantify clinical texting data in a pediatric cardiovascular ICU (CICU).METHODS: This is a mixed-methods, retrospective single center study. A survey of frontline CICU providers (pediatric fellows, nurse practitioners, and physician assistants) was conducted to assess attitudes characterizing text messaging on cognitive burden. Text messaging data were abstracted and quantified between January 29, 2020, and April 18, 2020, and the patterns of text messages were analyzed per shift and by provider.RESULTS: The survey was completed by 33 of 39 providers (85%). Out of responders, 78% indicated that clinical text messaging frequently or very frequently disrupts critical thinking and workflow. They also felt that the burden of messages was worse during the night shift. Through abstraction, 31926 text messages were identified. A median of 15 (interquartile range: 12-19) messages per hour were received. A median of 5 messages were received per hour per provider during the day shift and 6 during the night shift. From the entire study period, there were total 2 hours of high-frequency texting (≥15 texts per hour) during the day shift and 68 hours during the night shift.CONCLUSION: In our study, providers in the CICU received a large number of texts with a disproportionate burden during the night shift. Text messages are a potential source of cognitive overload for providers. Optimization of text messaging may be needed to mitigate cognitive burden for frontline providers.

  View details for DOI 10.1542/hpeds.2021-005869

  View details for PubMedID 34497133

• Effect of Time of Daily Data Collection on the Calculation of Catheter-associated Urinary Tract Infection Rates. Pediatric quality & safety Donnelly, L. F., Wood, M., Loh, L., Tekic, N., Shin, A. Y., Scheinker, D. 2021; 6 (5): e466

  Abstract

  Introduction: According to the National Healthcare Safety Network (NHSN) definitions for Catheter-associated urinary tract infections (CAUTI) rates, determination of the number of urinary catheter days must occur by calculating the number of catheters in place "for each day of the month, at the same time of day" but does not define at what time of day this occurs. The purpose of this review was to determine if a data collection time of 11 am would yield a greater collection of urinary catheter days than that done at midnight.Methods: During a 20-month period, the number of urinary catheter days was calculated using once-a-day electronic measurements to identify a urinary catheter presence. We used data collected at 11 am and collected at midnight (our historic default) in comparing the calculated urinary catheter days and resultant CAUTI rates.Results: There were 7,548 patients who had a urinary tract catheter. The number of urinary catheter days captured using the 11 am collection time was 15,425, and using the midnight collection time was 10,234, resulting in a 50.7% increase. The CAUTI rate per 1,000 urinary catheter days calculated using the 11 am collection method was 0.58, and using the midnight collection method was 0.88, a reduced CAUTI rate of 33.6%.Conclusion: The data collection time can significantly impact the calculation of urinary catheter days and on calculated CAUTI rates. Variations in how healthcare systems define their denominator per current National Healthcare Safety Network policy may result in significant differences in reported rates.

  View details for DOI 10.1097/pq9.0000000000000466

  View details for PubMedID 34476317

• Development and Implementation of a Real-time Bundle-adherence Dashboard for Central Line-associated Bloodstream Infections. Pediatric quality & safety Chemparathy, A., Seneviratne, M. G., Ward, A., Mirchandani, S., Li, R., Mathew, R., Wood, M., Shin, A. Y., Donnelly, L. F., Scheinker, D., Lee, G. M. 2021; 6 (4): e431

  Abstract

  Introduction: Central line-associated bloodstream infections (CLABSIs) are the most common hospital-acquired infection in pediatric patients. High adherence to the CLABSI bundle mitigates CLABSIs. At our institution, there did not exist a hospital-wide system to measure bundle-adherence. We developed an electronic dashboard to monitor CLABSI bundle-adherence across the hospital and in real time.Methods: Institutional stakeholders and areas of opportunity were identified through interviews and data analyses. We created a data pipeline to pull adherence data from twice-daily bundle checks and populate a dashboard in the electronic health record. The dashboard was developed to allow visualization of overall and individual element bundle-adherence across units. Monthly dashboard accesses and element-level bundle-adherence were recorded, and the nursing staff's feedback about the dashboard was obtained.Results: Following deployment in September 2018, the dashboard was primarily accessed by quality improvement, clinical effectiveness and analytics, and infection prevention and control. Quality improvement and infection prevention and control specialists presented dashboard data at improvement meetings to inform unit-level accountability initiatives. All-element adherence across the hospital increased from 25% in September 2018 to 44% in December 2019, and average adherence to each bundle element increased between 2018 and 2019.Conclusions: CLABSI bundle-adherence, overall and by element, increased across the hospital following the deployment of a real-time electronic data dashboard. The dashboard enabled population-level surveillance of CLABSI bundle-adherence that informed bundle accountability initiatives. Data transparency enabled by electronic dashboards promises to be a useful tool for infectious disease control.

  View details for DOI 10.1097/pq9.0000000000000431

  View details for PubMedID 34235355

• Quantifying Pediatric Intensive Care Unit Staffing Levels at a Pediatric Academic Medical Center: A Mixed Methods Approach. Journal of nursing management Ostberg, N., Ling, J., Winter, S. G., Som, S., Vasilakis, C., Shin, A. Y., Cornell, T. T., Scheinker, D. 2021

  Abstract

  AIM: Identify, simulate, and evaluate the formal and informal patient-level and unit-level factors that nurse managers use to determine the number of nurses for each shift.BACKGROUND: Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last-minute adjustments or inappropriate staffing levels.METHODS: Staffing schedules at a pediatric intensive care unit (PICU) were simulated based on nurse-to-patient assignment rules from interviews with nursing management. Multivariate regression modeled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels.RESULTS: Nurse-to-patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift.CONCLUSION: Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand.IMPLICATIONS FOR NURSING MANAGEMENT: Data-driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last-minute adjustments.

  View details for DOI 10.1111/jonm.13346

  View details for PubMedID 33894027

• Quantifying Electronic Health Record Data: A Potential Risk for Cognitive Overload. Hospital pediatrics Gal, D. B., Han, B., Longhurst, C., Scheinker, D., Shin, A. Y. 2021

  Abstract

  OBJECTIVES: To quantify and describe patient-generated health data.METHODS: This is a retrospective, single-center study of patients hospitalized in the pediatric cardiovascular ICU between February 1, 2020, and February 15, 2020. The number of data points generated over a 24-hour period per patient was collected from the electronic health record. Data were analyzed by type, and frontline provider exposure to data was extrapolated on the basis of patient-to-provider ratios.RESULTS: Thirty patients were eligible for inclusion. Nineteen were hospitalized after cardiac surgery, whereas 11 were medical patients. Patients generated an average of 1460 (SD 509) new data points daily, resulting in frontline providers being presented with an average of 4380 data points during a day shift (7:00 am to 7:00 pm). Overnight, because of a higher patient-to-provider ratio, frontline providers were exposed to an average of 16060 data points. There was no difference in data generation between medical and surgical patients. Structured data accounted for >80% of the new data generated.CONCLUSIONS: Health care providers face significant generation of new data daily through the contemporary electronic health record, likely contributing to cognitive burden and putting them at risk for cognitive overload. This study represents the first attempt to quantify this volume in the pediatric setting. Most data generated are structured and amenable to data-optimization systems to mitigate the potential for cognitive overload and its deleterious effects on patient safety and health care provider well-being.

  View details for DOI 10.1542/hpeds.2020-002402

  View details for PubMedID 33500357

• Hyperoxia During Cardiopulmonary Bypass Is Associated With Mortality in Infants Undergoing Cardiac Surgery. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Beshish, A. G., Jahadi, O., Mello, A., Yarlagadda, V. V., Shin, A. Y., Kwiatkowski, D. M. 2021

  Abstract

  OBJECTIVES: Patients undergoing cardiac surgery using cardiopulmonary bypass have variable degrees of blood oxygen tension during surgery. Hyperoxia has been associated with adverse outcomes in critical illness. Data are not available regarding the association of hyperoxia and outcomes in infants undergoing cardiopulmonary bypass. We hypothesize that among infants undergoing cardiac surgery, hyperoxia during cardiopulmonary bypass is associated with greater odds of morbidity and mortality.DESIGN: Retrospective study.SETTING: Single center at an academic tertiary children's hospital.PATIENTS: All infants (< 1 yr) undergoing cardiopulmonary bypass between January 1, 2015, and December 31, 2017, excluding two patients who were initiated on extracorporeal membrane oxygenation in the operating room.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The study included 469 infants with a median age of 97 days (interquartile range, 14-179 d), weight 4.9 kg (interquartile range, 3.4-6.4 kg), and cardiopulmonary bypass time 128 minutes (interquartile range, 91-185 min). A PaO2 of 313 mm Hg (hyperoxia) on cardiopulmonary bypass had highest sensitivity with specificity greater than 50% for association with operative mortality. Approximately, half of the population (237/469) had hyperoxia on cardiopulmonary bypass. Infants with hyperoxia were more likely to have acute kidney injury, prolonged postoperative length of stay, and mortality. They were younger, weighed less, had longer cardiopulmonary bypass times, and had higher Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery mortality scores. There was no difference in sex, race, preoperative creatinine, single ventricle physiology, or presence of genetic syndrome. On multivariable analysis, hyperoxia was associated with greater odds of mortality (odds ratio, 4.3; 95% CI, 1.4-13.2) but failed to identify an association with acute kidney injury or prolonged postoperative length of stay. Hyperoxia was associated with greater odds of mortality in subgroup analysis of neonatal patients.CONCLUSIONS: Hyperoxia occurred in a substantial portion of infants undergoing cardiopulmonary bypass for cardiac surgery. Hyperoxia during cardiopulmonary bypass was an independent risk factor for mortality and may be a modifiable risk factor. Furthermore, hyperoxia during cardiopulmonary bypass was associated with four-fold greater odds of mortality within 30 days of surgery. Hyperoxia failed to identify an association with development of acute kidney injury or prolonged postoperative length of stay when controlling for covariables. Validation of our data among other populations is necessary to better understand and elucidate potential mechanisms underlying the association between excess oxygen delivery during cardiopulmonary bypass and outcome.

  View details for DOI 10.1097/PCC.0000000000002661

  View details for PubMedID 33443979

• Assessment of physician training and prediction of workforce needs in paediatric cardiac intensive care in the United States. Cardiology in the young Horak, R. V., Marino, B. S., Werho, D. K., Rhodes, L. A., Costello, J. M., Cabrera, A. G., Cooper, D. S., Bai, S., Tabbutt, S., Rao, I., Scheinker, D., Shin, A. Y., Krawczeski, C. D. 2021: 1-6

  Abstract

  To assess the training and the future workforce needs of paediatric cardiac critical care faculty.REDCap surveys were sent May-August 2019 to medical directors and faculty at the 120 US centres participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database. Faculty and directors were asked about personal training pathway and planned employment changes. Directors were additionally asked for current faculty numbers, expected job openings, presence of training programmes, and numbers of trainees. Predictive modelling of the workforce was performed using respondents' data. Patient volume was projected from US Census data and compared to projected provider availability.Sixty-six per cent (79/120) of directors and 62% (294/477) of contacted faculty responded. Most respondents had training that incorporated critical care medicine with the majority completing training beyond categorical fellowship. Younger respondents and those in dedicated cardiac ICUs were more significantly likely to have advanced training or dual fellowships in cardiology and critical care medicine. An estimated 49-63 faculty enter the workforce annually from various training pathways. Based on modelling, these faculty will likely fill current and projected open positions over the next 5 years.Paediatric cardiac critical care training has evolved, such that the majority of faculty now have dual fellowship or advanced training. The projected number of incoming faculty will likely fill open positions within the next 5 years. Institutions with existing or anticipated training programmes should be cognisant of these data and prepare graduates for an increasingly competitive market.

  View details for DOI 10.1017/S1047951121004893

  View details for PubMedID 34924098

• "Echo pause" for postoperative transthoracic echocardiographic surveillance. Echocardiography (Mount Kisco, N.Y.) Cox, K., Arunamata, A., Krawczeski, C. D., Reddy, C., Kipps, A. K., Long, J., Roth, S. J., Axelrod, D. M., Hanley, F., Shin, A., Selamet Tierney, E. S. 2019

  Abstract

  BACKGROUND: No guidelines exist for inpatient postoperative transthoracic echocardiographic (TTE) surveillance in congenital heart disease. We prospectively evaluated indications for postoperative TTEs in patients with congenital heart disease to identify areas to improve upon (Phase 1) and then assessed the impact of a simple pilot intervention (Phase 2).METHODS: We included patients with RACHS-1 (Risk Adjustment for Congenital Heart Surgery) scores of 2 and 3 to keep the cohort homogenous. During Phase 1, we collected data prospectively to identify postoperative TTEs for which there were no new findings and no associated clinical management decisions ("potentially redundant" TTEs). During Phase 2, prior to placement of a TTE order, an "Echo Pause" was performed during rounds to prompt review of prior TTE results and indication for the current order. The number of "potentially redundant" TTEs during Phase 1 vs. Phase 2 was compared.RESULTS: During Phase 1, 98 postoperative TTEs were performed on 51 patients. Potentially "redundant" TTEs were identified in two main areas: (a) TTEs ordered to evaluate pericardial effusion and (b) TTEs ordered with the indication of "postoperative," "follow-up," or "discharge" in the setting of a prior complete postoperative TTE and no apparent change in clinical status. During Phase 2, 101 TTEs were performed on 63 patients. The number of "potentially redundant" TTEs decreased from 14/98 (14%) to 5/101 (5%) (P=.026).CONCLUSION: Our results suggest that the number of "potentially redundant" TTEs during inpatient postoperative surveillance of patients with congenital heart disease can be decreased by a simple intervention during rounds such as an "Echo Pause."

  View details for DOI 10.1111/echo.14505

  View details for PubMedID 31628768

• A Quality Bundle to Support High-Risk Pediatric Ventricular Assist Device Implantation. Pediatric cardiology Knoll, C., Chen, S., Murray, J. M., Dykes, J. C., Yarlagadda, V. V., Rosenthal, D. N., Almond, C. S., Maeda, K., Shin, A. Y. 2019

  Abstract

  Pediatric ventricular assist device (VAD) implantation outcomes are increasingly promising for children with dilated cardiomyopathy and advanced decompensated heart failure (ADHF). VAD placement in patients with clinical features such as complex congenital cardiac anatomy, small body size, or major comorbidities remains problematic. These comorbidities have been traditionally prohibitive for VAD consideration leaving these children as a treatment-orphaned population. Here we describe the quality bundle surrounding these patients with ADHF considered high risk for VAD implantation at our institution. Over a 7-year period, a quality bundle aimed at the peri-operative care for children with high-risk features undergoing VAD implantation was incrementally implemented at a tertiary children's hospital. Patients were considered high risk if they were neonates (<30days), had single-ventricle physiology, non-dilated cardiomyopathy, biventricular dysfunction, or significant comorbidities. The quality improvement bundle evolved to include (1) structured team-based peri-operative evaluation, (2) weekly VAD rounds addressing post-operative device performance, (3) standardized anticoagulation strategies, and (4) a multidisciplinary system for management challenges. These measures aimed to improve communication, standardize management, allow for ongoing process improvement, and incorporate principles of a high-reliability organization. Between January 2010 and December 2017, 98 patients underwent VAD implantation, 48 (49%) of which had high-risk comorbidities and a resultant cohort survival-to-transplant rate of 65%. We report on the evolution of a quality improvement program to expand the scope of VAD implantation to patients with high-risk clinical profiles. This quality bundle can serve as a template for future large-scale collaborations to improve outcomes in these treatment-orphaned subgroups.

  View details for DOI 10.1007/s00246-019-02123-1

  View details for PubMedID 31087144

• The authors reply. Critical care medicine Smith, A. H., Anand, V., Banerjee, M., Bates, K. E., Brunetti, M. A., Cooper, D. S., Lehrich, J., Mistry, K. P., Pasquali, S. K., Shin, A. Y., Tabbutt, S., Gaies, M. 2019; 47 (3): e268–e269

  View details for PubMedID 30768518

• Younger age remains a risk factor for prolonged length of stay after bidirectional cavopulmonary anastomosis. Cardiology in the young Koth, A. M., Algaze, C. A., Sakarovitch, C., Long, J., Kamra, K., Wright, G. E., Alexander-Banys, B., Maeda, K., Shin, A. Y. 2019: 1–6

  Abstract

  OBJECTIVE: This study sets out to determine the influence of age at the time of surgery as a risk factor for post-operative length of stay after bidirectional cavopulmonary anastomosis.METHODS: All patients undergoing a Glenn procedure between January 2010 and July 2015 were included in this retrospective cohort study. Demographic data were examined. Standard descriptive statistics was used. A univariable analysis was conducted using the appropriate test based on data distribution. A propensity score for balancing the group difference was included in the multi-variable analysis, which was then completed using predictors from the univariable analysis that achieved significance of p<0.1.RESULTS: Over the study period, 50 patients met the inclusion criteria. Patients were separated into two cohorts of ⩾4 months (28 patients) and <4 months (22 patients). Other than height and weight, the two cohorts were indistinguishable in their pre-operative saturation, medications, catheterisation haemodynamics, atrioventricular valve regurgitation, and ventricular function. After adjusting group differences, younger age was associated with longer post-operative length of hospitalisation - adjusted mean 15 (±2.53) versus 8 (±2.15) days (p=0.03). In a multi-variable regression analysis, in addition to ventricular dysfunction (beta coefficient=8.8, p=0.05), Glenn procedures performed before 4 months were independently associated with longer length of stay (beta coefficient=-6.9, p=0.03).CONCLUSION: We found that Glenn procedures performed after 4 months of age had shorter post-operative length of stay when compared to a younger cohort. These findings suggest that balancing timing of surgery to decrease the inter-stage period should take into consideration differences in post-operative recovery with earlier operations.

  View details for PubMedID 30698131

• LEVERAGING AGGREGATE DATA AT THE POINT OF CARE REDUCES VARIATION FOR PEDIATRIC NEUROSURGERY PATIENTS Steffen, K., Su, F., Algaze, C., Duethman, L., Jacobs, K., Casazza, M., Chantra, J., Loh, L., Shin, A., Grant, G. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000498593401642

• Sacrificing the Future for the Sake of the Present. Annals of surgery Collins, R. T., Shin, A. Y., Hanley, F. L. 2019

  View details for DOI 10.1097/SLA.0000000000003432

  View details for PubMedID 31425297

• Creating a Defined Process to Improve the Timeliness of Serious Safety Event Determination and Root Cause Analysis. Pediatric quality & safety Donnelly, L. F., Palangyo, T. n., Bargmann-Losche, J. n., Rogers, K. n., Wood, M. n., Shin, A. Y. 2019; 4 (5): e200

  Abstract

  Serious Safety Events (SSEs) are defined as events in which there is a deviation from clinically accepted performance standards, causation, and significant patient harm or death. Given the nature of SSEs, it is important that the processes for declaration of SSEs, the performance of a root cause analysis (RCA), and action plan formation occur quickly, such that the window for potential recurrence of similar events is as small as possible. This manuscript describes a process put in place to improve the timeliness of SSE determination and RCA conduction and evaluates the effect of the process change on these parameters.A causal analysis was performed of the baseline process to determine factors contributing to long process times. A new process was created and implemented both for the SSE determination process and the RCA completion process. We calculated the mean time for the pre-implementation phase (April 2016-December 2017) and the post-implementation phase (March 2018-January 2019) for both SSE determination and RCA completion. We evaluated differences with a two-sided t test assuming unequal variances.Comparing pre- versus post- implementation phases, the mean time for SSE determination for events that met the SSE criteria decreased from 38.4 to 4.8 days (P < 0.0001), determination for events that did not meet the SSE criteria decreased from 38.4 to 3.8 days (P < 0.0001), and RCA completion time dropped from 118.0 to 26.2 days (P < 0.0001).A targeted intervention can significantly reduce SSE determination and RCA conduction times.

  View details for DOI 10.1097/pq9.0000000000000200

  View details for PubMedID 31745504

  View details for PubMedCentralID PMC6831051

• Birth Location of Infants with Critical Congenital Heart Disease in California. Pediatric cardiology Purkey, N. J., Axelrod, D. M., McElhinney, D. B., Rigdon, J., Qin, F., Desai, M., Shin, A. Y., Chock, V. Y., Lee, H. C. 2018

  Abstract

  The American Academy of Pediatrics classifies neonatal intensive care units (NICUs) from level I to IV based on the acuity of care each unit can provide. Birth in a higher level center is associated with lower morbidity and mortality in high-risk populations. Congenital heart disease accounts for 25-50% of infant mortality related to birth defects in the U.S., but recent data are lacking on where infants with critical congenital heart disease (CCHD) are born. We used a linked dataset from the Office of Statewide Health Planning and Development to access ICD-9 diagnosis codes for all infants born in California from 2008 to 2012. We compared infants with CCHD to the general population, identified where infants with CCHD were born based on NICU level of care, and predicted level IV birth among infants with CCHD using logistic regression techniques. From 2008 to 2012, 6325 infants with CCHD were born in California, with 23.7% of infants with CCHD born at a level IV NICU compared to 8.4% of the general population. Level IV birth for infants with CCHD was associated with lower gestational age, higher maternal age and education, the presence of other congenital anomalies, and the diagnosis of a single ventricle lesion. More infants with CCHD are born in a level IV NICU compared to the general population. Future studies are needed to determine if birth in a lower level of care center impacts outcomes for infants with CCHD.

  View details for PubMedID 30415381

• Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program. Pediatric quality & safety Algaze, C. A., Shin, A. Y., Nather, C., Elgin, K. H., Ramamoorthy, C., Kamra, K., Kipps, A. K., Yarlagadda, V. V., Mafla, M. M., Vashist, T., Krawczeski, C. D., Sharek, P. J. 2018; 3 (6): e115

  Abstract

  Introduction: Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children's hospital.Methods: The Lucile Packard Children's Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay.Results: Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0+0.5 versus 1.9+1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3+1.1 versus 4.6+2.1 days; P < 0.001) and postoperative length of stay (mean 5.9+1.6 versus 7.9+2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration.Conclusions: We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.

  View details for DOI 10.1097/pq9.0000000000000115

  View details for PubMedID 31334447

• Variation in Adjusted Mortality for Medical Admissions to Pediatric Cardiac ICUs. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Gaies, M., Ghanayem, N. S., Alten, J. A., Costello, J. M., Lasa, J. J., Chanani, N. K., Shin, A. Y., Retzloff, L., Zhang, W., Pasquali, S. K., Banerjee, M., Tabbutt, S. 2018

  Abstract

  OBJECTIVES: Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium.DESIGN: Observational analysis.SETTING: Pediatric Cardiac Critical Care Consortium clinical registry.PATIENTS: All cardiac ICU admissions that did not include cardiac surgery.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio <1) and one had higher-than-expected (standardized mortality ratio >1) mortality.CONCLUSIONS: We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning.

  View details for PubMedID 30371635

• Variation in Case-Mix Adjusted Unplanned Pediatric Cardiac ICU Readmission Rates. Critical care medicine Smith, A. H., Anand, V., Banerjee, M., Bates, K. E., Brunetti, M. A., Cooper, D. S., Lehrich, J., Mistry, K. P., Pasquali, S. K., Shin, A. Y., Tabbutt, S., Gaies, M. 2018

  Abstract

  OBJECTIVES: To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals DESIGN:: Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry.PATIENTS: Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48 hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both.CONCLUSIONS: This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.

  View details for PubMedID 30252712

• Diagnostic errors in paediatric cardiac intensive care CARDIOLOGY IN THE YOUNG Bhat, P. N., Costello, J. M., Aiyagari, R., Sharek, P. J., Algaze, C. A., Mazwi, M. L., Roth, S. J., Shin, A. Y. 2018; 28 (5): 675–82

  Abstract

  IntroductionDiagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU.Paediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015.The response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient's condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors.Paediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.

  View details for PubMedID 29409553

• Cost-effectiveness of Humanitarian Pediatric Cardiac Surgery Programs in Low- and Middle-Income Countries JAMA Network Open Cardarelli, M., Vaikunth, S., Mills, K., DiSessa, T., Molloy, F., Sauter, E., Bowtell, K., Rivera, R., Shin, A., Novick, W. 2018

  View details for DOI 10.1001/jamanetworkopen.2018.4707

• The Epidemiology of Health-Care Associated Infections in Pediatric Cardiac Intensive Care Units. The Pediatric infectious disease journal Alten, J. A., Rahman, A. F., Zaccagni, H. J., Shin, A., Cooper, D. S., Blinder, J. J., Retzloff, L., Aban, I. B., Graham, E. M., Zampi, J., Domnina, Y., Gaies, M. G. 2017

  Abstract

  BACKGROUND: Health-care associated infections (HAI) represent serious complications for patients within pediatric cardiac intensive care units (CICU). HAI are associated with increased morbidity, mortality, and resource utilization. There are few studies describing the epidemiology of HAI across the entire spectrum of patients (surgical and non-surgical) receiving care in dedicated pediatric CICUs.METHODS: Retrospective analyses of 22,839 CICU encounters from 10/2013-9/2016 across 22 North American CICUs contributing data to the Pediatric Cardiac Critical Care Consortium clinical registry.RESULTS: HAI occurred in 2.4% of CICU encounters at a rate of 3.3 HAI/1000 CICU days, with 73% of HAI occurring in children <1 year. Eighty encounters (14%) had ≥ 2 HAI. Aggregate rates for the four primary HAI: CLABSI 1.1/1000 line days; CAUTI 1.5/1000 catheter days; VAP 1.9/1000 ventilator days; SSI 0.81/100 operations. Surgical and non-surgical patients had similar HAI rates/1000 CICU days. Incidence was twice as high in surgical encounters, and increased with surgical complexity; postoperative infection occurred in 2.8% of encounters. Prematurity, younger age, presence of congenital anomaly, STAT 4-5 surgery, admission with an active medical condition, open sternum, and extracorporeal membrane oxygenation were independently associated with HAI. In univariable analysis, HAI was associated with longer hospital length of stay and durations of urinary catheter, central venous catheter, and ventilation. Mortality was 24.4% in patients with HAI vs. 3.4% in those without, p<0.0001.CONCLUSIONS: We provide comprehensive multicenter benchmark data regarding rates of HAI within dedicated pediatric CICUs. We confirm that while rare, HAIs of all types are associated with significant resource utilization and mortality.

  View details for PubMedID 29280785

• Programmatic Approach to Management of Tetralogy of Fallot With Major Aortopulmonary Collateral Arteries A 15-Year Experience With 458 Patients CIRCULATION-CARDIOVASCULAR INTERVENTIONS Bauser-Heaton, H., Borquez, A., Han, B., Ladd, M., Asija, R., Downey, L., Koth, A., Algaze, C. A., Wise-Faberowski, L., Perry, S. B., Shin, A., Peng, L. F., Hanley, F. L., McElhinney, D. B. 2017; 10 (4)

  Abstract

  Tetralogy of Fallot with major aortopulmonary collateral arteries is a complex and heterogeneous condition. Our institutional approach to this lesion emphasizes early complete repair with the incorporation of all lung segments and extensive lobar and segmental pulmonary artery reconstruction.We reviewed all patients who underwent surgical intervention for tetralogy of Fallot and major aortopulmonary collateral arteries at Lucile Packard Children's Hospital Stanford (LPCHS) since November 2001. A total of 458 patients underwent surgery, 291 (64%) of whom underwent their initial procedure at LPCHS. Patients were followed for a median of 2.7 years (mean 4.3 years) after the first LPCHS surgery, with an estimated survival of 85% at 5 years after first surgical intervention. Factors associated with worse survival included first LPCHS surgery type other than complete repair and Alagille syndrome. Of the overall cohort, 402 patients achieved complete unifocalization and repair, either as a single-stage procedure (n=186), after initial palliation at our center (n=74), or after surgery elsewhere followed by repair/revision at LPCHS (n=142). The median right ventricle:aortic pressure ratio after repair was 0.35. Estimated survival after repair was 92.5% at 10 years and was shorter in patients with chromosomal anomalies, older age, a greater number of collaterals unifocalized, and higher postrepair right ventricle pressure.Using an approach that emphasizes early complete unifocalization and repair with incorporation of all pulmonary vascular supply, we have achieved excellent results in patients with both native and previously operated tetralogy of Fallot and major aortopulmonary collateral arteries.

  View details for DOI 10.1161/CIRCINTERVENTIONS.116.004952

  View details for PubMedID 28356265

• Practice Patterns in Postoperative Echocardiographic Surveillance after Congenital Heart Surgery in Children: A Single Center Experience JOURNAL OF PEDIATRICS Arunamata, A., Axelrod, D. M., Kipps, A. K., McElhinney, D. B., Shin, A. Y., Hanley, F. L., Olson, I. L., Roth, S. J., Tierney, E. S. 2017; 180: 87-?

  Abstract

  To review current institutional practice and describe factors contributing to variation in inpatient postoperative imaging surveillance after congenital heart surgery.We reviewed records of all children who underwent congenital heart surgery from June to December 2014. Number and primary indications for postoperative transthoracic echocardiograms (TTEs), providers involved, cardiovascular intensive care unit (CVICU) and total hospital length of stay, and Risk-Adjustment for Congenital Heart Surgery-1 scores were recorded.A total of 253 children (age at surgery: 8 months [2 days-19 years]) received 556 postoperative TTEs (median 1 TTE/patient [1-14]), and 23% had ≥3 TTEs. Fifteen of 556 TTEs (2.7%) revealed a new abnormal finding. The majority of TTEs (59%) were performed in the CVICU (1.5 ± 1.1 TTEs/week/patient), with evaluation of function as the most common indication (44%). Attending physician practice >10 years was not associated with fewer TTEs (P = .12). Patients with ≥3 TTEs had higher Risk-Adjustment for Congenital Heart Surgery-1 scores (P = .001), longer CVICU lengths of stay (22 vs 3 days; P < .0001), longer overall hospitalizations (28 vs 7 days; P < .0001), and a higher incidence of mechanical circulatory support (10% vs 0%; P < .0001) than those with <3 TTEs. Eight patients with ≥3 TTEs did not survive, compared with 3 with <3 TTEs (P = .0004).There was wide intra-institutional variation in echocardiographic use among similar complexity surgeries. Frequency of postoperative echocardiographic surveillance was associated with degree of surgical complexity and severity of postoperative clinical condition. Few studies revealed new abnormal findings. These results may help establish evidence-based guidelines for inpatient echocardiographic surveillance after congenital heart surgery.

  View details for DOI 10.1016/j.jpeds.2016.09.061

  View details for Web of Science ID 000390028100018

• Haemodynamic profiles of children with end-stage heart failure. European heart journal Chen, S. n., Dykes, J. C., McElhinney, D. B., Gajarski, R. J., Shin, A. Y., Hollander, S. A., Everitt, M. E., Price, J. F., Thiagarajan, R. R., Kindel, S. J., Rossano, J. W., Kaufman, B. D., May, L. J., Pruitt, E. n., Rosenthal, D. N., Almond, C. S. 2017; 38 (38): 2900–2909

  Abstract

  To evaluate associations between haemodynamic profiles and symptoms, end-organ function and outcome in children listed for heart transplantation.Children <18 years listed for heart transplant between 1993 and 2013 with cardiac catheterization data [pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac index (CI)] in the Pediatric Heart Transplant Study database were included. Outcomes were New York Heart Association (NYHA)/Ross classification, renal and hepatic dysfunction, and death or clinical deterioration while on waitlist. Among 1059 children analysed, median age was 6.9 years and 46% had dilated cardiomyopathy. Overall, 58% had congestion (PCWP >15 mmHg), 28% had severe congestion (PCWP >22 mmHg), and 22% low cardiac output (CI < 2.2 L/min/m2). Twenty-one per cent met the primary outcome of death (9%) or clinical deterioration (12%). In multivariable analysis, worse NYHA/Ross classification was associated with increased PCWP [odds ratio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.07, P = 0.01], renal dysfunction with increased RAP (OR 1.04, 95% CI 1.01-1.08, P = 0.007), and hepatic dysfunction with both increased PCWP (OR 1.03, 95% CI 1.01-1.06, P < 0.001) and increased RAP (OR 1.09, 95% CI 1.06-1.12, P < 0.001). There were no associations with low output. Death or clinical deterioration was associated with severe congestion (OR 1.6, 95% CI 1.2-2.2, P = 0.002), but not with CI alone. However, children with both low output and severe congestion were at highest risk (OR 1.9, 95% CI 1.1-3.5, P = 0.03).Congestion is more common than low cardiac output in children with end-stage heart failure and correlates with NYHA/Ross classification and end-organ dysfunction. Children with both congestion and low output have the highest risk of death or clinical deterioration.

  View details for PubMedID 29019615

• Fluid overload independent of acute kidney injury predicts poor outcomes in neonates following congenital heart surgery. Pediatric nephrology (Berlin, Germany) Mah, K. E., Hao, S. n., Sutherland, S. M., Kwiatkowski, D. M., Axelrod, D. M., Almond, C. S., Krawczeski, C. D., Shin, A. Y. 2017

  Abstract

  Fluid overload (FO) is common after neonatal congenital heart surgery and may contribute to mortality and morbidity. It is unclear if the effects of FO are independent of acute kidney injury (AKI).This was a retrospective cohort study which examined neonates (age < 30 days) who underwent cardiopulmonary bypass in a university-affiliated children's hospital between 20 October 2010 and 31 December 2012. Demographic information, risk adjustment for congenital heart surgery score, surgery type, cardiopulmonary bypass time, cross-clamp time, and vasoactive inotrope score were recorded. FO [(fluid in-out)/pre-operative weight] and AKI defined by Kidney Disease Improving Global Outcomes serum creatinine criteria were calculated. Outcomes were all-cause, in-hospital mortality and median postoperative hospital and intensive care unit lengths of stay.Overall, 167 neonates underwent cardiac surgery using cardiopulmonary bypass in the study period, of whom 117 met the inclusion criteria. Of the 117 neonates included in the study, 76 (65%) patients developed significant FO (>10%), and 25 (21%) developed AKI ≥ Stage 2. When analyzed as FO cohorts (< 10%,10-20%, > 20% FO), patients with greater FO were more likely to have AKI (9.8 vs. 18.2 vs. 52.4%, respectively, with AKI ≥ stage 2; p = 0.013) and a higher vasoactive-inotrope score, and be premature. In the multivariable regression analyses of patients without AKI, FO was independently associated with hospital and intensive care unit lengths of stay [0.322 extra days (p = 0.029) and 0.468 extra days (p < 0.001), respectively, per 1% FO increase). In all patients, FO was also associated with mortality [odds ratio 1.058 (5.8% greater odds of mortality per 1% FO increase); 95% confidence interval 1.008,1.125;p = 0.032].Fluid overload is an important independent contributor to outcomes in neonates following congenital heart surgery. Careful fluid management after cardiac surgery in neonates with and without AKI is warranted.

  View details for PubMedID 29128923

• Temporary Circulatory Support in U.S. Children Awaiting Heart Transplantation. Journal of the American College of Cardiology Yarlagadda, V. V., Maeda, K. n., Zhang, Y. n., Chen, S. n., Dykes, J. C., Gowen, M. A., Shuttleworth, P. n., Murray, J. M., Shin, A. Y., Reinhartz, O. n., Rosenthal, D. N., McElhinney, D. B., Almond, C. S. 2017; 70 (18): 2250–60

  Abstract

  Extracorporeal membrane oxygenation (ECMO) has long served as the standard of care for short-term mechanical circulatory support in pediatrics. It is unknown whether newer-generation temporary circulatory support (TCS) devices afford children a meaningful survival advantage over ECMO.This study sought to determine whether bridge-to-heart transplant survival with a TCS device is superior to ECMO after adjusting for patient differences.All children ≤21 years of age listed for heart transplant from 2011 to 2015 who received a TCS device or ECMO as a bridge to transplant were identified using Organ Procurement and Transplantation Network data. Children supported with a TCS device were compared with a propensity score (PS)-matched cohort of children supported with ECMO as a bridge to transplant. The primary endpoint was Kaplan-Meier survival to transplant.The number of TCS devices implanted in children increased from ≤3 per year before 2011 to 50 in 2015. Overall, 93 patients implanted with TCS devices were included for analysis (59% left ventricular assist devices, 23% right ventricular assist devices, 18% biventricular assist devices). The most commonly used device was the CentriMag-PediMag system (65%), followed by TandemHeart (18%), Rotaflow (6%), and Impella (5%). Among 164 PS-matched patients, support duration was longer for the TCS cohort (median 19 days vs. 6 days; p < 0.001), and was longest for the CentriMag-PediMag (24 days vs. 6 days; p < 0.001) with 27% supported for >60 days. Compared with the ECMO cohort, the PS-matched TCS cohort had longer survival to transplant (hazard ratio: 0.49; 95% confidence interval: 0.30 to 0.79) and longer overall survival (hazard ratio: 0.61; 95% confidence interval: 0.39 to 0.96), with 90-day mortality before transplant that was modestly reduced (from 45% with ECMO to 39% with TCS).The use of TCS devices in children as a bridge to transplant has risen rapidly in recent years, led by the growth of magnetically levitated centrifugal flow pumps. Compared with conventional ECMO, TCS durations are longer, and more importantly, patient survival is superior.

  View details for PubMedID 29073953

• Unique Molecular Patterns Uncovered in Kawasaki Disease Patients with Elevated Serum Gamma Glutamyl Transferase Levels: Implications for Intravenous Immunoglobulin Responsiveness PLOS ONE Wang, Y., Li, Z., Hu, G., Hao, S., Deng, X., Huang, M., Ren, M., Jiang, X., Kanegaye, J. T., Ha, K., Lee, J., Li, X., Jiang, X., Yu, Y., Tremoulet, A. H., Burns, J. C., Whitin, J. C., Shin, A. Y., Sylvester, K. G., McElhinney, D. B., Cohen, H. J., Ling, X. B. 2016; 11 (12)

  Abstract

  Resistance to intravenous immunoglobulin (IVIG) occurs in 10-20% of patients with Kawasaki disease (KD). The risk of resistance is about two-fold higher in patients with elevated gamma glutamyl transferase (GGT) levels. We sought to understand the biological mechanisms underlying IVIG resistance in patients with elevated GGT levels.We explored the association between elevated GGT levels and IVIG-resistance with a cohort of 686 KD patients (Cohort I). Gene expression data from 130 children with acute KD (Cohort II) were analyzed using the R square statistic and false discovery analysis to identify genes that were differentially represented in patients with elevated GGT levels with regard to IVIG responsiveness. Two additional KD cohorts (Cohort III and IV) were used to test the hypothesis that sialylation and GGT may be involved in IVIG resistance through neutrophil apoptosis.Thirty-six genes were identified that significantly explained the variations of both GGT levels and IVIG responsiveness in KD patients. After Bonferroni correction, significant associations with IVIG resistance persisted for 12 out of 36 genes among patients with elevated GGT levels and none among patients with normal GGT levels. With the discovery of ST6GALNAC3, a sialyltransferase, as the most differentially expressed gene, we hypothesized that sialylation and GGT are involved in IVIG resistance through neutrophil apoptosis. We then confirmed that in Cohort III and IV there was significantly less reduction in neutrophil count in IVIG non-responders.Gene expression analyses combining molecular and clinical datasets support the hypotheses that: (1) neutrophil apoptosis induced by IVIG may be a mechanism of action of IVIG in KD; (2) changes in sialylation and GGT level in KD patients may contribute synergistically to IVIG resistance through blocking IVIG-induced neutrophil apoptosis. These findings have implications for understanding the mechanism of action in IVIG resistance, and possibly for development of novel therapeutics.

  View details for DOI 10.1371/journal.pone.0167434

  View details for Web of Science ID 000392853100008

  View details for PubMedID 28002448

  View details for PubMedCentralID PMC5176264

• Web-based Real-Time Case Finding for the Population Health Management of Patients With Diabetes Mellitus: A Prospective Validation of the Natural Language Processing-Based Algorithm With Statewide Electronic Medical Records. JMIR medical informatics Zheng, L., Wang, Y., Hao, S., Shin, A. Y., Jin, B., Ngo, A. D., Jackson-Browne, M. S., Feller, D. J., Fu, T., Zhang, K., Zhou, X., Zhu, C., Dai, D., Yu, Y., Zheng, G., Li, Y., McElhinney, D. B., Culver, D. S., Alfreds, S. T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2016; 4 (4)

  Abstract

  Diabetes case finding based on structured medical records does not fully identify diabetic patients whose medical histories related to diabetes are available in the form of free text. Manual chart reviews have been used but involve high labor costs and long latency.This study developed and tested a Web-based diabetes case finding algorithm using both structured and unstructured electronic medical records (EMRs).This study was based on the health information exchange (HIE) EMR database that covers almost all health facilities in the state of Maine, United States. Using narrative clinical notes, a Web-based natural language processing (NLP) case finding algorithm was retrospectively (July 1, 2012, to June 30, 2013) developed with a random subset of HIE-associated facilities, which was then blind tested with the remaining facilities. The NLP-based algorithm was subsequently integrated into the HIE database and validated prospectively (July 1, 2013, to June 30, 2014).Of the 935,891 patients in the prospective cohort, 64,168 diabetes cases were identified using diagnosis codes alone. Our NLP-based case finding algorithm prospectively found an additional 5756 uncodified cases (5756/64,168, 8.97% increase) with a positive predictive value of .90. Of the 21,720 diabetic patients identified by both methods, 6616 patients (6616/21,720, 30.46%) were identified by the NLP-based algorithm before a diabetes diagnosis was noted in the structured EMR (mean time difference = 48 days).The online NLP algorithm was effective in identifying uncodified diabetes cases in real time, leading to a significant improvement in diabetes case finding. The successful integration of the NLP-based case finding algorithm into the Maine HIE database indicates a strong potential for application of this novel method to achieve a more complete ascertainment of diagnoses of diabetes mellitus.

  View details for PubMedID 27836816

• Exploring the Role of Polycythemia in Patients With Cyanosis After Palliative Congenital Heart Surgery. Pediatric critical care medicine Siehr, S. L., Shi, S., Hao, S., Hu, Z., Jin, B., Hanley, F., Reddy, V. M., McElhinney, D. B., Ling, X. B., Shin, A. Y. 2016; 17 (3): 216-222

  Abstract

  To understand the relationship between polycythemia and clinical outcome in patients with hypoplastic left heart syndrome following the Norwood operation.A retrospective, single-center cohort study.Pediatric cardiovascular ICU, university-affiliated children's hospital.Infants with hypoplastic left heart syndrome admitted to our medical center from September 2009 to December 2012 undergoing stage 1/Norwood operation.None.Baseline demographic and clinical information including first recorded postoperative hematocrit and subsequent mean, median, and nadir hematocrits during the first 72 hours postoperatively were recorded. The primary outcomes were in-hospital mortality and length of hospitalization. Thirty-two patients were included in the analysis. Patients did not differ by operative factors (cardiopulmonary bypass time and cross-clamp time) or traditional markers of severity of illness (vasoactive inotrope score, lactate, saturation, and PaO2/FIO2 ratio). Early polycythemia (hematocrit value > 49%) was associated with longer cardiovascular ICU stay (51.0 [± 38.6] vs 21.4 [± 16.2] d; p < 0.01) and total hospital length of stay (65.0 [± 46.5] vs 36.1 [± 20.0] d; p = 0.03). In a multivariable analysis, polycythemia remained independently associated with the length of hospitalization after controlling for the amount of RBC transfusion (weight, 4.36 [95% CI, 1.35-7.37]; p < 0.01). No difference in in-hospital mortality rates was detected between the two groups (17.6% vs 20%).Early polycythemia following the Norwood operation is associated with longer length of hospitalization even after controlling for blood cell transfusion practices. We hypothesize that polycythemia may be caused by hemoconcentration and used as an early marker of capillary leak syndrome.

  View details for DOI 10.1097/PCC.0000000000000654

  View details for PubMedID 26825044

• Prospective stratification of patients at risk for emergency department revisit: resource utilization and population management strategy implications. BMC emergency medicine Jin, B., Zhao, Y., Hao, S., Shin, A. Y., Wang, Y., Zhu, C., Hu, Z., Fu, C., Ji, J., Wang, Y., Zhao, Y., Jiang, Y., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2016; 16 (1): 10-?

  Abstract

  Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities.We set to develop and validate a method to estimate patient ED revisit risk in the subsequent 6 months from an ED discharge date. An ensemble decision-tree-based model with Electronic Medical Record (EMR) encounter data from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), was developed and validated, assessing patient risk for a subsequent 6 month return ED visit based on the ED encounter-associated demographic and EMR clinical history data. A retrospective cohort of 293,461 ED encounters that occurred between January 1, 2012 and December 31, 2012, was assembled with the associated patients' 1-year clinical histories before the ED discharge date, for model training and calibration purposes. To validate, a prospective cohort of 193,886 ED encounters that occurred between January 1, 2013 and June 30, 2013 was constructed.Statistical learning that was utilized to construct the prediction model identified 152 variables that included the following data domains: demographics groups (12), different encounter history (104), care facilities (12), primary and secondary diagnoses (10), primary and secondary procedures (2), chronic disease condition (1), laboratory test results (2), and outpatient prescription medications (9). The c-statistics for the retrospective and prospective cohorts were 0.742 and 0.730 respectively. Total medical expense and ED utilization by risk score 6 months after the discharge were analyzed. Cluster analysis identified discrete subpopulations of high-risk patients with distinctive resource utilization patterns, suggesting the need for diversified care management strategies.Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. It promises to provide increased opportunity for high ED utilization identification, and optimized resource and population management.

  View details for DOI 10.1186/s12873-016-0074-5

  View details for PubMedID 26842066

  View details for PubMedCentralID PMC4739399

• NLP based congestive heart failure case finding: A prospective analysis on statewide electronic medical records. International journal of medical informatics Wang, Y., Luo, J., Hao, S., Xu, H., Shin, A. Y., Jin, B., Liu, R., Deng, X., Wang, L., Zheng, L., Zhao, Y., Zhu, C., Hu, Z., Fu, C., Hao, Y., Zhao, Y., Jiang, Y., Dai, D., Culver, D. S., Alfreds, S. T., Todd, R., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 84 (12): 1039-1047

  Abstract

  In order to proactively manage congestive heart failure (CHF) patients, an effective CHF case finding algorithm is required to process both structured and unstructured electronic medical records (EMR) to allow complementary and cost-efficient identification of CHF patients.We set to identify CHF cases from both EMR codified and natural language processing (NLP) found cases. Using narrative clinical notes from all Maine Health Information Exchange (HIE) patients, the NLP case finding algorithm was retrospectively (July 1, 2012-June 30, 2013) developed with a random subset of HIE associated facilities, and blind-tested with the remaining facilities. The NLP based method was integrated into a live HIE population exploration system and validated prospectively (July 1, 2013-June 30, 2014). Total of 18,295 codified CHF patients were included in Maine HIE. Among the 253,803 subjects without CHF codings, our case finding algorithm prospectively identified 2411 uncodified CHF cases. The positive predictive value (PPV) is 0.914, and 70.1% of these 2411 cases were found to be with CHF histories in the clinical notes.A CHF case finding algorithm was developed, tested and prospectively validated. The successful integration of the CHF case findings algorithm into the Maine HIE live system is expected to improve the Maine CHF care.

  View details for DOI 10.1016/j.ijmedinf.2015.06.007

  View details for PubMedID 26254876

• Development, Validation and Deployment of a Real Time 30 Day Hospital Readmission Risk Assessment Tool in the Maine Healthcare Information Exchange PLOS ONE Hao, S., Wang, Y., Jin, B., Shin, A. Y., Zhu, C., Huang, M., Zheng, L., Luo, J., Hu, Z., Fu, C., Dai, D., Wang, Y., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 10 (10)

  Abstract

  Identifying patients at risk of a 30-day readmission can help providers design interventions, and provide targeted care to improve clinical effectiveness. This study developed a risk model to predict a 30-day inpatient hospital readmission for patients in Maine, across all payers, all diseases and all demographic groups.Our objective was to develop a model to determine the risk for inpatient hospital readmission within 30 days post discharge. All patients within the Maine Health Information Exchange (HIE) system were included. The model was retrospectively developed on inpatient encounters between January 1, 2012 to December 31, 2012 from 24 randomly chosen hospitals, and then prospectively validated on inpatient encounters from January 1, 2013 to December 31, 2013 using all HIE patients.A risk assessment tool partitioned the entire HIE population into subgroups that corresponded to probability of hospital readmission as determined by a corresponding positive predictive value (PPV). An overall model c-statistic of 0.72 was achieved. The total 30-day readmission rates in low (score of 0-30), intermediate (score of 30-70) and high (score of 70-100) risk groupings were 8.67%, 24.10% and 74.10%, respectively. A time to event analysis revealed the higher risk groups readmitted to a hospital earlier than the lower risk groups. Six high-risk patient subgroup patterns were revealed through unsupervised clustering. Our model was successfully integrated into the statewide HIE to identify patient readmission risk upon admission and daily during hospitalization or for 30 days subsequently, providing daily risk score updates.The risk model was validated as an effective tool for predicting 30-day readmissions for patients across all payer, disease and demographic groups within the Maine HIE. Exposing the key clinical, demographic and utilization profiles driving each patient's risk of readmission score may be useful to providers in developing individualized post discharge care plans.

  View details for DOI 10.1371/journal.pone.0140271

  View details for Web of Science ID 000362511000113

  View details for PubMedID 26448562

• Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care. World journal for pediatric & congenital heart surgery Maher, K. O., Chang, A. C., Shin, A., Hunt, J., Wong, H. R. 2015; 6 (4): 588-596

  Abstract

  The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care.

  View details for DOI 10.1177/2150135115606087

  View details for PubMedID 26467873

• Online Prediction of Health Care Utilization in the Next Six Months Based on Electronic Health Record Information: A Cohort and Validation Study JOURNAL OF MEDICAL INTERNET RESEARCH Hu, Z., Hao, S., Jin, B., Shin, A. Y., Zhu, C., Huang, M., Wang, Y., Zheng, L., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. 2015; 17 (9)

  Abstract

  The increasing rate of health care expenditures in the United States has placed a significant burden on the nation's economy. Predicting future health care utilization of patients can provide useful information to better understand and manage overall health care deliveries and clinical resource allocation.This study developed an electronic medical record (EMR)-based online risk model predictive of resource utilization for patients in Maine in the next 6 months across all payers, all diseases, and all demographic groups.In the HealthInfoNet, Maine's health information exchange (HIE), a retrospective cohort of 1,273,114 patients was constructed with the preceding 12-month EMR. Each patient's next 6-month (between January 1, 2013 and June 30, 2013) health care resource utilization was retrospectively scored ranging from 0 to 100 and a decision tree-based predictive model was developed. Our model was later integrated in the Maine HIE population exploration system to allow a prospective validation analysis of 1,358,153 patients by forecasting their next 6-month risk of resource utilization between July 1, 2013 and December 31, 2013.Prospectively predicted risks, on either an individual level or a population (per 1000 patients) level, were consistent with the next 6-month resource utilization distributions and the clinical patterns at the population level. Results demonstrated the strong correlation between its care resource utilization and our risk scores, supporting the effectiveness of our model. With the online population risk monitoring enterprise dashboards, the effectiveness of the predictive algorithm has been validated by clinicians and caregivers in the State of Maine.The model and associated online applications were designed for tracking the evolving nature of total population risk, in a longitudinal manner, for health care resource utilization. It will enable more effective care management strategies driving improved patient outcomes.

  View details for DOI 10.2196/jmir.4976

  View details for Web of Science ID 000361809800005

  View details for PubMedID 26395541

• Utility of Clinical Biomarkers to Predict Central Line-associated Bloodstream Infections After Congenital Heart Surgery. Pediatric infectious disease journal Shin, A. Y., Jin, B., Hao, S., Hu, Z., Sutherland, S., McCammond, A., Axelrod, D., Sharek, P., Roth, S. J., Ling, X. B. 2015; 34 (3): 251-254

  Abstract

  Central line associated bloodstream infections is an important contributor of morbidity and mortality in children recovering from congenital heart surgery. The reliability of commonly used biomarkers to differentiate these patients have not been specifically studied.This was a retrospective cohort study in a university-affiliated children's hospital examining all patients with congenital or acquired heart disease admitted to the cardiovascular intensive care unit following cardiac surgery who underwent evaluation for a catheter-associated bloodstream infection.Among 1260 cardiac surgeries performed, 451 encounters underwent an infection evaluation post-operatively. Twenty-five instances of CLABSI and 227 instances of a negative infection evaluation were the subject of analysis. Patients with CLABSI tended to be younger (1.34 vs 4.56 years, p = 0.011) and underwent more complex surgery (RACHS-1 score 3.79 vs 3.04, p = 0.039). The two groups were indistinguishable in WBC, PMNs and band count at the time of their presentation. On multivariate analysis, CLABSI was associated with fever (adjusted OR 4.78; 95% CI, 1.6 to 5.8) and elevated CRP (adjusted OR 1.28; 95% CI, 1.09 to 1.68) after adjusting for differences between the two groups. Receiver operating characteristic analysis demonstrated the discriminatory power of both fever and CRP (area under curve 0.7247, 95% CI, 0.42 to 0.74 and 0.58, 95% CI 0.4208 to 0.7408). We calculated multilevel likelihood ratios for a spectrum of temperature and CRP values.We found commonly used serum biomarkers such as fever and CRP not to be helpful discriminators in patients following congenital heart surgery.

  View details for DOI 10.1097/INF.0000000000000553

  View details for PubMedID 25232780

• Real-time web-based assessment of total population risk of future emergency department utilization: statewide prospective active case finding study. Interactive journal of medical research Hu, Z., Jin, B., Shin, A. Y., Zhu, C., Zhao, Y., Hao, S., Zheng, L., Fu, C., Wen, Q., Ji, J., Li, Z., Wang, Y., Zheng, X., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 4 (1)

  Abstract

  An easily accessible real-time Web-based utility to assess patient risks of future emergency department (ED) visits can help the health care provider guide the allocation of resources to better manage higher-risk patient populations and thereby reduce unnecessary use of EDs.Our main objective was to develop a Health Information Exchange-based, next 6-month ED risk surveillance system in the state of Maine.Data on electronic medical record (EMR) encounters integrated by HealthInfoNet (HIN), Maine's Health Information Exchange, were used to develop the Web-based surveillance system for a population ED future 6-month risk prediction. To model, a retrospective cohort of 829,641 patients with comprehensive clinical histories from January 1 to December 31, 2012 was used for training and then tested with a prospective cohort of 875,979 patients from July 1, 2012, to June 30, 2013.The multivariate statistical analysis identified 101 variables predictive of future defined 6-month risk of ED visit: 4 age groups, history of 8 different encounter types, history of 17 primary and 8 secondary diagnoses, 8 specific chronic diseases, 28 laboratory test results, history of 3 radiographic tests, and history of 25 outpatient prescription medications. The c-statistics for the retrospective and prospective cohorts were 0.739 and 0.732 respectively. Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. Cluster analysis in both the retrospective and prospective analyses revealed discrete subpopulations of high-risk patients, grouped around multiple "anchoring" demographics and chronic conditions. With the Web-based population risk-monitoring enterprise dashboards, the effectiveness of the active case finding algorithm has been validated by clinicians and caregivers in Maine.The active case finding model and associated real-time Web-based app were designed to track the evolving nature of total population risk, in a longitudinal manner, for ED visits across all payers, all diseases, and all age groups. Therefore, providers can implement targeted care management strategies to the patient subgroups with similar patterns of clinical histories, driving the delivery of more efficient and effective health care interventions. To the best of our knowledge, this prospectively validated EMR-based, Web-based tool is the first one to allow real-time total population risk assessment for statewide ED visits.

  View details for DOI 10.2196/ijmr.4022

  View details for PubMedID 25586600

  View details for PubMedCentralID PMC4319080

• Development, Validation and Deployment of a Real Time 30 Day Hospital Readmission Risk Assessment Tool in the Maine Healthcare Information Exchange. PloS one Hao, S., Wang, Y., Jin, B., Shin, A. Y., Zhu, C., Huang, M., Zheng, L., Luo, J., Hu, Z., Fu, C., Dai, D., Wang, Y., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 10 (10)

  Abstract

  Identifying patients at risk of a 30-day readmission can help providers design interventions, and provide targeted care to improve clinical effectiveness. This study developed a risk model to predict a 30-day inpatient hospital readmission for patients in Maine, across all payers, all diseases and all demographic groups.Our objective was to develop a model to determine the risk for inpatient hospital readmission within 30 days post discharge. All patients within the Maine Health Information Exchange (HIE) system were included. The model was retrospectively developed on inpatient encounters between January 1, 2012 to December 31, 2012 from 24 randomly chosen hospitals, and then prospectively validated on inpatient encounters from January 1, 2013 to December 31, 2013 using all HIE patients.A risk assessment tool partitioned the entire HIE population into subgroups that corresponded to probability of hospital readmission as determined by a corresponding positive predictive value (PPV). An overall model c-statistic of 0.72 was achieved. The total 30-day readmission rates in low (score of 0-30), intermediate (score of 30-70) and high (score of 70-100) risk groupings were 8.67%, 24.10% and 74.10%, respectively. A time to event analysis revealed the higher risk groups readmitted to a hospital earlier than the lower risk groups. Six high-risk patient subgroup patterns were revealed through unsupervised clustering. Our model was successfully integrated into the statewide HIE to identify patient readmission risk upon admission and daily during hospitalization or for 30 days subsequently, providing daily risk score updates.The risk model was validated as an effective tool for predicting 30-day readmissions for patients across all payer, disease and demographic groups within the Maine HIE. Exposing the key clinical, demographic and utilization profiles driving each patient's risk of readmission score may be useful to providers in developing individualized post discharge care plans.

  View details for DOI 10.1371/journal.pone.0140271

  View details for PubMedID 26448562

• Outcomes following cardiac catheterization after congenital heart surgery. Catheterization and cardiovascular interventions Siehr, S. L., Martin, M. H., Axelrod, D., Efron, B., Peng, L., Roth, S. J., Perry, S., Shin, A. Y. 2014; 84 (4): 622-628

  Abstract

  Describe outcomes following unplanned cardiac catheterization after congenital heart surgery.Utility of cardiac catheterization following congenital heart surgery is relatively understudied.Retrospective study examining demographics, indications, and outcomes of unplanned cardiac catheterization after congenital heart surgery at a single institution.Between October 2004 and April 2011, 120 patients underwent 150 unplanned postoperative cardiac catheterizations. Median day of catheterization was postoperative day 20 (range 1-269 days). Survival 30 days postcatheterization was 85%; overall survival to hospital discharge was 72%. Indications for catheterization: 63 for hemodynamic evaluation, 46 for likely intervention, and 41 for assessment of surgical repair. Of the 150 hemodynamic/interventional catheterizations, 103 (69%) were associated with a change in clinical management: 59 trans-catheter interventions, 22 re-operations, 11 changes in medication, six changes in surgical plan, and five withdrawals of support. Complications included hemorrhage in two patients, supraventricular tachycardia in two patients, and transient complete heart block requiring cardiopulmonary resuscitation in one patient.Cardiac catheterization following congenital heart surgery may enable important diagnostic and therapeutic changes in clinical and surgical management. Complications were rare.

  View details for DOI 10.1002/ccd.25490

  View details for PubMedID 24659225

• Outcomes Following Cardiac Catheterization After Congenital Heart Surgery CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Siehr, S. L., Martin, M. H., Axelrod, D., Efron, B., Peng, L., Roth, S. J., Perry, S., Shin, A. Y. 2014; 84 (4): 622-628

  Abstract

  Describe outcomes following unplanned cardiac catheterization after congenital heart surgery.Utility of cardiac catheterization following congenital heart surgery is relatively understudied.Retrospective study examining demographics, indications, and outcomes of unplanned cardiac catheterization after congenital heart surgery at a single institution.Between October 2004 and April 2011, 120 patients underwent 150 unplanned postoperative cardiac catheterizations. Median day of catheterization was postoperative day 20 (range 1-269 days). Survival 30 days postcatheterization was 85%; overall survival to hospital discharge was 72%. Indications for catheterization: 63 for hemodynamic evaluation, 46 for likely intervention, and 41 for assessment of surgical repair. Of the 150 hemodynamic/interventional catheterizations, 103 (69%) were associated with a change in clinical management: 59 trans-catheter interventions, 22 re-operations, 11 changes in medication, six changes in surgical plan, and five withdrawals of support. Complications included hemorrhage in two patients, supraventricular tachycardia in two patients, and transient complete heart block requiring cardiopulmonary resuscitation in one patient.Cardiac catheterization following congenital heart surgery may enable important diagnostic and therapeutic changes in clinical and surgical management. Complications were rare.

  View details for DOI 10.1002/ccd.25490

  View details for Web of Science ID 000342826900018

• Sedative and analgesic use on night and day shifts in a pediatric cardiovascular intensive care unit. AACN advanced critical care Staveski, S. L., Tesoro, T. M., Cisco, M. J., Roth, S. J., Shin, A. Y. 2014; 25 (2): 114-118

  Abstract

  The use of sedative and analgesic medications is directly linked to patient outcomes. The practice of administering as-needed sedative or analgesic medications deserves further exploration. We hypothesized that important variations exist in the practice of administering as-needed medications in the intensive care unit (ICU). We aimed to determine the influence of time of day on the practice of administering as-needed sedative or analgesic medications to children in the ICU.Medication administration records of patients admitted to our pediatric cardiovascular ICU during a 4-month period were reviewed to determine the frequency and timing of as-needed medication usage by shift.A total of 152 ICU admissions (1854 patient days) were reviewed. A significantly greater number of as-needed doses were administered during the night shift (fentanyl, P = .005; lorazepam, P = .03; midazolam, P = .0003; diphenhydramine, P = .0003; and chloral hydrate, P = .0006). These differences remained statistically significant after excluding doses given during the first 6 hours after cardiovascular surgery. Morphine administration was similar between shifts (P = .08).We identified a pattern of increased administration of as-needed sedative or analgesic medications during nights. Further research is needed to identify the underlying causes of this practice variation.

  View details for DOI 10.1097/NCI.0000000000000023

  View details for PubMedID 24752023

• Risk prediction of emergency department revisit 30 days post discharge: a prospective study. PloS one Hao, S., Jin, B., Shin, A. Y., Zhao, Y., Zhu, C., Li, Z., Hu, Z., Fu, C., Ji, J., Wang, Y., Zhao, Y., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2014; 9 (11)

  Abstract

  Among patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization.A decision tree based model with discriminant Electronic Medical Record (EMR) features was developed and validated, estimating patient ED 30 day revisit risk. A retrospective cohort of 293,461 ED encounters from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), between January 1, 2012 and December 31, 2012, was assembled with the associated patients' demographic information and one-year clinical histories before the discharge date as the inputs. To validate, a prospective cohort of 193,886 encounters between January 1, 2013 and June 30, 2013 was constructed. The c-statistics for the retrospective and prospective predictions were 0.710 and 0.704 respectively. Clinical resource utilization, including ED use, was analyzed as a function of the ED risk score. Cluster analysis of high-risk patients identified discrete sub-populations with distinctive demographic, clinical and resource utilization patterns.Our ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.

  View details for DOI 10.1371/journal.pone.0112944

  View details for PubMedID 25393305

  View details for PubMedCentralID PMC4231082

• Clopidogrel in Infants with Systemic-to-Pulmonary-Artery Shunts NEW ENGLAND JOURNAL OF MEDICINE Wessel, D. L., Berger, F., Li, J. S., Daehnert, I., Rakhit, A., Fontecave, S., Newburger, J. W. 2013; 368 (25): 2377-2384

  Abstract

  Infants with cyanotic congenital heart disease palliated with placement of a systemic-to-pulmonary-artery shunt are at risk for shunt thrombosis and death. We investigated whether the addition of clopidogrel to conventional therapy reduces mortality from any cause and morbidity related to the shunt.In a multicenter, double-blind, event-driven trial, we randomly assigned infants 92 days of age or younger with cyanotic congenital heart disease and a systemic-to-pulmonary-artery shunt to receive clopidogrel at a dose of 0.2 mg per kilogram of body weight per day (467 infants) or placebo (439 infants), in addition to conventional therapy (including aspirin in 87.9% of infants). The primary efficacy end point was a composite of death or heart transplantation, shunt thrombosis, or performance of a cardiac procedure due to an event considered to be thrombotic in nature before 120 days of age.The rate of the composite primary end point did not differ significantly between the clopidogrel group (19.1%) and the placebo group (20.5%) (absolute risk difference, 1.4 percentage points; relative risk reduction with clopidogrel, 11.1%; 95% confidence interval, -19.2 to 33.6; P=0.43), nor did the rates of the three components of the composite primary end point. There was no significant benefit of clopidogrel treatment in any subgroup, including subgroups defined by shunt type. Clopidogrel recipients and placebo recipients had similar rates of overall bleeding (18.8% and 20.2%, respectively) and severe bleeding (4.1% and 3.4%, respectively).Clopidogrel therapy in infants with cyanotic congenital heart disease palliated with a systemic-to-pulmonary-artery shunt, most of whom received concomitant aspirin therapy, did not reduce either mortality from any cause or shunt-related morbidity. (Funded by Sanofi-Aventis and Bristol-Myers Squibb; ClinicalTrials.gov number, NCT00396877.).

  View details for DOI 10.1056/NEJMoa1114588

  View details for Web of Science ID 000320601700007

  View details for PubMedID 23782178

• Surgical management of neonatal atrioventricular septal defect with aortic arch obstruction. Annals of thoracic surgery Shuhaiber, J., Shin, A. Y., Gossett, J. G., Wypij, D., Backer, C. L., Hanley, F. L., Khan, M. S., Fraser, C. D., Jacques, F., Manning, P. B., Van Arsdell, G., Mayer, J. E., Costello, J. M. 2013; 95 (6): 2071-2077

  Abstract

  For neonates with atrioventricular septal defect and aortic arch obstruction including coarctation of the aorta, we sought to determine whether a difference in outcomes exists after a primary neonatal versus staged surgical repair (neonatal arch repair with delayed intracardiac repair).This retrospective cohort study included consecutive neonates with atrioventricular septal defect and aortic arch obstruction who underwent cardiac surgery before 28 days of age at six centers from 1990 to 2009. Characteristics and outcomes between patients undergoing neonatal versus staged repair were compared.Of 66 study patients, 31 (47%) underwent primary neonatal repair and 35 (53%) underwent staged repair. At baseline echocardiogram, a greater percentage of neonatal repair patients had relative unbalanced ventricular size (56% versus 35%, p = 0.02). There were no other differences in demographic characteristics, cardiac anatomical or functional details, or surgical technique. Those undergoing neonatal repair tended to be more likely to have at least moderate left atrioventricular valve regurgitation early after repair (42% versus 19%, p = 0.05) and to have at least one major in-hospital complication (42% versus 20%, p = 0.06). After the initial cardiac operation, compared with the neonatal repair group, patients undergoing staged repair had greater survival (87% versus 57% at 6 years, log-rank p = 0.02) and freedom from the first unplanned cardiac reoperation (69% versus 45% at 6 years, log-rank p = 0.005).For neonates with atrioventricular septal defect and aortic arch obstruction, when compared with neonatal repair, a staged approach was associated with improved survival and lower morbidity.

  View details for DOI 10.1016/j.athoracsur.2012.11.069

  View details for PubMedID 23415240

• Embedding time-limited laboratory orders within computerized provider order entry reduces laboratory utilization*. Pediatric critical care medicine Pageler, N. M., Franzon, D., Longhurst, C. A., Wood, M., Shin, A. Y., Adams, E. S., Widen, E., Cornfield, D. N. 2013; 14 (4): 413-419

  Abstract

  : To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.: Cohort study with historical controls.: A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.: This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).: A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.: Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.: Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.

  View details for DOI 10.1097/PCC.0b013e318272010c

  View details for PubMedID 23439456

• Reducing Mortality Related to Adverse Events in Children PEDIATRIC CLINICS OF NORTH AMERICA Shin, A. Y., Longhurst, C. A., Sharek, P. J. 2012; 59 (6): 1293-?

  Abstract

  Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.

  View details for DOI 10.1016/j.pcl.2012.09.002

  View details for Web of Science ID 000312618600007

  View details for PubMedID 23116526

• SURGICAL MANAGEMENT OF ATRIOVENTRICULAR SEPTAL DEFECTS WITH AORTIC ARCH OBSTRUCTION IN NEONATES: A MULTICENTER STUDY J Am Coll Cardiol. Costello JM, Shin AY, Shuhaiber J 2012; 59 (E778)
• Cardiac troponin increases among runners in the Boston Marathon ANNALS OF EMERGENCY MEDICINE Fortescue, E. B., Shin, A. Y., Greenes, D. S., Mannix, R. C., Agarwal, S., Feldman, B. J., Shah, M. I., Rifai, N., Landzberg, M. J., Newburger, J. W., Almond, C. S. 2007; 49 (2): 137-143

  Abstract

  Studies indicate that running a marathon can be associated with increases in serum cardiac troponin levels. The clinical significance of such increases remains unclear. We seek to determine the prevalence of troponin increases and epidemiologic factors associated with these increases in a large and heterogeneous cohort of marathon finishers.Entrants in the 2002 Boston Marathon were recruited 1 to 2 days before the race. Data collected included demographic and training history, symptoms experienced during the run, and postrace troponin T and I levels. Simple descriptive statistics were performed to describe the prevalence of troponin increases and runner characteristics.Of 766 runners enrolled, 482 had blood analyzed at the finish line. In all, 34% were women, 20% were younger than 30 years, and 92% had run at least 1 previous marathon. Most runners (68%) had some degree of postrace troponin increase (troponin T > or = 0.01 ng/mL or troponin I > or = 0.1 ng/mL), and 55 (11%) had significant increases (troponin T > or = 0.075 ng/mL or troponin I > or = 0.5 ng/mL). Running inexperience (< 5 previous marathons) and young age (< 30 years) were associated with elevated troponins. These correlates were robust throughout a wide range of troponin thresholds considered. Health factors, family history, training, race performance, and symptoms were not associated with increases.Troponin increases were relatively common among marathon finishers and can reach levels typically diagnostic for acute myocardial infarction. Less marathon experience and younger age appeared to be associated with troponin increases, whereas race duration and the presence of traditional cardiovascular risk factors were not. Further work is needed to determine the clinical significance of these findings.

  View details for DOI 10.1016/j.annemergmed.2006.09.024

  View details for Web of Science ID 000243957800002

  View details for PubMedID 17145114

• Aortic atresia or severe left ventricular outflow tract obstruction with ventricular septal defect: Results of primary biventricular repair in neonates 42nd Annual Meeting of the Society-of-Thoracic-Surgeons Nathan, M., Rimmer, D., del Nido, P. J., Mayer, J. E., Bacha, E. A., Shin, A., Regan, W., Gonzalez, R., Pigula, F. ELSEVIER SCIENCE INC. 2006: 2227–32

  Abstract

  Aortic atresia or severe aortic stenosis and left ventricular outflow tract obstruction is a frequent component of complex congenital heart disease. Aortic atresia or severe aortic stenosis and left ventricular outflow tract obstruction with two adequate ventricles is sometimes treated by Norwood palliation followed by late biventricular repair. We reviewed our experience with primary biventricular repair in this group of neonates.Retrospective review identified 17 neonates (10 males) with aortic atresia or severe left ventricular outflow tract obstruction with ventricular septal defect and an adequate left ventricle undergoing primary biventricular repair between 1986 and 2002. Mean age was 7.7 +/- 2.9 days, weight 3.3 +/- 0.7 kg, and body surface area 0.21 +/- 0.04 kg/m2. Associated anomalies included arch hypoplasia, 7 (41%); aortic atresia, 7 (41%); and coarctation, 5 (29%). Results are reported as mean +/- standard deviation.Median follow-up was 6 years (range, 1 to 17.7 years). Three of the 17 (18%) died within 30 days. There were no deaths in this series since 1992. Nine patients (38.9%) required one reoperation, 7 of which were for conduit stenosis, 1 for left ventricular outflow tract obstruction, and 1 for residual ventricular septal defect with left ventricle-to-right atrium shunt. Freedom from death at 10 years was 82% by Kaplan-Meier estimate.Excellent long-term survival can be achieved by primary biventricular repair as corroborated by our survival rate of 82%. Primary biventricular repair is an effective operation for aortic atresia and severe left ventricular outflow tract obstruction with adequate sized left ventricle that avoids interstage attrition associated with Norwood palliation and is our procedure of choice.

  View details for DOI 10.1016/j.athoracsur.2006.05.124

  View details for Web of Science ID 000242297200039

  View details for PubMedID 17126139

• The Boston Marathon study: A novel approach to research during residency PEDIATRICS Shin, A. Y., Almond, C. S., Mannix, R. C., Duncan, C. N., Son, M. B., McLauchlan, H. M., Kanaan, U. B., Litzow, J. M., Riney, P. S., Trenor, C. C., Fortescue, E. B., Vinci, R. J., Greenes, D. S. 2006; 117 (5): 1818-1822

  Abstract

  Resident physicians from a pediatric academic training program developed a hospital-wide research project in an effort to enhance their residency research experience. In this model, residents themselves assumed primary responsibility for each stage of a large prospective clinical research study. The project, which was integrated successfully into the residency program, enabled a large group of residents, with mentorship from a dedicated faculty member, to benefit from a structured clinical research experience while providing the flexibility necessary to meet the demands of a busy residency curriculum. Careful topic selection with a well-defined end point, faculty involvement, resident collegiality, and institutional support were factors identified by study leaders as central to the success of this model.

  View details for DOI 10.1542/peds.2005-1249

  View details for Web of Science ID 000237207300076

  View details for PubMedID 16651344