The PROMISE Program Reduces Cardiac Arrests in High-Risk PatientsThe PROMISE Program Reduces Cardiac Arrests in High-Risk Patients https://pediatricsnationwide.org/wp-content/uploads/2023/02/Promise-Photo.png 600 400 Mary Bates, PhD Mary Bates, PhD https://secure.gravatar.com/avatar/c6233ca2b7754ab7c4c820e14eb518c8?s=96&d=mm&r=g
- February 28, 2023
- Mary Bates, PhD
This proactive quality improvement initiative improved outcomes for high-risk pediatric cardiology patients undergoing cardiac intervention.
Faculty within The Heart Center at Nationwide Children’s recently initiated proactive risk mitigation strategies to reduce post-procedural cardiac arrests in high-risk congenital heart patients. In a new paper, the team used quality improvement methodology to show that their efforts resulted in fewer post-procedure cardiac arrests which was associated with a decrease in overall and post-procedural length of stay.
Approximately 40,000 children undergo congenital heart surgery each year in the United States, and 2-3% of them experience a post-procedure cardiac arrest.
“While 3% does not seem like a big number, cardiac arrest is oftentimes a devastating outcome,” says Tara Cosgrove, MD, MBOE, a pediatric cardiologist at Nationwide Children’s and first author of the new study. “Only about half of the children that have an arrest survive, and a large percentage of survivors experience long-lasting and serious health repercussions.”
In 2019, Dr. Cosgrove and colleagues observed that The Heart Center had a higher-than-expected rate of post-operative cardiac arrests compared to other centers. Since cardiac arrests are relatively rare events, the team decided to try to proactively mitigate risk before the events occurred through communication, collaboration, and situational awareness. They formed a multidisciplinary quality improvement team to develop criteria to identify high-risk patients for whom interventions could be targeted.
In July 2020, the team enrolled these high-risk patients in the PROactive MItigation to decrease Serious adverse Events (PROMISE) program. Patients in the program underwent two multidisciplinary reviews (termed PROMISE calls) involving key peri-procedural stakeholders, once before the procedure and then immediately post-procedure. These PROMISE calls were conducted over a virtual platform and followed a checklist of important factors that may contribute to the patient’s specific risk.
Using a quality improvement statistical tool called a g-chart, which can track changes in rare events, Dr. Cosgrove and colleagues measured the number of high-risk cases between cardiac arrests. Over the first 12 months of the PROMISE Program, they saw the median number of high-risk cases between arrests rise from 3 to 7, an increase of 133% which has been sustained for nearly two years.
The team also used some traditional statistical tools to evaluate the program’s impacts, but the small sample size and low overall frequency of cardiac arrests resulted in too little power to reach statistical significance.
“Prior to the project, we had 21% of high-risk patients experience a post-procedure cardiac arrest, and after implementation, that was reduced to 8%,” says Dr. Cosgrove. “That wasn’t statistically significant, but it is certainly clinically significant.”
In addition, the research team documented a reduction in post-procedural length of hospital stay for patients in the PROMISE Program, from an average of 45 days to 19 days.
Dr. Cosgrove says that the PROMISE calls have succeeded in facilitating multidisciplinary discussions of patient-specific risks along with the development of risk mitigation strategies.
“I want to stress that the entire success of the PROMISE program is attributed to the hard working front line staff within The Heart Center, specifically the Cardiac ICU providers and Cardiothoracic Surgical Teams directly caring for these incredibly complex patients” says Dr. Cosgrove. “They are the backbone of the PROMISE program and deserve an enormous amount of credit as they are the ones who succeeded in improving patient outcomes.”
The Heart Center team hopes to utilize principals of the PROMISE Program, namely proactive risk mitigation, situational awareness, collaboration and communication to other high-risk populations within the division and has shared program success and key learnings with other divisions at Nationwide Children’s to aid in local spread. . The PROMISE project team at Nationwide Children’s are also helping to bring the program to other institutions with recent spread to the heart center at University Hospitals Rainbow Babies and Children’s Hospital in Cleveland, Ohio.
Cosgrove TC, Gauntt J, Carrillo SA, Cassidy SC, Gajarski RJ, Galantowicz M, Krawczeski CD. Proactive risk mitigation for cardiac arrest prevention in high-risk patients with congenital heart disease. JTCVS Open. Published online November 4, 2022. Doi: 10.1016/j.xjon.2022.10.008.
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