Reducing Hospital Stays After Fontan Procedures by More Than 66%

Reducing Hospital Stays After Fontan Procedures by More Than 66% 1024 575 Pam Georgiana
Black and white photo of boy sitting up on hospital bed

A new quality improvement initiative implements new guidelines using an innovative chest tube commonly used in adults.


Before April 2020, the average length of hospital stay for patients undergoing the Fontan procedure at Nationwide Children’s was about 23 days. This prolonged hospitalization stay was longer than many other institutions due to prolonged chest tube drainage.

“Most patients recover quickly from the Fontan procedure except for their chest tube drainage. Our routine pre-guideline was for the patient to remain in the hospital until their chest tubes stopped drainage and were removed. This often added multiple days to their hospital stay,” Janet M. Simsic, MD, the medical director for the Cardiac Intensive Care Unit in The Heart Center at Nationwide Children’s, explains.

Dr. Simsic and Virginia Kathleen Cox, APRN, a nurse practitioner on the Cardiac Thoracic Surgery team, knew that prolonged hospital stays were not easy on their young patients and their families.

“Kids do so much better at home. They are more active and engaged when they are in familiar surroundings,” Cox explains. “We decided to find out if we could send patients home with a chest tube safely.”

For a quality improvement study, Dr. Simsic and Kathleen worked with the surgical team to implement new standardized clinical practice guidelines utilizing an ambulatory drain used in adults. This drain is a catheter system that allows the patient to go home with their chest tubes and return back to the hospital periodically for drainage. To our knowledge, the drain had never been used in this way in children.

The guidelines also included diuresis, fluid restriction and pulmonary vasodilation with supplemental oxygen and sildenafil. Patients were discharged from the hospital with the catheter drain in place. The team compared clinical outcome variables before and after guideline implementation. As a balancing measure, they also tracked 30-day readmissions. The study was recently published in Pediatric Quality & Safety.

Of the 35 patients who underwent the Fontan procedure from April 2020 to July 2022, the average hospital length of stay was 8 days in 2020 and 7 days by 2022. There was no change in 30-day readmission after guideline implementation. All patients went home with the drain.

“Cutting the length of stay by more than two-thirds is such a positive improvement in our patients’ recovery process. We are very pleased with the results,” Dr. Simsic says.

The new guidelines also required monitoring patients as outpatients to drain their catheters when needed. Cox and her team saw patients in the clinic after 48 to 72 hours at home, then twice a week, and then once a week until the drain was removed. The team drained the catheter during each one-hour visit and monitored medications like diuretics.

“At first, we were concerned that families would be overwhelmed by the prospect of going home with a chest tube or, conversely, unwilling to come back to the hospital for check-ins,” Cox says. “On the contrary, we found out our families were more than willing to return to the hospital for monitoring if it got their child home faster.”

These new guidelines are now standard procedure at Nationwide Children’s. As of early April 2024, 57 patients have gone home with the ambulatory drain, and all have followed the guidelines successfully.

“Patient satisfaction is very high. There have been no complications. Our patients resume their active toddler lives, and their families are happy to get back to their daily routine,” Cox reports.

“This initiative wouldn’t have been successful without the support of the surgical team and our postoperative monitoring team,” Dr. Simsic says.



Cox V, Hart S, Hersey D, et al. Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure. Pediatr Qual Saf. 2023;8(3):e661. Published 2023 Jun 7. doi:10.1097/pq9.0000000000000661

About the author

Pam Georgiana is a brand marketing professional and writer located in Bexley, Ohio. She believes that words bind us together as humans and that the best stories remind us of our humanity. She specialized in telling engaging stories for healthcare, B2B services, and nonprofits using classic storytelling techniques. Pam has earned an MBA in Marketing from Capital University in Columbus, Ohio.