Presurgical planning conference

Presurgical planning conferences have remained a key component of congenital cardiac care for well over 50 years and are a familiar feature of most pediatric cardiology/cardiac surgery programs [10]. Traditionally this approach involved only cardiology and surgery; for example, in the author’s experience at the University of California, San Francisco, during Pediatric Residency training in the 1980s, a Cardiology Fellow would present the history and physical examination findings, and the additional data such as ECG, chest radiograph, cardiac catheterization angiograms and physiologic calculations, and laboratory data. In later years, echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI) results were added to the data presented. After this presentation, a surgical plan was made after discussion among the (usually senior) cardiologists and surgeons. The junior members of the team were reluctant to speak and rarely did so. Duignan and colleagues prospectively evaluated clinical decision‐making in 107 consecutive patients in a joint Pediatric Cardiology‐Cardiac Surgery Conference, deeming 50% of the cases as complex [11]. Among these patients, Duignan and colleagues identified occasional patients with the same data sets that had different clinical decisions, some instances of the same complex patient being revisited, and two different treatment plans resulting. Anchoring bias (tendency to recommend procedures within one’s own field, i.e. surgery or interventional catheterization) was identified in several cases, and the lack of validated decision‐making algorithms in the field of congenital cardiac care was noted. The TCH Heart Center has attempted to minimize these issues with the following approaches.

At TCH, Surgical Case Conferences reviewing upcoming cases for the week have involved anesthesiologists, intensivists, nurses, consultants, radiologists, trainees in all disciplines, and any other interested clinician in the Heart Center for over 25 years; and in pre‐COVID 19 pandemic times often over 100 people gathered in the Helen B. Taussig Auditorium to discuss and confirm, and at times alter, the surgical plan (Figure 4.1). A structured template, with a clinical presentation by the cardiology, surgery, or intensive care fellow, followed by the display of pertinent imaging findings by an echocardiographer, or cardiac MRI/CT specialist dedicated for the conference and prepared in advance, is followed by proposed surgical plan and discussion, confirming or at times changing the plan. Ninety minutes on Monday morning is allotted to the presentation of approximately 15–20 patients; requiring presentation and discussion to be efficient and accomplished in 3–5 minutes for the straightforward patients. In the COVID‐19 pandemic era, this and all large Heart Center Conferences have been converted to a videoconference format (Figure 4.2). In both settings, all attendees are encouraged to voice their opinions about the proposed plan for a case, even if they are a member of the junior faculty or trainee groups.

New patient case conferences

Additional clinical decision‐making opportunities exist for new patients, and existing patients requiring decisions about the next steps in clinical care. Further, 90 minutes each on Monday and Wednesday afternoons are allotted to two such conferences, where primary cardiologists present to representatives from Cardiac Surgery and Catheterization Laboratory, to decide on a treatment plan.

A specialized conference for Adult Congenital Heart Disease (ACHD) patients is held once a week for 60 minutes, where a multidisciplinary group discusses the unique needs of this patient group, including medical, catheter, and surgical therapy. Representatives from surgery, ACHD cardiology, ACHD ICU, anesthesia, and nursing are present in these weekly conferences. As with the other patient decision‐making conferences, the entire Heart Center is invited to attend these conferences.

Morning report

In addition to these formal conferences, each day starts with a morning report where the entire Heart Center can attend; after a brief review of the inpatient Heart Center census and planned admissions and discharges there is an opportunity to present newly admitted patients, or patients otherwise in need of clinical treatment decisions urgently (within 24–48 hours) who cannot wait for the formal case conferences (Figures 4.2 and 4.3). As with the formal planning conferences, any attendee is encouraged to speak up and voice their views on a proposed treatment plan, and at the end of the presentation, a consensus is reached about the planned treatment. These presentations often result in cases added to the surgical or catheterization schedule the same day as the presentation. For example, on the day of this chapter writing, an infant with tetralogy of Fallot, and PDA stent with cyanotic spells was presented in morning report, and dilation of PDA stent vs. surgery was discussed, the consensus was for surgery and successful repair was accomplished that day.

Data, validation, and consistency in clinical decision‐making

This system of clinical decision‐making has evolved as the TCH Heart Center has grown in numbers of cases handled and personnel available, so that every patient has the advantage of the collective experience and wisdom of the entire Heart Center through a transparent process striving to attain consistency in decision‐making, e.g. all patients with the same condition will receive the same or similar treatment plan, that is data and outcomes‐driven and widely known to all who have an interest. The above‐noted Surgical Case Conference is an opportunity for a second review to confirm the surgical plan before the patient enters the OR and occasionally results in a change in the plan. Periodically, through additional Heart Center quality conferences noted below, outcome data for major lesions or other lesions of interest are reviewed, both for local cases, for large databases such as the Society of Thoracic Surgeons’ Congenital Heart Surgery Database, and recently published literature. Through this process, a consensus is reached to change approaches to specific lesions. Two recent examples include the decision to move to primary stenting of the PDA for most neonates with right‐sided obstructive lesions in need of a stable source of pulmonary blood flow instead of a Blalock‐Taussig‐Thomas shunt; and transcatheter occlusion of the PDA in premature and other small neonates instead of ligation by thoracotomy.

Although the field of validated decision‐making algorithms in CHD is relatively new, one example is an approach developed at TCH for Anomalous Aortic Origin of the Coronary Arteries (AAOCA), where the three treatment strategies are: observation without exercise restriction; exercise restriction; and surgical intervention [12]. Using decision analysis, a formal quantitative approach that analyzes different management strategies under conditions of uncertainly, an algorithm was developed utilizing outcomes from the published literature, and individual patient characteristics such as age and symptomatology. Life expectancy and quality‐adjusted life expectancy were the outcomes, and a cohort of 10,000 hypothetical identical patients underwent a first‐order Monte Carlo simulation, with further sensitivity analyses. Surgery was the preferred management strategy for most patients under 30 years of age for anomalous left coronary artery; and for patients <25 years of age for anomalous right coronary. Utilizing the principles proposed in this algorithm, 47 of 163 patients with AAOCA underwent surgery; 82% of the entire group was allowed unrestricted sports exercise activity; and of the surgical patients, 3 (6.4%) are restricted from sports exercise activity(Figure 4.4) [13]. All patients in the cohort were alive, whether they underwent surgery or not, during the follow‐up period. The formation of a multidisciplinary team, with support from clinical data science specialists, is key to the success of this program.

Multidisciplinary Surgical Patient ICU Rounds

Because of the early start to the surgical cases and the additional early morning conferences, the practice of rounding on surgical patients in the Cardiac ICU (CICU) at 6:15 AM Monday–Friday has been practiced for many years. This has resulted in a large group of surgeons, surgical trainees, advanced practice providers, CICU physicians and trainees, nursing leadership, the bedside nurse, and even the parents present in (or mostly outside in the hall) the CICU, traveling from patient to patient. A brief, standardized presentation by the ICU, surgical, and nursing providers for the patient was followed by surgical plans, i.e. removal of the chest tubes, pacing wires, sternal closure, etc. for the day. It was typical to have limited sight and hearing lines to the presenter, the patient, the displayed radiographs, and the physiological monitors. The COVID‐19 pandemic has prevented the gathering of large groups near the bedside and given rise to some novel methods to present the patient’s data to a multidisciplinary group. At the time of this writing, Surgical Rounds are conducted over videoconferencing with all participants (20–40 on most days) logged in at their respective desks. The presenters communicate the data, while the chest radiograph and real‐time physiologic monitoring data are displayed on the screen (Figure 4.5). Joint decisions are made about surgical and major ICU issues, with all participants able to see and hear all the data, and with the ability to speak up to allow their perspectives to be communicated. The process is also more efficient in this manner, with as many as 30–40 active surgical patients presented in the allotted 45 minutes. The entire Heart Center is invited to these rounds, as with all of the other major patient care conferences.

Performance Rounds

Once per week a 60‐minute meeting is devoted to Performance Rounds, where selected patients from surgery or the catheterization laboratory are presented in a standardized, visual, infographic time‐based format where the horizontal axis is time (days) and the vertical axis is the perceived risk level to the patient, from threats, errors, unintended clinical states and their linkage; risk increases with the intensity of the activity and decreases with the de‐escalation of care (Figure 4.6). Increased risk is conferred during surgery, generally the highest risk state in a patient’s journey, and decreased with tracheal extubation, sternal closure, weaning off inotropes, discharge to ward, and discharge to home. Data is collected from electronic medical records, bedside data, adverse event reporting mechanisms, and staff interviews. This approach was described by Hickey and colleagues, who reported on 524 patient care “flights” surrounding a surgical procedure [14]. In 12% of flights the patients failed to de‐escalate sequentially, and in the timeframe expected, through the risk levels. Failed de‐escalations were strongly associated with errors (426 in 257 flights, p < 0.0001). More serious errors were associated with the 29% rate of failed de‐escalation, vs. 4% in flights with no consequential error (p < 0.0001). Using this process at the TCH Heart Center, outcomes data for the major procedures have been developed, both internal center‐specific outcomes, and from national databases such as the Society of Thoracic Surgeons’ Congenital Heart Surgery Database. A team of outcome specialists develops the infographics and presents the data, and the entire Heart Center staff is invited. In recent years interventional cardiac catheterization procedures have been added to Performance Rounds. Before these rounds, the themes of psychological safety (see below), and confidentiality of the privileged patient care information are emphasized. Surgeons’, cardiologists’, and anesthesiologists’ names are listed on the infographic, and they are encouraged to explain any unexpected events for the benefit of the entire Heart Center, with the goal of collective learning, communication, and improving patient care, and not to direct blame to the individual practitioner. Themes and issues that are identified, i.e. communication errors, delayed care, technical errors, decision‐making errors, etc., are discussed, and if emerging patterns are perceived over multiple patients, they are referred formally to the Quality and Outcomes Team for a deeper dive into causes and solutions. These issues are brought back to the Heart Center for updates on changes to processes and outcomes. Routine simple surgery or catheterization laboratory cases, without unexpected progress in de‐escalation, are presented in a list format but not otherwise discussed.

Heart Center Quality Conference

Once per week a 60‐minute conference is devoted to quality and outcomes data and reports from each of the clinical disciplines in the Heart Center, on a rotating basis. This includes a Surgical Morbidity and Mortality conference, Catheterization Laboratory Quality Conference, CICU Quality and Outcomes presentation, Cardiovascular Anesthesiology Quality Presentation, and presentations from Nursing, Adult CHD, Outpatient Cardiology, Echocargiography, and other components of the Heart Center clinical enterprise.

Multidisciplinary meeting

Every Friday early morning, 45 minutes are devoted to a Quality and Outcomes Multidisciplinary Meeting, where only the attending physicians from Surgery, Anesthesiology, and CICU, plus a Nursing and Perfusion leader, are invited, for a discussion of each surgical case done in the past week, to review the immediate perioperative course and outcomes, communicate common important issues to the group, and give each member an opportunity to discuss their decision‐making process and how it may have contributed to the outcome. The surgeon starts by briefly presenting the case, and then the anesthesiologist and intensivist have an opportunity to add to the discussion. The smaller group is conducive to frank discussions about opportunities for improvement; identifying significant issues that affect the entire perioperative team that then can be assigned an individual to lead more data collection and solutions to the problem. Great successes are also discussed and celebrated, and those involved in the case can enlighten the group, again for the benefit of future patients.

Figure 4.7 displays the calendar of the weekly multidisciplinary meetings in the TCH Heart Center.

Heart Center Town Hall

With a very large group of practitioners and supporting staff that now numbers greater than 500 individuals, it can be challenging to communicate important events, announcements, initiatives, and strategies to all Heart Center members. Quarterly Heart Center Town Halls, 60 minutes in length, are held, with the Heart Center Executive Committee leadership leading the agenda and introducing additional speakers; there are always at least 15–20 minutes left for comments and questions, and unanswered questions are addressed separately by email (Figure 4.8).

Heart Center annual retreat

Once every year, non‐emergent patient care is paused for 4 hours, and the entire Heart Center participates in a “retreat” – in reality on site at TCH. During these retreats, a theme is prepared, and after Heart Center leadership presentations, speakers from the Heart Center, or outside speakers make presentations followed by questions and comments from the audience. Once again, all Heart Center members at any level of seniority are encouraged to ask questions and make comments, for the benefit of the entire group. Some annual retreat themes have included: improving communication across silos, integrating teams and processes, transparency, psychological safety, shared decision‐making, patient/family experience, partnerships with external providers, and shared common purposes [15, 16]. In the pre‐pandemic era, several hundred people gathered in a large auditorium and enjoyed well‐prepared content, for example, presentations on psychological safety from a well‐regarded Rice University School of Business professor with substantive research in this area (Figure 4.9). In the current pandemic era, this activity is conducted by videoconference; with participants encouraged to write questions, or ask live if they prefer.