Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol

Nancy A Pike; Carol A Okuhara; Joy Toyama; Barbara P Gross; Winfield J Wells; Vaughn A Starnes

doi:10.1016/j.jtcvs.2015.06.042

Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol

J Thorac Cardiovasc Surg. 2015 Sep;150(3):481-7. doi: 10.1016/j.jtcvs.2015.06.042. Epub 2015 Jun 26.

Authors

Nancy A Pike¹, Carol A Okuhara², Joy Toyama³, Barbara P Gross², Winfield J Wells⁴, Vaughn A Starnes⁴

Affiliations

¹ Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; School of Nursing, University of California Los Angeles, Los Angeles, Calif. Electronic address: npike@sonnet.ucla.edu.
² Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif.
³ School of Nursing, University of California Los Angeles, Los Angeles, Calif.
⁴ Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Keck School of Medicine, University of Southern California, Los Angeles, Calif.

PMID: 26254747
DOI: 10.1016/j.jtcvs.2015.06.042

Abstract

Background: Persistent pleural effusions after the Fontan procedure contribute to prolonged hospitalization and increased costs. We report our experience using a modified Wisconsin Fontan protocol to reduce chest tube drainage and hospital length of stay (LOS).

Methods: Single institutional retrospective chart review of 120 consecutive patients (60 before and 60 after initiation of our protocol) undergoing an extracardiac Fontan procedure from January 2004 to February 2007. Protocol influence was assessed by comparing group differences on duration of pleural drainage, requirement for nothing by mouth/total parenteral nutrition, hospital LOS, readmission for pleural effusion, and total hospital costs.

Results: Groups were similar in demographic characteristics, single ventricle morphology, preoperative hemodynamic parameters, and operative and immediate postoperative management. Median duration of pleural drainage and hospital LOS was reduced in the post- versus preprotocol groups: 4 days (interquartile range [IQR], 4-5 days) pre versus 6 days (IQR, 5-10 days) (P < .0001) and 6 days (IQR, 5-9 days) versus 8 days (IQR, 6-13 days) (P = .005), respectively. Pleural drainage lasting >1 week was also less common postprotocol: 23 (38%) before versus 7 (12%) after (P = .001). Fewer postprotocol patients required nothing by mouth/total parenteral nutrition to control effusions: 5 pre versus 0 post (P = .06), and fewer readmissions for effusions (14 before vs 7 after [P = .1]). An average total cost savings of 22% and readmissions savings of 29% resulted in nearly $500,000 in institutional savings over the study period.

Conclusions: A modified Fontan protocol resulted in reduced time to chest tube removal, hospital LOS, and chest tube drainage lasting >1 week. There was a strong trend toward avoiding nothing by mouth/total parenteral nutrition to control pleural effusion and lower hospital costs.

Keywords: Fontan; congenital heart disease; pleural effusion; postoperative care; protocol.

MeSH terms

Child, Preschool
Cost Savings
Drainage / adverse effects
Female
Fontan Procedure / adverse effects*
Fontan Procedure / economics
Heart Defects, Congenital / diagnosis
Heart Defects, Congenital / economics
Heart Defects, Congenital / surgery*
Hospital Costs
Humans
Length of Stay* / economics
Los Angeles
Male
Parenteral Nutrition, Total
Patient Readmission* / economics
Pleural Effusion / diagnosis
Pleural Effusion / economics
Pleural Effusion / etiology
Pleural Effusion / therapy*
Postoperative Care / adverse effects
Postoperative Care / economics
Postoperative Care / methods*
Retrospective Studies
Time Factors
Treatment Outcome