As a pediatric cardiology fellow nearly a decade ago, Michael Gaies remembers asking hospital colleagues a simple question: How good are we at providing cardiac intensive care for children?

"There wasn't a good answer because there wasn't a good way to measure our performance. We didn't have access to the right data," recalls Gaies, M.D., director of quality at the Congenital Heart Center at Michigan Medicine's C.S. Mott Children's Hospital.

It was the beginning of a massive effort to change the culture around critical pediatric heart care at children's hospitals across the country. Gaies, along with Mott congenital heart program co-director John Charpie, M.D., Ph.D., ultimately launched the Pediatric Cardiac Critical Care Consortium. PC4 aims to improve the quality of care for pediatric heart patients through transparent data sharing that allows hospitals to evaluate their own outcomes and learn best practices from high-performing peers.

And the effort is having an impact. Eighteen hospitals were able to significantly reduce deaths and improve care for children with critical heart conditions, suggests a just-published analysis of 19,600 hospitalizations that included cardiac surgery at the participating sites in the PC4 registry.

Postoperative mortality dropped by 24% among participating sites between 2014 and 2018, according to the Michigan Medicine-led research in the Journal of the American College of Cardiology. Major complications also fell by 12%, time on a ventilator declined by 13% and length of stay in the ICU was down by 5%.

Authors aimed to measure improvement in outcomes after two years of participation in the collaborative. Outcomes were compared between the two-year baseline period and all months afterward.

"These changes in outcomes seem to reflect PC4's commitment to transparency between institutions and collaboration to share best practices," says Gaies, the study's lead author and PC4 founder.

"Hospitals are working together to create a culture of collaboration rather than competition. This work is having a tremendous impact on children and families affected by critical heart disease."

Researchers analyzed mortality, complications and length-of-stay trends over the same time period at 17 comparable hospitals that were not part of PC4 and found no evidence of improvement at these hospitals. These data strengthen the conclusion that improvement seen at the PC4 hospitals is likely the result of participation in PC4 and not due to a trend in improvement across the field, Gaies says.

Learning from top performers

Many children with critical pediatric and congenital cardiovascular disease require surgery in the newborn period or later in infancy. Outcomes for pediatric cardiac surgery have improved over several decades, but the improvements have leveled off more recently, Gaies says.

Mortality remains high for complex operations while postoperative complications result in morbidity that can affect survivors across their lifespan. Variations in outcomes also persist across hospitals, particularly for complex surgery.

"Our data told us there were opportunities to learn from each other to improve the quality of ICU care for babies and children who require heart surgery," Gaies says.

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PC4 is modeled after similar collaboratives nationally and in the state of Michigan that work to reduce postoperative morbidity and mortality. A National Institutes of Health grant to the University of Michigan provided initial funds for PC4, but the initiative now relies on hospital and donor investments.

Member hospitals are required to share clinical outcome data with one another through a registry with information about perioperative practices and outcomes that include postoperative mortality, complications, duration of mechanical ventilation and length of stay. 

More than 50 hospitals now contribute data to the registry, up from just six hospitals in 2013 when it began. Cases may be submitted in real-time immediately after a patient's discharge, and participants have access to a web-based reporting platform that is updated each morning.

"Access to timely, actionable, and transparent clinical outcome data likely creates an important Hawthorne effect for hospitals that previously had limited opportunities to critically evaluate their quality of care," Gaies says. "Just being aware of your own performance has a powerful impact.  We get motivated to change our practice when we see what is possible by our peers."

"We aren't just talking with colleagues in the same building, but with peers across the nation, almost every day," he adds. "We're all on one team."

Participants regularly reach out to high-performing hospitals in areas of care in which they seek to improve and work with them to adopt successful practices at their own sites. Panels of experts from high-performing hospitals also explain their practices at PC4's annual meeting and through webinars. 

In order to expand these efforts beyond the cardiac ICU setting, PC4 recently joined forces with other large research and improvement networks, together forming a new initiative known as Cardiac Networks United.

There's still a lot of work ahead, Gaies says. Implementing and sustaining new practices that improve cardiac ICU care requires long-term commitment across multiple care teams.

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But he and colleagues are encouraged by the difference the collaboration is already making.

"Institutions are sharing insight on practices and resources that underlie their excellent performance," Gaies says. "We are seeing experts across the country committed to working together to improve the care of kids with congenital heart disease.  This collaboration reveals the very best of people who care for these children and families."

John Charpie, M.D., Ph.D., co-director of the congenital heart program at Mott, is the paper's senior author.

Disclosure: Co-authors Justin Dimick, chair of the Department of Surgery at the U-M Medical School; and John Birkmeyer, of Sound Physicians, Tacoma, Washington, are co-founders and equity owners of ArborMetrix, Inc., which provides software and analytic support to the Pediatric Cardiac Critical Care Consortium.