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Ann Thorac Surg. 2019 May;107(5):1427-1433. doi: 10.1016/j.athoracsur.2018.09.024. Epub 2018 Oct 31.

Sustainability of Infant Cardiac Surgery Early Extubation Practices After Implementation and Study.

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Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan. Electronic address:
Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan.
Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
Department of Pediatrics, Emory University, Atlanta, Georgia; Sibley Heart Center, Emory University, Atlanta, Georgia.
Michigan Congenital Heart Outcomes Research and Discovery Unit, Pediatric Cardiac Critical Care Consortium Data Coordinating Center, University of Michigan, Ann Arbor, Michigan.



The Pediatric Heart Network Collaborative Learning Study (PHN CLS) successfully changed practice at four hospitals to increase the rate of early extubation within 6 hours after infant heart surgery. It is unknown whether this practice continued after study completion.


We linked the PHN CLS dataset to the Pediatric Cardiac Critical Care Consortium registry to compare outcomes at four active hospitals between the study period (post-clinical practice guideline [CPG]) and the first year after study completion (follow-up) after a 3-month washout. Inclusion and exclusion criteria were the same across eras. Primary outcome was early extubation rate after tetralogy of Fallot or aortic coarctation repair. Secondary outcomes included time to first extubation and intensive care and hospital lengths of stay.


There were 121 patients in the post-CPG era and 139 patients in the follow-up era with no difference in patient characteristics or operation subtypes. Post-CPG early extubation rate declined from 67% to 30% in follow-up (p < 0.0001); time to first extubation increased (4.5 versus 13.5 hours, p < 0.0001). One hospital maintained the rate of early extubation (72% versus 67%), whereas the other three hospitals had significantly lower rates in follow-up (p < 0.02 for each). Intensive care (2.8 versus 2.9 days) and postoperative hospital (6 versus 5 days) stays did not differ between eras (p > 0.05 for both). Findings were consistent across operation subtypes.


Extubation practice in the first year of follow-up after the PHN CLS reverted toward prestudy levels. One of four hospitals maintained its early extubation strategy, suggesting that specific implementation and maintenance approaches may effectively sustain impact from quality initiatives.

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