Development of a Charge Adjustment Model for Cardiac Catheterization

A methodology that would allow for comparison of charges across institutions has not been developed for catheterization in congenital heart disease. A single institution catheterization database with prospectively collected case characteristics was linked to hospital charges related and limited to an episode of care in the catheterization laboratory for fiscal years 2008–2010. Catheterization charge categories (CCC) were developed to group types of catheterization procedures using a combination of empiric data and expert consensus. A multivariable model with outcome charges was created using CCC and additional patient and procedural characteristics. In 3 fiscal years, 3,839 cases were available for analysis. Forty catheterization procedure types were categorized into 7 CCC yielding a grouper variable with an R2 explanatory value of 72.6 %. In the final CCC, the largest proportion of cases was in CCC 2 (34 %), which included diagnostic cases without intervention. Biopsy cases were isolated in CCC 1 (12 %), and percutaneous pulmonary valve placement alone made up CCC 7 (2 %). The final model included CCC, number of interventions, and cardiac diagnosis (R2 = 74.2 %). Additionally, current financial metrics such as APR-DRG severity of illness and case mix index demonstrated a lack of correlation with CCC. We have developed a catheterization procedure type financial grouper that accounts for the diverse case population encountered in catheterization for congenital heart disease. CCC and our multivariable model could be used to understand financial characteristics of a population at a single point in time, longitudinally, and to compare populations

Information Management and Hospital Enterprise Information Systems

Effective information management in knowledge-based industries, such as healthcare, is crucial to their success in achieving desired outcomes and product goals. Advances in computer and information technology, along with the evolution of the field of biomedical informatics, have contributed to the maturation of healthcare electronic information systems whose purposes are to support patient care and sustain hospital operations. Access to data across application systems through better integration of system components has become a preferred model for information system architecture and, as a result, institutions often choose to adopt enterprise-wide systems architecture formats using single-vendor application packages. Whether the information system architecture is comprised of multiple, variably, or non-integrated core components or is an integrated enterprise-wide system, this chapter emphasizes how data access, even using a hybrid information system structure, can be used to drive and, hopefully, advance the delivery of care

Anesthesia considerations for children with pulmonary hypertension

Children with pulmonary arterial hypertension undergoing anesthesia pose a challenge. The prevalence of morbidity and mortality in this subgroup is substantially greater than that in the general population. In this article, we attempt to describe the adverse events that occur and also identify some of the factors that may precipitate them. We also suggest mechanisms to attenuate or prevent these crises

Which criteria should be used to select patients for the Fontan operation?

The Fontan operation has improved the survival of children born with single ventricle physiology. Selecting candidates for the Fontan operation may be difficult on borderline cases. No clear criterion has been established on the risk for staged Fontan palliation. Another aspect that remains controversial is the indications for fenestration. Intraoperative pulmonary flow study may identify high-risk patients for the procedure. In this report, the authors describe their results with Fontan procedures in children with pulmonary pressure >15 mmHg

Perioperative Care of the Infant With Single Ventricle Physiology

Opinion statement Among patients with congenital heart defects, neonates with single ventricle disease continue to challenge clinicians despite significant improvements in survival over the past 30 years. The cardiac anatomical variants associated with the term “single ventricle” are characterized by severe hypoplasia (or absence) of either ventricle, typically in association with obstruction or atresia of either the pulmonary or systemic outflow tracts. Physiologically, the single ventricle receives both pulmonary and systemic venous blood and ejects simultaneously into the pulmonary and systemic circulations, a pattern commonly referred to as single ventricle physiology. Medical and surgical management strategies, though palliative, are aimed at achieving the optimal balance of systemic blood flow and pulmonary blood flow to maximize oxygen delivery. Patients with single ventricle physiology have a greater risk of dying than those with biventricular circulations and are generally committed to multiple palliative interventions throughout childhood with considerable risk. Surgical intervention in the newborn period involves Norwood Stage I palliation, placement of a systemic-to-pulmonary artery shunt, or banding of the pulmonary artery, depending on the status of the outflow tracts. Heart transplantation is offered as the initial approach in some centers. The management strategy and the actual delivery of care from the time of birth (or at time of diagnosis) through the postoperative period is crucial to optimize the short-term and long-term outcomes. Whereas survival following initial palliation in experienced centers is as high as 95%, emphasis is now appropriately shifting toward the control of in-hospital morbidity and optimizing long-term functional outcome. Centers are continually striving to gather and apply new knowledge related to the underlying anatomical and physiologic problems while seeking to improve decision making and care of the patient with single ventricle physiology

Emergency Care for Infants and Children with Acute Cardiac Disease

Children occasionally present to the emergency department with life-threatening congenital or acquired cardiac disease. Presenting symptoms may be nonspecific, and accurate assessment and timely interventions are required to achieve optimal outcomes in this heterogeneous and complex patient population. In this article, we review 4 common scenarios: neonates presenting with ductal-dependent congenital heart disease, infants with tetralogy of Fallot who develop hypercyanotic episodes, children with decompensated congestive heart failure, and those with cardiac tamponade. In each instance, presenting signs and symptoms are discussed, and practical suggestions are offered for the initial diagnostic approach and management

Pediatric Extracorporeal Life Support in Specialized Situations

Objectives: The purpose of this review was to provide a systematic review of the literature regarding the use of extracorporeal life support (ECLS) in various specialized conditions, as part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support. Data Sources: MEDLINE and PubMed. Study Selection: Searches for published abstracts and articles were conducted using the following MeSH terms: extracorporeal life support, extracorporeal membrane oxygenation, or mechanical support, and pediatric or children. Data Extraction: Abstracts of all articles including case reports were reviewed; the full article was reviewed if the abstract indicated that it focused on extracorporeal life support for conditions other than primary respiratory disease or persistent pulmonary hypertension of the newborn and described outcomes such as survival to hospital discharge. Studies with potential overlapping patients were highlighted in the review process and summary results. Data Synthesis: Classification of recommendations and level of evidence are expressed in the American College of Cardiology Foundation/American Heart Association format. Conclusions: The majority of specialized situations where extracorporeal life support is used fall into the category of class II-III evidence. Class I indications for extracorporeal life support in the pediatric population include myocarditis and in the context of acute interventions in the cardiac catheterization laboratory

Assessing the introduction of enterprise-wide clinical information systems in pediatric medical center

Advances in computer technology have enabled the evolution from traditionally paper-based medical record systems that are fragmented, with associated difficulties in retrieving critical information, to highly accessible and potentially integrated electronic clinical information systems. Hospitals and clinical environments that have employed electronic information systems until recently have typically done so using department or group-specific systems (i.e., by specialty or clinical practice) offered by separate vendors that are often implemented incrementally. This approach, frequently described as best of breed, has been justified when the individual component systems are deemed the best available options for a given application, even if multiple vendor systems that do not interface are ultimately employed. More recent implementation strategies have involved deployment of single vendor, integrated systems across the entire hospital enterprise. A shift from the best of breed strategy toward the enterprise-wide single vendor application strategy has happened due to cost, medical record fragmentation, strain on the institution's technical and support infrastructure, and the emergence of vendor products designed to serve multiple application needs under a single umbrella. This article builds off our implementation experience at Children's Hospital Boston to describe considerations, including potential benefits and pitfalls, of introducing an enterprise-wide clinical information system in a tertiary care pediatric center