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Background: Packed red blood cells (PRBC) are often ordered for pediatric cardiac catheterizations (PCC) with no current appropriate use guidelines, resulting in increased utilization. A quality improvement (QI) project was created to focus on optimizing ordering of PRBC for PCC. The primary aim was to increase adherence to new guidelines to > 97%, with a global aim to decrease patient cost. Methods: Retrospective chart review was performed to collect baseline data. For PDSA cycle 1, we updated our own PRBC ordering guidelines by risk stratifying procedures. The PCC report was updated to include documentation of PRBC ordering or transfusion. PDSA cycle 2 included further refinement of the guidelines, and improved awareness amongst those placing the pre-PCC orders. Process measures included ensuring the need for PRBC stated during every pre-PCC time-out, and consistent documentation in the PCC report. Balancing measures included monitoring the rate of PRBC transfusion within 24 hours post-PCC, and incidence of emergency release of PRBCs. Results: For 3 months of baseline data, 112/403 of CCPs (27.8%) had PRBC ordered, 87.5% (98/112) of which followed the prior protocol, with 13/403 (3.2%) receiving PRBC transfusion during CCP. With our revised guidelines, there could be > 20% reduction in PRBC ordering, with estimated > $20,000 cost savings based on 1 crossmatch ($173) and 1 unit PRBC ($730) prepared. For PDSA cycle 1, 27/81 (33%) of PCC had PRBC ordered, with 92% adherence to the updated guidelines, and 100% documentation compliance. For PDSA cycle 2, 13/47 (27.6%) had PRBC ordered with 100% adherence to ordering guidelines. During both cycles, 3 patients had PRBC transfusions within 24 hours of their procedure for other medical reasons not related to bleeding. No cases required emergency release of PRBC. There was a statistically significant process change from a median of 86% to 100% adherence (p=0.01) since implementation of the updated guidelines. Conclusion: With revised guidelines and improved adherence, hospital resources and charges were decreased in low-risk cardiac catheterization procedures without an increase in adverse events. This model can be utilized in other systems to similarly reduce resource utilization and costs.

Current risk adjustment models for congenital heart surgery do not fully incorporate multiple factors unique to neonates such as granular gestational age (GA) and birth weight (BW) z score data. This study sought to develop a Neonatal Risk Adjustment Model for congenital heart surgery to address these deficiencies.Cohort study of neonates undergoing cardiothoracic surgery during the neonatal period captured in the Pediatric Cardiac Critical Care Consortium database between 2014 and 2020. Candidate predictors were included in the model if they were associated with mortality in the univariate analyses. GA and BW z score were both added as multicategory variables. Mortality probabilities were predicted for different GA and BW z scores while keeping all other variables at their mean value.The C statistic for the mortality model was 0.8097 (95% confidence interval, 0.7942-0.8255) with excellent calibration. Mortality prediction for a neonate at 40 weeks GA and a BW z score 0 to 1 was 3.5% versus 9.8% for the same neonate at 37 weeks GA and a BW z score -2 to -1. For preterm infants the mortality prediction at 34 to 36 weeks with a BW z score 0 to 1 was 10.6%, whereas it was 36.1% for the same infant atlt;32 weeks with a BW z score of -2 to -1.This Neonatal Risk Adjustment Model incorporates more granular data on GA and adds the novel risk factor BW z score. These 2 factors refine mortality predictions compared with traditional risk models. It may be used to compare outcomes across centers for the neonatal population.