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South Texas Pediatric & Congenital Heart Center
2014-2015
OUTCOMES and
PROGRAMMATIC
REVIEW
A partnership for advanced pediatric care
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UTCardioThoracicSurgery.com
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SOUTH TEXAS PEDIATRIC &
CONGENITAL HEART TEAM
We are pleased to share with you the progress of the South Texas Pediatric and Congenital
Heart Center – a partnership between University Health System and the University of Texas
Health Science Center at San Antonio (UTHSCSA). In 2014 our program moved to its new
home at University Hospital. We envisioned constructing a new congenital heart program with
the sole purpose of focusing resources and expertise across all disciplines towards the care of
children and families challenged by congenital heart disease. The program and concept has
undergone a dramatic evolution as we prepare for the opening of our dedicated inpatient and
outpatient Pediatric and Congenital Cardiac Center at University Hospital in the fall of 2016.
Our Pediatric and Congenital Cardiac Program has superior outcomes of any program in
the nation. We are committed to focusing upon excellence via a defined process for patient
and family-centered care. This is achieved through our dedicated Pediatric and Congenital
Cardiac Unit at University Hospital, a specialized-care unit supported by a multidisciplinary
team of caregivers staffed by physicians, nurses and ancillary-care providers who are
committed to the care of families affected by congenital heart disease. Our program has
structured multidisciplinary mechanisms to continuously focus upon the metrics that define
our outcomes as well as being invested in several quality-improvement initiatives. Having
a transparent approach to communication with our colleagues, and more importantly our
patients and families, is one of our keys to success.
In this booklet, we share the program’s recent highlights and growth. We hope to illustrate
our commitment to being a regional and national leader in the delivery of high-quality care.
We believe a committed partnership between UTHSCSA and University Health System,
along with a focused directive to spread our approach to care within South and West Texas
will allow the growth and maturation of our team and program. As we continue to grow, we
remain steadfast in our belief that the personal, programmatic and institutional investments
we make today will produce a Center we will be proud of for years to come. We look forward
to working with you to continue to improve our program and our outcomes. In doing so, we
will be capable of truly impacting and changing the lives of all the families we are privileged to
serve. Our responsibility is to care for these families as if they were our own. Our commitment
is thus not only to heal and treat diseased hearts, but to provide families with logistical and
emotional support during their child's medical and surgical care.
PROGRAM SERVICES
AT A GLANCE
• Fetal echocardiography and cardiology
• Prenatal consultation services with cardiothoracic surgery
• Pediatric cardiology: initial evaluation, follow up and preventative care
• Intersocietal Accreditation Commission accredited Pediatric
Echocardiography Laboratory
• Diagnostic and Interventional Cardiac Catheterization procedures
• Neonatal, Infant, Pediatric and Adult Congenital Cardiac Surgery
• Extracorporeal Membrane Oxygenation (ECMO)
• Dedicated Pediatric and Congenital Cardiac Unit
• Opening of inpatient and outpatient Family Centered Pediatric and
Congenital Cardiac Center – Fall, 2016
PROGRAMMATIC
VOLUMES and OUTCOMES
Inpatient Echocardiograms
2014: 1,305
2015: 1,763
Programmatic Growth = 35.1%
Inpatient Echocardiograms
1800
1600
1400
1200
1000
800
600
400
200
0
2014
ADD THIS TEXT: Programmatic Growth = 35.1%
2015
DIAGNOSTIC TESTING and CARDIAC IMAGING
Cardiac Catheterization Volumes
2014:
2015:
Diagnostic: 49
Diagnostic: 37
Intervention: 66
Intervention: 54
Electrophysiology Studies (Total EP): 34
Electrophysiology Studies (Total EP): 39
Cardiac Catheterization
Volumes
Total = 149
Total = 130
160
140
120
100
2014
80
2015
60
40
20
0
Diagnostic
Intervention
Total EP
Overall Total
SURGICAL VOLUMES
and OUTCOMES
Cardiothoracic Surgical Volumes
2014:
Total Patients: 105
Total Cases: 149
Neonatal Patients: 31
Neonatal Cases: 52
2015:
Total Patients: 123
Total Cases: 165
Neonatal Patients: 35
Neonatal Cases: 55
Programmatic Patient Growth of 17%
Programmatic Case Volume Growth of 11%
Neonatal Patient GrowthCardiothoracic
of 13%
Surgical Volumes
180
160
140
120
Patients
100
Cases
80
60
40
20
0
2014
ADD THIS TEXT:
Programmatic Patient Growth = 17%
2015
SURGICAL VOLUMES and OUTCOMES
Cardiothoracic Surgical Mortality
2014: 1.34% (2 patients)
2015: 2.42% (4 patients)
Cardiothoracic Surgical Mortality
5
STS National Mortality Average = 3.2%
4
3
2
1
0
DD THIS TEXT:
2014
2015
Single Ventricle Patient Volumes
2014: 7 patients
Operative Mortality – 1 patient
Survival to Discharge = 85.7%
2015: 13 patients
Operative Mortality – 2 patients
Survival to Discharge = 84.6%
Single Ventricle Patient Growth = 86%
Single Ventricle Patients
14
12
10
8
6
4
2
0
TEXT:
tricle Patient Growth = 86%
2014
2015
SURGICAL VOLUMES and OUTCOMES
Single Ventricle Stage I Palliation Survival to Discharge
Operative Mortality – 1 patient
Survival to Discharge = 85.7%
Operative Mortality – 2 patients
Survival to Discharge = 84.6%
Single Ventricle Survival to Discharge
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
2014
2015
SURGICAL VOLUMES and OUTCOMES
Adult Congenital Cases
(patients over 18 years of age at time of surgery):
2014: 3
2015: 13
Adult Congenital Cases
14
12
10
8
6
4
2
0
2014
2015
REFERRAL SUMMARY
Referral Patterns for Cardiac Surgery (patients):
Referring Source – 2014 / 2015
UTHSCSA Division of Pediatric Cardiology – 53 / 49
El Paso – 14 / 20
Military Cardiologists – 17 / 17
DHR Partnership – 4 / 8
Laredo – 4 / 3
Austin – 1 / 2
Jatin Patel (San Antonio Private Practice Pediatric Cardiologist) – 0 / 4
San Antonio PediatriX Cardiology – 1 / 7
HeartGift, San Antonio – 7 / 6
Marc Feldman (UTHSCSA Adult Cardiologist) – 1 / 4
Other Physicians – 3 / 3
60
50
40
30
2014
2015
20
10
0
UTHSCSA
Pedi
Cardiology
El Paso
Military
RGV
Laredo
Austin
J. Patel
SA PedatriX
HeartGift
M. Feldman
Other
Referral Sources: Referral
2014
SA PedatriX
1%
J. Patel
Austin 0%
Laredo
4%
1%
Sources
2014
M. Feldman
1%
HeartGift
7%
Other
3%
RGV
4%
UTHSCSA Pedi Cardiology
50%
Military
16%
El Paso
13%
REFERRAL SUMMARY
Referral Sources
Referral Sources: 2015
2015
M. Feldman Other
3%
2%
HeartGift
5%
J. Patel
3%
Austin
2%
Laredo
2%
SA PedatriX
6%
UTHSCSA Pedi Cardiology
40%
RGV
8%
Military
14%
El Paso
16%
PEDIATRIC and CONGENITAL
CARDIAC UNIT
The Pediatric & Congenital Cardiac Unit (PCCU) serves the inpatient practice of the
South Texas Pediatric and Congenital Heart Center. The faculty of the UTHSCSA
Division of Pediatric Critical Care provides 24/7 in-unit patient care; the heart team
is led by an attending physician and consists of a mid-level provider or Critical Care
fellow. In 2015, the PCCU continued its successful course of integrating the efforts
of UT-Kids/UTHSCSA faculty and University Hospital dedicated staff.
PCCU Highlights
Patient Care
•Focused educational program including designed curriculum, mock codes, and clearly
identified process to advance based upon experience
•Peripherally Inserted Central Catheter (PICC) team and protocol in development
•Created a formal procedure for transfusion of blood collected in the Operating Room
(“cell-saver”) or blood product initiated there, such as reconstituted blood. This might
be the first or among the few such formally established procedures in the country
•In collaboration with Anesthesiology and CT-Surgery created a process to improve
efficiency of transition from the PCCU to the Operating Room
Quality Measures
•Longest days (353 days) between central line infections: 0.85/1000 Central Line Days
vs. national average of 1/1000 Central line Days
•Consistently in the top two in quality metrics server by the Pediatric CMT (central line
infection, urinary catheter infection, hand hygiene, patient satisfaction)
•Low mortality rate of all admissions to the PCCU.
2014: 2.8%
2015: 1.6%
Staff Advancement
•Increased nursing FTE from 20.4 to 23.25
•Patient care coordinator joined the Unit
•Four nursing staff attended two national educational conferences focused on cardiac
critical care
•83.3% baccalaureate-prepared nurses vs. magnet national average of 65.78%
Facility Improvement
Our new Pediatric Cardiac Care Unit (PCCU), set for completion fall 2016, will include four
hotel-like rooms for parents to sleep just a few steps from their child's room, along with a
common living area, a shared kitchen and laundry.
PEDIATRIC and CONGENITAL CARDIAC UNIT
Program Expansion
•Increased direct transfers to the PCCU.
2014: 19 – Eagle Pass (6), Edinburg* (2), Laredo (2)
2015: 35 – Edinburg* (6), El Paso (6), Eagle Pass (3)
•The PCCU admitted patients from a wide geographic distribution ranging from West Texas
to the Rio Grande Valley Region (Figure 1).
•PCCU admissions increased by almost 30 % (from 249 admissions in 2014 to 321 in 2015)
with Pediatric Cardiac Critical Care Service seeing a 157 % increase.
2014: Total = 249 with 37 direct admit to Cardiac Critical Care
2015: Total = 321 with 95 direct admit to Cardiac Critical Care
Figure 1:
Geographic
distribution of
facilities served
by the PCCU
El Paso (6)
Austin
New Braunfels (1)
Seguin (1)
San Antonio (13)
Uvalde (1)
Carrizo Springs (1)
Eagle Pass (3)
Laredo (1)
Edinburg (6)
Recognition
McAllen (1)
Harlinggen (1)
•Praised by Joint Commission surveyor
•A 2015 graduate fellow of the Division of Critical Care Medicine is now an attending at a
very active pediatric cardiac program in Albuquerque, New Mexico
Academic Contribution
•Dr. Carrillo, fellow graduate of Pedi Critical Care Medicine, presented a podium abstract
on the practice of immunization in infant with congenital heart disease (2015 American
Academy of Pediatrics national meeting)
QUALITY IMPROVEMENT
INITIATIVES
Sternal Wound Infection Project
This project was initiated in 2011 when we looked at sternal wound infections following
pediatric cardiac surgery via a survey study of all programs across the United States. We
discovered very little protocolized consistency in approach to limit infections. This study
was published in the Annals of Thoracic Surgery. As a follow up, our group embarked
upon creating a data driven protocol for the prevention of sternal wound infections and
implemented it within our program from 2011-2013. We found that the implementation of the
protocol decreased our incidence of sternal wound infections, and our result was published
in the World Journal for Pediatric and Congenital Cardiac Surgery in 2013. Subsequently we
became the lead institution in a two-year prospective multi-institutional study involving 10
programs looking at a uniform protocolized approach towards decreasing the incidence of
sternal wound infections. This study has been performed in conjunction with the Society of
Thoracic Surgeons National Database. Our data collection has just been completed and we
are in the process of data analysis prior to formal presentation and manuscript submission.
Fontan Protocol
In June of 2015 our program initiated a protocolized approach for patients undergoing thirdstage palliation for single ventricle disease – the Fontan Procedure. This operation is well
known to be associated with prolonged hospital stays secondary to pleural effusions. Our
team used a data-driven approach to create a formalized protocol for all patients receiving
the Fontan procedure, which included specific surgical, intensive care and pharmacologic
therapies. Since the initiation of the protocol, our programmatic lengths of stay for a Fontan
Procedure have decreased from an average of 66 percent.
Early Extubation Protocol
In December of 2015, our program initiated an early extubation strategy for patients
undergoing congential heart surgery. More specifically, we are tracking our ability to extubate
a patient in the operating room setting versus within six hours upon arrival to the PCCU.
This study involves inclusion of a well-defined subset of patients. We have constructed this
protocol using parameters defined by other studies; however, we submit that this particular
approach is more encompassing than previously published reports. It is our belief that we
must evaluate the safety of such an approach and if we deem it to be a safe therapeutic
initiative, to further evaluate our ability to extubate patients earlier and in doing so, shorten
hospital stays.
ACHIEVEMENTS
1. Humanitarian Efforts
Our program has been committed to several humanitarian endeavors to narrow the global
disparity in the delivery of congenital cardiac care. Congenital heart disease is the most
common birth defect in the world, impacting nearly one percent of all live births. Over 90
percent of children in the world who are in need of a surgical intervention for congenital
heart disease do not have access to care.
HeartGift San Antonio
HeartGift, San Antonio was established in 2008. Its purpose is to bring children from
underserved regions of the world to San Antonio for corrective heart surgery. To date our
program has performed corrective surgery on 43 patients. Since our partnership with UHS,
we have performed corrective surgery on 13 patients from seven different countries. These
countries include Uganda, Mongolia, Philippines, Honduras, Bolivia, Kenya and Jamaica.
Medical Humanitarian Trip to Palestine and the Gaza Strip
In October of 2015, a nine-person team from San Antonio and UHS/UTHSCSA embarked
on a 10-day trip to the Gaza Strip and performed corrective surgical procedures on nine
children with congenital heart disease. This is the sixth time a trip has been made by team
members to the Middle East with a total of 81 patients receiving surgical intervention.
Medical Humanitarian Trip to Lima, Peru
In January of 2016, our seven-person team embarked upon a 10-day trip to Lima, Peru and
performed corrective surgical procedures on children with congenital heart disease.
2. Optum Center of Excellence Designation
As of January 2016, Optum has designated 19 congenital heart programs in the U.S. as
Centers of Excellence. Our program is one of those centers and one of only three in the state
of Texas. Per their website, Optum states:
“Patients with complex medical conditions are more likely to get better care when they
are treated by experienced, knowledgeable physicians, and better care leads to shorter
hospital stays, higher success rates, faster recoveries and lower costs. At Optum, we have
provided access to clinically superior, cost-effective health care for complex medical
conditions since 1986. Find out how we can assist you or your organization.”
www.myoptumhealthcomplexmedical.com/gateway/public/chd/chd.jsp
ACHIEVEMENTS
3. William Randolph Hearst Foundation Endowment
The William Randolph Hearst Endowment and Chair in Congenital Heart Disease was
created in October of 2013 as the program was in transition to move to University
Health System. This endowment has grown to $800,000 through funds not only from
the Hearst Foundation, but also the President’s office at UTHSCSA, as well as local
philanthropic support. This Endowment has allowed for a yearly visiting professorship to
be created, which has been extremely educational for the entire program in regards to
bringing nationally recognized physicians to San Antonio. In addition, the endowment is
in the process of funding a large portion of the Information Technology and Academic
Resources within the newly designed inpatient and outpatient Pediatric and Congenital
Heart Center at University Health System.
4. Doctor’s Hospital At Renaissance Partnership
University Health System and UTHSCSA jointly have partnered with Doctor’s Hospital
at Renaissance (DHR) for the care of children and families with congenital heart disease
in the Rio Grande Valley Region. This partnership was initiated in August of 2015 with
the first formal surgical clinic held at DHR on September 24, 2015. We are seeing fetal
consultations as well as pre- and post-operative surgical patients. This partnership, in its
infancy, has already yielded a 100% increase in patient referrals from the Region to our
program. In addition, a pediatric cardiology summit was held involving all local pediatric
cardiologists on January 20, 2016, at which time further discussions were held regarding
the amalgamation of pediatric cardiothoracic surgical services for the area. We will
continue to hold a monthly clinic as well as well-defined outreach initiatives in 2016. In
addition, we are pleased to be a template for other pediatric subspecialty services who
wish to create a formal partnership with DHR. The objective of creating a University
Health System/UTHSCSA multispecialty pediatric clinic at DHR would be a key initiative
for furthering the pediatric initiative in the Rio Grande Valley Region.
PROGRAMMATIC NATIONAL
ACADEMIC WORK and PUBLICATIONS
PEER-REVIEWED PUBLICATIONS
Peer-reviewed Publications
Carroll N, Beers K, Maldonado E, Calhoon JH, Husain SA. Novel Annular and Subvalvar
Enlargement in Congenital Mitral Valve Replacement. Annals of Thoracic Surgery –
Submitted.
Weston C, Husain SA, Curzon C, Neish SR, Kennedy G, Bonagurio K, Gosselin, K.
Improvingoutcomes for infants with single ventricle disease through standardized
feeding during the inter-stage period; Journal of Pediatric Nursing – Submitted.
Jacobs JP, He X, Mayer JE, Austin EH, Quintessenza JA, Kark TR, Vricella L, Mavroudis C,
O’Brien SM, Pasquali SK, Hill KD, Husain SA, Overman DM, St. Louis JD, Han JM, Shahian
DM, Cameron D, Jacobs ML. Mortality Trends in Pediatric and Congenital Heart Surgery:
An Analysis of the STS Congenital Heart Surgery Database; Annals of Thoracic Surgery –
Accepted and In Print.
Nelson E, Calhoon JH. Presidential Address: America and Thoracic Surgery. Southern
Thoracic Surgical Association Presidential Address. Annals of Thoracic Surgery. 2016 Accepted and In print.
Brown DW, Mangeot C, Anderson JB, Peterson LE, King EC, Lihn SL, Neish SR, Fleishman
C, Phelps C, Hanke S, Beekman RH, Lannon CM; National Pediatric Cardiology Quality
Improvement Collaborative. Digoxin Use Is Associated With Reduced Interstage
Mortality in Patients With No History of Arrhythmia After Stage I Palliation for Single
Ventricle Heart Disease. J Am Heart Assoc. 2016 Jan 11;5(1).
Husain SA. The Continued Evolution of a Transformational Operation: New Options
for Wrapping the Ross Autograft. Journal of Thoracic and Cardiovascular Surgery The
Journal of Thoracic and Cardiovascular Surgery, 2015 Vol. 149, Issue 4, p1142-1143.
Husain SA, Rahman M, Baisden C, Forgione D, Kane LC, Neish SR, Calhoon JH. Creating
A “Value Index”: A Method to Compare Regional Programs Performing Congenital Heart
Surgery. Journal of Health Care Finance, 2015;42:1.
Kane LC, Woodward C, Husain SA, Frei-Jones M. Thromboelastrography reduces
transfusionsin Pediatric Cardiac Surgery; Journal of Surgical Research 2016
Jan;200(1):21-7
Anderson JB, Beekman RH 3rd, Kugler JD, Rosenthal GL, Jenkins KJ, Klitzner TS, Martin
GR, Neish SR, Brown DW, Mangeot C, King E, Peterson LE, Provost L, Lannon C; National
Pediatric Cardiology Quality Improvement Collaborative. Improvement in Interstage
Survival in a National Pediatric Cardiology Learning Network. Circ Cardiovasc Qual
Outcomes. 2015, Jul;8(4):428-36.
Husain SA. Cardiac Strangulation: Should We Worry? Journal Of Thoracic and
Cardiovascular Surgery, 2014;14:833
Eilers AL, Nazarullah AN, Shipper ES, Jagirdar JS, Calhoon JH, Husain SA. Cardiac
Inflammatory Myofibroblastic Tumor: A Comprehensive Review of the Literature. World
Journal of Pediatric and Congenital Heart Surgery, 2014;5:556-564.
Husain, SA, Pasquali SK, Jacobs JP, Hill K, Kim S, Kane LC, Calhoon JH, Jacobs ML.
Geographic Variation of Congenital Heart Disease Requiring Operative Intervention with
the First Year of Life: An Analysis of The Society of Thoracic Surgeons Congenital Heart
Surgery Database – Annals of Thoracic Surgery 2014;98:912-8.
Anderson JB, Beekman RH 3rd, Kugler JD, Rosenthal GL, Jenkins KJ, Klitzner TS,
Martin GR, Neish SR, Darbie L, King E, Lannon C; National Pediatric Cardiology Quality
Improvement Collaborative. Use of a learning network to improve variation in interstage
weight gain after the Norwood operation. Congenit Heart Dis. 2014 Nov-Dec;9(6):512-20.
Baker-Smith CM, Wilhelm CM, Neish SR, Klitzner TS, Beekman RH 3rd, Kugler JD, Martin
GR, Lannon C, Jenkins KJ, Rosenthal GL. Predictors of prolonged length of intensive care
unit stay after stage I palliation: a report from the National Pediatric Cardiology Quality
Improvement Collaborative. Pediatr Cardiol. 2014 Mar;35(3):431-40.
National Speaker Invited Presentations
Husain SA, Fullerton D. Aortic Root Enlargement Techniques: Society of Thoracic Surgeons
(STS) 52nd Annual Conference. Phoenix, AZ. Jan 27, 2016
Jacobs JP, Mayer JE, Austin EH, Quintessenza JA, Karl TR, Vricella L, Mavroudis C, O’Brien
SM, Pasquali SK, Hill KD, Husain SA, Overman DM, Han JM, Shahian DM, Cameron D, Jacobs
ML. Mortality Trends in Pediatric and Congenital Heart Surgery: An Analysis of the STS
Congenital Heart Surgery Database – Southern Thoracic Surgical Association – 62st annual
meeting, Orlando, FL Nov. 5-8, 2015
Joseph H, Ryan C, Fancher WN, Kane LC, Das NA, Husain SA, Northrup W, Calhoon JH.
Understanding Pulmonary Valve Architecture and Variation: Implications for the Ross
Procedure - Southern Thoracic Surgical Association – 62st annual meeting, Orlando, FL Nov.
5-8, 2015
Husain SA. Right Ventricular Outflow Tract – Anatomy, Physiology and Surgical Approaches.
AQO – STS Database Managers Conference. San Antonio, TX Oct. 21, 2015
Maldonado E. Congenital Heart Disease: Collaborating for Improved Care. San Antonio
Military Health System and Universities Research Forum, July 24, 2015
Husain SA. Disparities in the Delivery of Surgical Care For Congenital Heart Disease:
The Importance of Teamwork in the Operating Room: American Association for Surgical
Technologists Annual Conference. San Antonio, TX. May 15, 2015
Brown JW, Husain SA. Aortic Root Enlargement Techniques: Society of Thoracic Surgeons
(STS) 51st Annual Conference. San Diego, CA. Jan 28, 2015
Direct-patient referrals to University Hospital: 210-358-1583
Pediatric transfers and transports to University Hospital: 210-743-3100
Outpatient referrals with same-day appointments upon request: 210-341-7722
A partnership for advanced pediatric care
UniversityHealthSystem.com/Heart
UTCardioThoracicSurgery.com
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