Variation in clinical practice is inherent to the art of medicine, reflecting individualized and humanized care. The problem arises when the care provided lacks clear scientific evidence. While such variability may not result in differences in clinical outcomes, it can signal inefficiency in the system, leading to increased healthcare costs, inappropriate resource utilization, or even heightened morbidity due to unnecessary actions.

Today’s article examines the variability observed at a center before and after implementing a clinical practice guideline for the surgical repair of simple ventricular septal defect (VSD) in a pediatric hospital. In line with previously published data, their aim was to reduce clinical variability, thereby shortening hospital stays without increasing adverse events. The study retrospectively compared outcomes over three years of experience with the guideline against two years prior to its implementation. Exclusion criteria included patients older than one year with nonrestrictive VSD, presence of additional cardiac defects other than patent ductus arteriosus or atrial septal defect, prematurity, chronic kidney disease, chromosomal anomalies, significant comorbidities from other systems, and those requiring intubation for more than six hours. A total of 43 milestones were evaluated within the clinical pathway, of which 5 were deemed essential for successful postoperative outcomes. These included: scheduling the intervention as the first case of the day, ICU admission before 2:00 PM, administering the first dose of furosemide within the first 4 postoperative hours, initiating oral feeding within the first 4 hours, transitioning to oral analgesia by postoperative day one, and avoiding continuous infusions of sedatives or opioids.

The analysis included 23 patients managed under the clinical guideline and 25 from the pre-guideline period. Demographics were comparable between groups. Patients following the clinical pathway achieved, on average, 80% of evaluated milestones. Univariate analysis showed earlier initiation of oral feeding in patients under the guideline, with a mean time of 180 minutes versus 360 minutes in the pre-guideline group (p < .01). Additionally, the clinical pathway group reduced hospital stays by one day (p = .04). No differences were observed regarding adverse events, including mortality, reintervention rates, acute kidney injury, chest tube output, or readmissions.

The authors concluded that implementing clinical guidelines improved oral tolerance times and reduced hospital stays. Such guidelines in surgical settings could reduce clinical variability and enhance the quality of medical care.

COMMENTARY:

The best healthcare practice is one centered on patients and grounded in effectiveness, efficiency, and scientific evidence. Reducing variability fundamentally requires the creation of clinical protocols based on robust evidence. In order to achieve this, the authors established a working group tasked with defining care standards through evidence and consensus. The protocol was reinforced with continuous education and training, including monthly sessions with nursing units and multidisciplinary medical meetings.

This study highlights how early enteral feeding reduces unnecessary intravenous fluid administration, thereby preventing fluid overload. In pediatric patients, agitation is often linked to thirst or hunger. Their limited communication abilities can lead to the administration of sedatives or opioids to manage agitation. Early enteral feeding offers the added benefit of improving patient comfort, which in turn decreases the need for sedatives and/or opioids.

Clinical guidelines, like those described in this article, are essential steps toward enhanced recovery after surgery (ERAS) in pediatric cardiac surgery. ERAS is a relatively new concept in cardiac surgery, with the first guidelines emerging in 2019. Standardizing care allows the identification of patients who might benefit from fast-track management. Moreover, care standardization positively impacts the acute postoperative cardiac care of other patients in the unit.

This retrospective single-center study involved a small number of patients. One key limitation of such studies is the Hawthorne effect, where subjects alter their behavior due to awareness of being observed. This effect can also extend to healthcare personnel, potentially modifying their practices beyond adherence to the new protocol, leading to improved care delivery compared to the pre-guideline phase. Importantly, patients requiring intubation for more than six hours were excluded. Thus, the analysis aligns more with a per-treatment criterion than an intention-to-treat criterion, which might be more accurate. The authors justified this exclusion by arguing that such cases could not adhere to the clinical pathway’s milestones. However, this compromises the study’s internal validity, as it would be crucial to understand the reasons behind deviations from the protocol, such as delayed extubation.

In conclusion, the goal is not to eliminate variability entirely but to minimize it. However, it is critical to eliminate decisions that do not contribute to the objective benefit of our patients.

REFERENCE:

Ogdon TL, Loomba RS, Penk JS. Reduced length of stay after implementation of a clinical pathway following repair of ventricular septal defect. Cardiol Young. 2023 May 25:1-4. doi: 10.1017/S1047951123001245.