PM1011: Reduced Hospital Length of Stay Following Implementation of Postoperative Fontan Medical Management Guidelines

Purpose/Objectives: Patients following a Fontan operation frequently have increased hospital length of stay (LOS) secondary to prolonged chest tube drainage. The average LOS following the Fontan procedure at Nationwide Children’s Hospital was above the aggregate Society for Thoracic Surgery mean LOS.
The objective of this quality improvement project was to develop and implement standardized postoperative clinical management guidelines for patients following the Fontan procedure to decrease hospital length of stay.

Design/Methods: Retrospective review of all patients in the Heart Center who underwent the Fontan procedure from January 2010 to December 2019 revealed hospital length of stay greater than the STS mean. Standardized postoperative clinical management guidelines for patients following Fontan procedure were implemented in April 2020 (Figure 1). These guidelines were developed based on previously described protocols with several key features including the use of ambulatory PleurX chest tubes (BD, Franklin Lakes, NJ), aggressive diuresis and fluid restriction, and maximization of pulmonary vasodilation with supplemental oxygen and sildenafil. All surgeons began routine placement of PleurX chest tubes catheters in the pleural space at the time of the Fontan procedure. The chest tubes were capped once drainage decreased; all patients were discharged home with chest tubes in place. The patients returned for outpatient follow up by the cardiothoracic advanced nurse practitioners several times a week for uncapping and drainage until the chest tubes were removed. Clinical outcome variables before and after guideline implementation were compared.

Results: Pre guidelines, Jan 2010-Dec 2019, there were 205 patients who underwent Fontan procedure with an average length of hospital stay of 19+23 days (median 12; range 4-238). Post guidelines, April 2020-Oct 2021, there were 25 patients who underwent Fontan procedure with an average length of hospital stay of 9+6 days (median 7; range 5-38) (Figure 2). There was no change in 30-day readmissions following guideline implementation (20% pre vs 20% post). Average removal of PleurX chest tube was postoperative day 42+32 (median 34; range 8-169). Overall compliance for all guideline components was 77%. The most challenging components were the use of oxygen via NC (48% compliant) and the transition of diuretics to oral (64% compliant).

Conclusion/Discussion: Implementation of standardized postoperative clinical management guidelines for patients following Fontan procedure was successful in significantly reducing hospital length of stay without impacting readmission rates. Family satisfaction has been very positive based on unsolicited parental feedback.