Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project

Bates KE, Connelly C, Khadr L, Graupe M, Hlavacek AM, Morell E, Pasquali SK, Russell JL, Schachtner SK, Strohacker C, Tanel RE, Ware AL, Wooton S, Madsen NL, Kipps AK.J Am Heart Assoc. 2021 Nov 2;10(21):e020730. doi: 10.1161/JAHA.121.020730. Epub 2021 Oct 29. PMID: 34713712 


Take Home Points:

  • Using collaborative learning methodology across 9 centers, statistically significant decreases in the postoperative CT duration and reduction in LOS were successfully achieved without any increases in adverse events.
  • Collaborative learning is an effective methodology to reduce variation across centers and ultimately improve patient outcomes.

Dr. Masamichi Ono

Commentary from Dr. Masamichi Ono (Munich, Germany), section editor of Congenital Heart Surgery Journal Watch:


Nine pediatric heart centers collaborated through 2 learning networks. Patients undergoing one of 9 benchmark congenital heart operations were included (patients who underwent the Fontan operation were excluded). Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29).



Introducing collaborative learning model, they could shorten the duration of chest tube, and ICU length of stay in patients after 9 benchmark CHD operations. Collaborative learning model included regular data feedback on practices and outcomes using a shared data-reporting platform, monthly webinars to share intervention ideas and results, and quality improvement coaching. These efforts enabled to improve the postoperative management.



Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may influence postoperative length of stay (LOS). In this study, they showed collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. As results, the centerline CT duration was decreased from 72.6 to 61.3 hours, representing a 15.6% reduction. As for ICU LOS, the centerline LOS was decreased from 9.2 to 8.3 days, representing 9.8% reduction. There was no difference between baseline and intervention phases concerning frequency of CT replacement or hospital readmissions within 7 days because of pleural effusion. To shorten the postoperative ICU LOS, not only standardized management algorithm, but also collaborative learning across the center, play an important role.


They commented that the relationship between CT duration and LOS might vary depending on operation and patient age. For example, the LOS for a newborn following a Norwood operation is likely impacted more by the need to establish enteral feeding and preparation for inter-stage home monitoring than by CT duration, given the large gap between CT duration and LOS shown in our previous work. We agree with this comment in patients undergoing neonatal Norwood procedure.


Further expansion of the multicenter collaborative leaning structure might create more effective management protocol.


In this study, patients undergoing the Fontan procedure were excluded. As we all know, post-operative chest tube management is the most important issue in these patients. Further studies on this comfort are also expected.