title: Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol.
abstract: BACKGROUND
  Persistent pleural effusions after the Fontan procedure contribute to prolonged hospitalization and increased costs. We report our experience using a modified Wisconsin Fontan protocol to reduce chest tube drainage and hospital length of stay (LOS).
  
  
  METHODS
  Single institutional retrospective chart review of 120 consecutive patients (60 before and 60 after initiation of our protocol) undergoing an extracardiac Fontan procedure from January 2004 to February 2007. Protocol influence was assessed by comparing group differences on duration of pleural drainage, requirement for nothing by mouth/total parenteral nutrition, hospital LOS, readmission for pleural effusion, and total hospital costs.
  
  
  RESULTS
  Groups were similar in demographic characteristics, single ventricle morphology, preoperative hemodynamic parameters, and operative and immediate postoperative management. Median duration of pleural drainage and hospital LOS was reduced in the post- versus preprotocol groups: 4 days (interquartile range [IQR], 4-5 days) pre versus 6 days (IQR, 5-10 days) (P < .0001) and 6 days (IQR, 5-9 days) versus 8 days (IQR, 6-13 days) (P = .005), respectively. Pleural drainage lasting >1 week was also less common postprotocol: 23 (38%) before versus 7 (12%) after (P = .001). Fewer postprotocol patients required nothing by mouth/total parenteral nutrition to control effusions: 5 pre versus 0 post (P = .06), and fewer readmissions for effusions (14 before vs 7 after [P = .1]). An average total cost savings of 22% and readmissions savings of 29% resulted in nearly $500,000 in institutional savings over the study period.
  
  
  CONCLUSIONS
  A modified Fontan protocol resulted in reduced time to chest tube removal, hospital LOS, and chest tube drainage lasting >1 week. There was a strong trend toward avoiding nothing by mouth/total parenteral nutrition to control pleural effusion and lower hospital costs.
authors.affiliation: Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; School of Nursing, University of California Los Angeles, Los Angeles, Calif. Electronic address: npike@sonnet.ucla.edu.
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Pike
authors.affiliation: Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Okuhara
authors.affiliation: School of Nursing, University of California Los Angeles, Los Angeles, Calif.
authors.forename: Joy
authors.initials: J
authors.lastname: Toyama
authors.affiliation: Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif.
authors.forename: Barbara P
authors.initials: BP
authors.lastname: Gross
authors.affiliation: Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Keck School of Medicine, University of Southern California, Los Angeles, Calif.
authors.forename: Winfield J
authors.initials: WJ
authors.lastname: Wells
authors.affiliation: Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Keck School of Medicine, University of Southern California, Los Angeles, Calif.
authors.forename: Vaughn A
authors.initials: VA
authors.lastname: Starnes
mesh_terms: D002675:Child, Preschool; D017046:Cost Savings; D004322:Drainage / Q000009:adverse effects; D005260:Female; D018729:Fontan Procedure / Q000009:adverse effects* / Q000191:economics; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000191:economics / Q000601:surgery*; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D015141:Los Angeles; D008297:Male; D010289:Parenteral Nutrition, Total; D010359:Patient Readmission / Q000191:economics; D010996:Pleural Effusion / Q000175:diagnosis / Q000191:economics / Q000209:etiology / Q000628:therapy*; D011182:Postoperative Care / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
keywords: Fontan; congenital heart disease; pleural effusion; postoperative care; protocol