title: Implementation of a Quality Improvement Bundle Improves Echocardiographic Imaging after Congenital Heart Surgery in Children.
abstract: Postoperative echocardiography after congenital heart disease surgery is of prognostic importance, but variable image quality is problematic. We implemented a quality improvement bundle comprising of focused imaging protocols, procedural sedation, and sonographer education to improve the rate of optimal imaging (OI).
  
  
  
  Predischarge echocardiograms were evaluated in 116 children (median age, 0.51 years; range, 0.01-5.6 years) from two centers after tetralogy of Fallot repair, arterial switch operation, and bidirectional Glenn and Fontan procedures. OI rates were compared between the centers before and after the implementation of a quality improvement bundle at center 1, with center 2 serving as the comparator. Echocardiographic images were independently scored by a single reader from each center, blinded to center and time period. For each echocardiographic variable, quality score was assigned as 0 (not imaged or suboptimally imaged) or 1 (optimally imaged); structures were classified as intra- or extracardiac. The rate of OI was calculated for each variable as the percentage of patients assigned a score of 1.
  
  
  
  Intracardiac structures had higher OI than extracardiac structures (81% vs 57%; adjusted odds ratio [OR], 3.47; P < .01). Center 1 improved overall OI from 48% to 73% (OR, 4.44; P < .01), intracardiac OI from 69% to 85% (OR, 3.53; P = .01), and extracardiac OI from 35% to 67% (OR, 5.16; P < .01). There was no temporal difference for center 2.
  
  
  
  After congenital heart disease surgery in children, intracardiac structures are imaged more optimally than extracardiac structures. Focused imaging protocols, patient sedation, and sonographer education can improve OI rates.
authors.affiliation: Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, Missouri. Electronic address: aparthiban@cmh.edu.
authors.forename: Anitha
authors.initials: A
authors.lastname: Parthiban
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jami C
authors.initials: JC
authors.lastname: Levine
authors.affiliation: Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
authors.forename: Meena
authors.initials: M
authors.lastname: Nathan
authors.affiliation: Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Marshall
authors.affiliation: Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.
authors.forename: Girish S
authors.initials: GS
authors.lastname: Shirali
authors.affiliation: Department of Biostatistics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Simon
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Colan
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jane W
authors.initials: JW
authors.lastname: Newburger
authors.affiliation: Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.
authors.forename: Geetha
authors.initials: G
authors.lastname: Raghuveer
mesh_terms: D001900:Boston; D006348:Cardiac Surgical Procedures / Q000379:methods; D002675:Child, Preschool; D004452:Echocardiography / Q000592:standards*; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging* / Q000601:surgery*; D006801:Humans; D007089:Image Enhancement / Q000592:standards*; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008923:Missouri; D015588:Observer Variation; D064872:Patient Care Bundles / Q000379:methods*; D011182:Postoperative Care / Q000592:standards*; D058996:Quality Improvement / Q000458:organization & administration*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
keywords: Congenital heart disease; Echocardiography; Image quality; Pediatric; Postoperative; Quality improvement