peds.2014-1835.full

Improved Nutrition Delivery andNutrition Status in Critically Ill ChildrenWith Heart DiseaseJon Kaufman, MDa,b, Piyagarnt Vichayavilas, MS, RD, CNSCa,c, Michael Rannie, RN, MSd, Christine Peyton, MS, CPNP-AC,CCRNa,e, Esther Carpenter, BSN, CCRNa,e, Danielle Hull, MSc, Jennifer Alpern, BSN, RNa,e, Cindy Barrett, MD, MPHa,b,Eduardo M. da Cruz, MDa,b, Genie Roosevelt, MD, MPHf

abstractBACKGROUND: This initiative sought to improve nutrition delivery in critically illchildren with heart disease admitted to the cardiac ICU (CICU) and neonatesundergoing stage 1 palliation (S1P) for single-ventricle physiology throughinterdisciplinary team interventions. Specific goals were increased caloric andprotein delivery for all patients and a more nourished state for infants withsingle ventricles at the time of discharge.

METHODS:We developed a nutrition flow sheet in the electronic health record totrack whether daily nutrition goals were met. Interventions included nursesreporting daily whether caloric and protein goals were met, mandatoryinvolvement of feeding specialists, and introduction of an enteral nutritionguideline. For infants undergoing S1P, weight-for-age z score (as an indicatorfor assessing malnutrition) was calculated at admission and discharge.

RESULTS: The percentage of patient days per month when daily caloric goalswere met increased from 50.1% to 60.7%, and protein goals met increasedfrom 51.6% to 72.7%. Hospital length of stay, need for ventilation, andmortality did not differ. Patients undergoing S1P demonstrated a statisticallysignificant improvement in weight-for-age z score compared with thepreintervention group (P = .003). Thirteen S1P patients were dischargedundernourished in the preintervention group; 5 were severelyundernourished. In the intervention group, 4 patients were dischargedundernourished, and none were severely undernourished.

CONCLUSIONS: This initiative resulted in improved nutrition delivery fora heterogeneous population of cardiac patients in the CICU as well assignificant improvements in weight gain and nourishment status at dischargein infants undergoing S1P.

Outcomes for children with congenitaland acquired heart disease whoundergo surgical correction orpalliation have improved dramaticallyover the past 2 decades.1 Mortalityrates for even the most complicatedlesions have been reducedsignificantly.1–4 In particular, 30-dayand hospital mortality for infantsundergoing stage 1 palliation (S1P), orthe Norwood procedure, were 11.5%and 16%, respectively, according to the

recent Single Ventricle ReconstructionTrial.5 For this population of infants in

particular, significant postoperative

complications and morbidity persist,

and length of stay and cost of

hospitalization are problematic.4,6

Morbidity prolongs hospitalization,taxes institutional and financial

resources, stretches family support,

and places the child at risk for death.

Malnutrition and poor nutrition are

aThe Heart Institute at Children’s Hospital Colorado,bDepartment of Pediatrics, cClinical Nutrition at Children’sHospital Colorado, and dClinical Informatics at Children’sHospital Colorado, Aurora, Colorado; eSchool of Nursing,University of Colorado Anschutz Medical Campus, Aurora,Colorado; and fDepartment of Emergency Medicine, DenverHealth Hospital Authority, Denver, Colorado

Dr Kaufman, Ms Vichayavilas, and Mr Rannieconceptualized and designed the study, performeddata analysis, and drafted the initial manuscript;Ms Peyton, Ms Carpenter, Ms Hull and Ms Alperndesigned the study and assisted in data collection;Dr Barrett and Dr da Cruz conceptualized anddesigned the study and reviewed and revised themanuscript; Dr Roosevelt performed data andstatistical analysis and critically reviewed themanuscript; and all authors approved the finalmanuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-1835

DOI: 10.1542/peds.2014-1835

Accepted for publication Oct 28, 2014

Address correspondence to Jon Kaufman, MD,The Heart Institute and Department of Pediatrics,Children’s Hospital Colorado, 13123 E. 16th Ave,B100, Aurora, CO 80045. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2015 by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The authors have indicatedthey have no financial relationships relevant to thisarticle to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors haveindicated they have no potential conflicts of interestto disclose.

PEDIATRICS Volume 135, number 3, March 2015 QUALITY REPORT

common complications in infantswith congenital and acquired heartdisease. Poor caloric and proteindelivery and inability or loss of abilityto orally feed and breastfeed maycontribute to neurodevelopmentaland neurocognitive delays as well asto parental frustration, anxiety, anddisappointment.7–10 Lower thangrowth velocity than that expectedfor age and gender is prevalent ininfants and children with congenitalheart disease and may be due toinadequate nutrition delivery.11–15 Ininfants with single-ventriclephysiology, providing adequatenutrition can be particularlydifficult.8,10 For infants undergoingstaged palliation, the interstageperiod (after S1P and before theGlenn procedure) can be particularlychallenging and is a time of increasedrisk of mortality.16,17 Poor growthpatterns can negatively affect bothshort- and longer-term outcomes,including infection rates, length ofstay, and neurodevelopmental andneurocognitive performance.18,19

Improvements in nutrition delivery,consistent weight gain, and adequategrowth should be the expectation forpatients of all congenital heartcenters.

In 2011, the Children’s HospitalColorado’s Heart Institute identifiednutrition and feeding as areas forpractice improvement for all patientswith congenital and acquired heartdisease. A multistep qualityimprovement project was initiatedthat examined nutrition ona macrosystem level as well as ininfants with single-ventriclephysiology. The first objective of thisstudy was to evaluate interventionsdesigned to improve caloric andprotein delivery for all patientsadmitted to the cardiac ICU (CICU).Second, a CICU subset population ofinfants with single-ventriclephysiology was studied to evaluatethe impact of interventions on weightgain and nourishment status atdischarge. The specific aims of thisquality improvement project were to

improve daily calorie and proteindelivery to all patients in the CICU, aswell as to improve the nourishment ofinfants with single ventricles upondischarge after undergoing S1P.

METHODS

Setting

Children’s Hospital Colorado is a free-standing, 414-bed, children’s hospitaland a referral center for the RockyMountain region. The HeartInstitute’s CICU admits ∼650 childrenper year, and the CardiovascularSurgery Program performs ∼500cardiac procedures per year. Aninterdisciplinary team of nurses,physicians, occupational and speechtherapists, and a dietitian was formedin February 2011 to improvenutrition delivery for all patientsadmitted to the CICU and for infantswith single-ventricle physiology. Theprimary outcome variables for theCICU patients were percentage ofpatient days in a month when dailycaloric and protein goals were met.The primary outcome variable for thesingle-ventricle infants was theirweight-for-age z scores (WAZ) atdischarge. WAZ is a World HealthOrganization standard for assessingmalnutrition in children.20 We choseto include 2 patient populations inour study with different outcomemeasures to better evaluate how thesame interventions would affectdifferent populations of critically illchildren with heart disease.

Interventions

The team developed a nutrition flowsheet in the electronic health recordso the dietitian and informatics staffcould accurately track whethernutrition goals were met each day(Fig 1). The interdisciplinary teamthen introduced a series ofinterventions. First, Nurse IntegratedRounds were instituted, whichinvolved the bedside nurse activelyparticipating in systems-structuredpatient rounds. Several months later,night-shift nurses began calculating

their patients’ 24-hour caloricdelivery, which was reported to theday shift nurses for Nurse IntegratedRounds. Next, every admitted patientwas screened by a feeding and/orspeech therapist to determine at-riskcharacteristics for oral feeding failure.An enteral nutrition guideline forneonates and infants was alsoimplemented to promote safe,standardized enteral nutritionadvancement (Fig 2). Finally, thenutrition data were regularlyreviewed with the interdisciplinaryteam, and feedback was provided tothe clinical staff monthly.

Outcome Measures

To evaluate the interventions, theinvestigators queried the electronichealth record to identify all patientsreceiving nutrition support, definedas patients receiving enteral orparenteral nutrition or both, in theCICU during the study period.Baseline data (the preinterventionphase) was collected over 8 monthsfrom April 2011 to November 2011.The intervention phase was fromDecember 2011 to July 2013 (20months). Data included demographicand clinical characteristics includingthe presence of genetic abnormalitiesdefined as trisomy 21, 22q11, andother microdeletions andtranslocations abnormalities, surgicalversus medical admission and theRisk Adjustment for Congenital HeartSurgery (RACHS-1) score whenapplicable. The RACHS-1 isa procedure-driven complexitycategorization used by the Society ofThoracic Surgeons to adjust forbaseline case-mix differences whencomparing discharge mortalitybetween groups of patientsundergoing pediatric congenital heartsurgery.21 Also collected was whetherdaily protein and calorie goals weremet for each patient and, if goals werenot met, the percentage of goalcalories that was in fact delivered.

The following days were excluded:days of admission and discharge, daysof cardiac surgery, days when

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neonates received only starter/stocktotal parenteral nutrition (TPN;composed of 10% dextrose, 3%TrophAmine, and no electrolytes),days when only trophic feeds weredelivered, and days when nutritionsupport was not started. In thepreintervention phase, 22.5% of dayswere excluded; in the interventionphase, 28.3% days were excluded.Examples of why nutrition supportwas not started were volumelimitations, limited access, andmedication incompatibility. Starter/stock TPN is typically onlyadministered within the first 24 hoursof a neonate’s life. Days with feedinginterruptions were included. Reasonsfor interruptions in feedings are manyand varied and include clinical

indications such as emesis, abdominaldistention and fussiness, as well asinterruptions for procedures andstudies, and, rarely, staffing and supplyissues. As a part of the nutritionassessment, the dietitian entered thecaloric and protein goals daily andconcluded whether those daily goalswere met in the nutrition flow sheet.

Goal calories for full-term intubatedinfants were estimated to be 80kcal/kg. This was calculated energyexpenditure with an additional 30%to 40% for growth.20 Fornonventilated full-term infants, theircaloric goal ranges between 100 and130 kcal/kg, with frequentadjustments pending weight gainvelocity. Estimated energyrequirements are set higher for our

patients due to catch-uprequirements and high energyexpenditure. Patients who werefeeding on demand were notincluded. We collected the followingvariables on the CICU patients: theproportion of patients who requiredventilation .24 hours, hospitallength of stay, proportion of patientsreceiving TPN, the number of days ofTPN was received, incidence ofnecrotizing enterocolitis (NEC)requiring surgical exploration orintervention, rates of central-line-associated bloodstream infections,and mortality.

Neonates with diagnoses of singleventricles and who underwent S1Pwere identified by the HeartInstitute’s database of all

FIGURE 1Electronic health record nutrition flow sheet.

PEDIATRICS Volume 135, number 3, March 2015 e3

cardiothoracic surgical cases (CardioAccess Inc, Fort Lauderdale, FL). Allneonates with single ventricle wereadmitted to the CICU. Exclusioncriteria, for this subset, weregestational age ,35 weeks and/or

genetic abnormalities or syndromes.This cohort included a variety ofanatomic diagnoses; the majority hada hypoplastic left ventricle anda morphologically right systemicventricle. Three subjects of the 52

had hypoplastic right ventricles. Thepreintervention group includedinfants who underwent the Norwoodprocedure from February 2009 toNovember 2011 (34 months). Theintervention group included those

FIGURE 2Children’s Hospital Colorado Heart Institute Enteral Nutrition Guideline. CRP, C-reactive protein; cx, culture; GI, gastrointestinal; inc, increasing; NIRS, near-infraredspectroscopy; NPO, non per os; PCT, procalcitonin; PGE-1, prostaglandin E1; PO, per os; pt, patient; q, every; RD, registered dietitian; WBC, white blood cell count.

e4 KAUFMAN et al

who underwent the Norwoodprocedure from December 2011 toJuly 2013 (20 months). Thepreintervention group time framewas extended to ensure a similarnumber of patients for comparisonwith the intervention group.

For infants with single ventricle aged,7 days, admit weight was themean weight averaged over 6 daysor until surgery to account fornewborn fluid fluctuations. Infantstypically undergo S1P between 3 and6 days of life. Discharge weight wasthe weight on day of discharge fromhospital or day before dischargewhen the former was not available. Inthe preintervention group, 3 infantswho died after undergoing S1P beforedischarge were not included inanalysis because there was nodischarge weight. Also, 2 subjects inthe preintervention group wereexcluded because of geneticabnormalities. The interventiongroup did not have any deaths orgenetic abnormality exclusions.

Analytic Approach

Continuous variables, except for thesingle-ventricle admit weight,discharge weight, and WAZ scores,and are reported as median andinterquartile range given theirnonnormal distributions. Categoricalvariables are reported as proportionswith 95% confidence intervals (CIs).Relative risk and 95% CIs werecalculated. All statistical analyses

were performed with SPSS 22 (IBMSPSS, Armonk, NY). The percentage ofpatient days in a month when dailycaloric and protein goals were metwas plotted on statistical processcontrol (SPC) p charts. Three s limitswere used to set the upper and lowercontrol limits. The SPC p charts werecreated using QI Charts Version2.0.22 (Scoville Associates, TX).Because caloric delivery was analyzedas a dichotomous variable (ie, met vsnot met), the percentage of caloriesdelivered on days when caloric goalswere not met was also calculated.

For the infants undergoing S1P, theWorld Health Organization 2006Child Growth Standards were used.20

Differences in the single-ventriclephysiology patients’ weights and WAZscores between preintervention andintervention periods were analyzedwith an independent t test as theywere normally distributed. Wereported the number of children

discharged as malnourished: WAZscores under –2 were categorized asundernourished and less than –3 tobe severely undernourished.22 Thisstudy was approved by the Children’sHospital Colorado OrganizationalResearch Risk & QualityImprovement Review Panel asa quality improvement project.

RESULTS

Demographic, clinical characteristics,and outcomes for patients admittedto the CICU during the preinterventionand intervention study periods arepresented in Tables 1 and 2. Age,gender, admission weight, geneticabnormalities, ventilation .24 hours,length of hospital stay, TPN use,incidence of NEC, rates of central-line-associated bloodstream infections, andmortality were similar between the2 groups. Three infants developedNEC requiring surgical explorationand intervention. Two had never beenenterally fed and were TPNdependent; the third was on oral feedsad libitum. No infants on the enteralfeeding algorithm developed NEC.

The percentage of patient days ina month when daily caloric goalswere met increased from 50.1% to60.7% from the pre- intervention tointervention period. The percentageof patient days when daily proteingoals were met increased from51.6% to 72.7% from similar periods(Figs 3 and 4). After plotting thepre-intervention monthlypercentages, standard SPC charting

TABLE 1 All CICU Patients: Demographic and Clinical Characteristics

Patient Characteristic Preintervention Period(8 mo), n = 106

Intervention Period(20 mo), n = 260

Admission median age, mo (IQR) 1.6 (0.03–6.4) 1.4 (0.03–6.9)Male gender, n (%) (95% CI) 66 (62) (53–71) 158 (61) (55–67)Admission median wt, kg (IQR) 3.6 (3.0–6.0) 3.9 (3.0–6.4)Genetic abnormalities,a n (%) (95% CI) 13 (12) (7–20) 50 (19) (15–24)Surgical admission, (%) (95% CI) 75 (71) (61–79) 189 (73) (67–78)RACHS-1b Score 1–2 (95% CI) 16 (29) (19–42) 54 (34) (27–42)RACHS-1b Score 3 (95% CI) 18 (33) (22–46) 43 (27) (21–35)RACHS-1b Score 4 (95% CI) 8 (14) (7–26) 29 (19) (13–25)RACHS-1b Score 5-6 (95% CI) 13 (24) (14–36) 31 (20) (14–27)

A patient may be included in .1 group (eg, included in both preintervention and intervention periods). IQR, interquartilerange.a Included trisomy 21, 22q11, and other microdeletions and translocations abnormalities.b Not all surgical procedures are assigned a RACHS score.

TABLE 2 All CICU Patients: Outcome Variables

Patient Characteristic Preintervention Period(8 mo), n = 106

Intervention Period(20 mo), n = 260

Required ventilation .24 h, n (%) (95% CI) 91 (86) (78–91) 210 (81) (76–85)Median LOS, d (IQR) 15.5 (9–30) 19 (10–34)Received TPN, n (%) (95% CI) 66 (62) (53–71) 183 (70) (65–76)Median days of TPN use, n (IQR) 4 (2–7) 5 (2–10)Incidence of NEC,a n (%) (95% CI) 1 (1) (0–6) 2 (2) (0–3)Rate of CL-associated bloodstream

infection/1000 CL days (95% CI)1.29 (0–3.1) 0.72 (0–1.5)

Mortality, n (%) (95% CI) 7 (7) (3–13) 15 (6) (4–9)

A patient may be included in .1 group (eg, included in both preintervention and intervention periods). CL, central line;IQR, interquartile range; LOS, hospital length of stay.a Requiring surgical exploration or intervention.

PEDIATRICS Volume 135, number 3, March 2015 e5

rules for determining special causewere used as evidence ofimprovement.23 For the caloric goalp chart, 2 of 3 consecutive points wereobserved close to the upper controllimit; this was later followed by a run

of .8 consecutive points above thepreintervention mean. For the proteingoal p chart, there was a run of greaterthan 8 consecutive points above thepreintervention mean. Updated meanand control limits were plotted for the

intervention period in the SPC chartsafter special cause was detected. Thepercentage of calories delivered onpatient days when daily caloric goalsin a month were not met increasedfrom 60.6% to 76.4% from the

FIGURE 3SPC p chart: percentage of patient days in a month when daily caloric goals were met in the CICU.

FIGURE 4SPC p chart: percentage of patient days in a month when daily protein goals were met in the CICU.

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preintervention to intervention period(Fig 5).

Demographic and clinicalcharacteristics for infants with single-ventricle physiology who underwentS1P during the preintervention andintervention study periods arepresented in Table 3. Infants in bothgroups experienced nonstatisticallysignificant absolute weight gain;however, infants in the interventionphase were significantly morenourished at discharge than those inthe preintervention phase when theirweights were standardized for age(eg, WAZ scores; P = .007). Infants inthe intervention phase group also hada smaller difference in WAZ fromadmit to discharge indicatinga greater standardized for age weightgain when compared with thepreintervention group (P = .003;

Table 4). Infants in the interventionperiod were 1.6 times (95% CI:1.1–2.3) more likely to be dischargednourished than in the preinterventionperiod. Fewer subjects undergoingS1P in the intervention group weredischarged undernourished, and nonein the intervention group weredischarged severely undernourished(WAZ , –3; Table 5). No infants withsingle-ventricle physiology developedNEC during the study period.

DISCUSSION

This quality improvement initiativesuccessfully improved the dailycaloric and protein intake ina heterogeneous population ofcritically ill children. After initiation,61% of all CICU inpatients met theirdaily caloric goals, up from 50%.

Those who met daily protein goalsimproved to 73%, up from 52%. Thisproject also improved nutrition asmeasured by nourishment status forinfants in a specialized cohort: thoseundergoing stage 1 palliation forsingle-ventricle physiology. More ofthese infants were dischargednourished and less undernourished,and they demonstrated an improvedweight gain during theirhospitalization.

In addition, close attention to thesedata prompted investigation whenresults were outside of control limitsto discern cases of special cause (eg,in January 2013, a significant declinein caloric goals met was linked tolipid restrictions secondary toa national shortage; Fig 3).

There were multiple interventionsinitiated over a short time period, andthus the practice change with thegreatest effect is difficult to identify.Anecdotally, the authors believe thatthe adoption of a feeding algorithmand bedside CICU nurses reporting onnutrition status during daily roundswere the 2 most effectiveinterventions.8,10,24 These

TABLE 3 Single Ventricle Patients: Demographic and Clinical Characteristics

Patient Characteristic Preintervention Period(34 mo) n = 28

Intervention Period(20 mo) n = 28

Median age at surgery, d (IQR) 4 (3–5) 5 (3–7)Male gender (%) (95% CI) 18 (64) (46–79) 20 (71) (53–85)Median LOS, d (IQR) 31 (23–39.75) 30.5 (21.25–44)

IQR, interquartile range; LOS, hospital length of stay.

FIGURE 5Percentage of calories delivered on days when caloric goal was not met.

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interventions reduced variability infeeding advancement, increasedvisibility of the practice improvementeffort, and fostered nursingownership of nutrition practice.

The primary outcome variables ofpercentage of patient days in a monthwhen daily caloric and protein goalswas met, was a dichotomous variable,in contrast to analyzing the percentageof daily caloric and protein goalsdelivered. Therefore, the SPC charts(Figs 3 and 4) do not distinguishbetween a patient who met 20% ofthe goal and a patient who met 80% ofthe goal. Both values would bereported as a “no,” that is, the patient’snutrition goal for that day was notmet. However, the authors were ableto increase the percentage of caloricgoal delivered to patients in whomcaloric goals were not met by 15%during the intervention period. Themost significant and frequentlydocumented barrier to meetingnutritional goals in the CICU wasfeeding interruptions.

This initiative improved the delivery ofprotein and calories, but there was nosignificant difference in clinicaloutcomes such as need for ventilation,length of stay or mortality in the largerCICU population, or length of stay in thesingle-ventricle infants. These arecomplex clinical outcomes of whichproviding good nutrition is but 1

contributor.7,8,10 For example,Children’s Hospital Colorado’s HeartInstitute does not have a standardizedprocess for gastrostomy tube placementfor infants unable to meet their oralintake goals. Approximately 40% ofinfants with single-ventricle physiologyundergo gastrostomy tube placement;and the variability in this practice is feltto greatly affect length of stay.

In the single-ventricle population, weobserved an absolute decrease inpatients malnourished at the timehospital discharge, after undergoingS1P. Improved WAZ has beenassociated with improved outcomesin children with hypoplastic left heartsyndrome as they move through theirpalliative course.18 Although infantswith single-ventricle physiologyrepresent a small subset of allchildren with congenital heartdisease, they occupya disproportionate percentage ofa heart center’s clinical efforts andfinancial resources.4,6 Theiroutcomes, throughout their stagedpalliations and beyond, areconsidered markers of success forcongenital heart programs. Reductionof postoperative morbidity andcomplications in these patientsremains a formidable challenge.

Consistent delivery of nutritionalrequirements may not be feasible forchildren with congenital and acquired

heart disease. Efforts to sustain goalcalories may put these children at riskfor adverse events. Among these maybe the development of NEC, a greaterreliance on central venous catheters todelivery TPN, an increased risk ofinfection with TPN use, hepaticdysfunction, or prolongation of hospitallength of stay to ensure greater weightgain before discharge. Processes shouldbe in place to ensure that attempts toimprove nutrition do not compromiseother aspects of patient care. Duringthe intervention period, our cohort didnot experience an increase in theincidence of NEC, and there wasactually a reduction in catheter-associated bloodstream infections.

There are a number of limitations tothis study. The results reflect a singlecenter’s experience. Success wasaided by a dedicated CICU dietitianand nutrition assistant, as well asclinical informatics support. Thesepositions may not be available atother institutions. We recognize theinfluence of the Hawthorne effect:providers may have altered theirbehavior as attention and visibilitywere given to efforts to improvenutrition. There were other practiceimprovement initiatives in placeduring the intervention period, suchas efforts to reduce hospital-acquiredinfections. The positive results of ourstudy may have been influenced byother coexistent quality improvementinitiatives. WAZ analysis was limitedto the single ventricles; results maynot be generalizable to infants withother anatomic lesions. Finally, betterweight gain itself may not beassociated with improvements inneurodevelopmental andneurocognitive outcomes in infantswith single ventricles, as a recentpublication has demonstrated.19

CONCLUSIONS

This collaborative approach resulted inimproved caloric and protein deliveryto inpatient children with congenitaland acquired heart disease as well asimproved nourishment status in infants

TABLE 4 Single-Ventricle Infants’ Admission and Discharge Weight and Admission and DischargeWAZ Scores

Preintervention Period(n = 28)

Intervention Period(n = 28)

Difference in Means(95% CI)

P

Mean admission wt, kg 3.16 3.27 0.11 (–0.14 to 0.36) .379Mean discharge, wt, kg 3.49 3.76 0.27 (–0.05 to 0.57) .104Mean difference from

discharge to admit wt0.341 0.486 0.145 (–0.06 to 0.350) .162

Mean admit WAZ 20.361 20.132 0.229 (–0.317 to 0.776) .404Mean discharge WAZ 21.805 21.031 0.774 (0.219 to 1.329) .007Mean difference from

admit to discharge WAZ21.444 20.899 0.545 (0.188 to 0.901) .003

TABLE 5 Single-Ventricle Infants’ Nourishment Status at Discharge

Nourishment State at Discharge Mean WAZ Preintervention (n = 28) Intervention Period (n = 28)

Nourished $ –2 15 24Undernourished 22.01 to –3 8 4Undernourished , –3 5 0

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undergoing S1P for single-ventriclephysiology. Improvements in theseareas would seem to offeropportunities for programimprovement in congenital heartcenters where mortality rates arealready low.

ACKNOWLEDGMENTS

We acknowledge Sanja Batz, EmilyBordier, Kaitlyn Goure, Angela Haas,Shaunda Harendt, Debra Paul,Jennifer Rogers, and Sharon Sables-Baus for their contribution to thequality improvement initiative asfeeding therapists and specialists. Wealso acknowledge Samuel Schofieldfor database support and the nursesof the CICU for their support with theentire initiative.

REFERENCES

1. Jacobs JP, Wernovsky G, Elliott MJ.Analysis of outcomes for congenitalcardiac disease: can we do better?Cardiol Young. 2007;17(suppl 2):145–158

2. Sano S, Huang SC, Kasahara S, YoshizumiK, Kotani Y, Ishino K. Risk factors formortality after the Norwood procedureusing right ventricle to pulmonary arteryshunt. Ann Thorac Surg. 2009;87(1):178–185, discussion 185–186

3. Wernovsky G, Kuijpers M, Van RossemMC, et al. Postoperative course in thecardiac intensive care unit following thefirst stage of Norwood reconstruction.Cardiol Young. 2007;17(6):652–665

4. Czosek RJ, Anderson JB, Heaton PC,Cassedy A, Schnell B, Cnota JF. Stagedpalliation of hypoplastic left heartsyndrome: trends in mortality, cost, andlength of stay using a national databasefrom 2000 through 2009. Am J Cardiol.2013;111(12):1792–1799

5. Tabbutt S, Ghanayem N, Ravishankar C,et al; Pediatric Heart NetworkInvestigators. Risk factors for hospitalmorbidity and mortality after theNorwood procedure: A report from thePediatric Heart Network Single VentricleReconstruction trial. J ThoracCardiovasc Surg. 2012;144(4):882–895

6. Dean PN, Hillman DG, McHugh KE,Gutgesell HP. Inpatient costs and chargesfor surgical treatment of hypoplastic leftheart syndrome. Pediatrics. 2011;128(5).Available at: www.pediatrics.org/cgi/content/full/128/5/e1181

7. Kelleher DK, Laussen P, Teixeira-Pinto A,Duggan C. Growth and correlates ofnutritional status among infants withhypoplastic left heart syndrome (HLHS)after stage 1 Norwood procedure.Nutrition. 2006;22(3):237–244

8. Wolovits JS, Torzone A. Feeding andnutritional challenges in infants withsingle ventricle physiology. Curr OpinPediatr. 2012;24(3):295–300

9. Sables-Baus S, Kaufman J, Cook P, daCruz EM. Oral feeding outcomes inneonates with congenital cardiacdisease undergoing cardiac surgery.Cardiol Young. 2012;22(1):42–48

10. Medoff-Cooper B, Ravishankar C.Nutrition and growth in congenital heartdisease: a challenge in children. CurrOpin Cardiol. 2013;28(2):122–129

11. Okoromah CA, Ekure EN, Lesi FE,Okunowo WO, Tijani BO, Okeiyi JC.Prevalence, profile and predictors ofmalnutrition in children with congenitalheart defects: a case-controlobservational study. Arch Dis Child. 2011;96(4):354–360

12. Vaidyanathan B, Radhakrishnan R,Sarala DA, Sundaram KR, Kumar RK.What determines nutritional recovery inmalnourished children after correctionof congenital heart defects? Pediatrics.2009;124(2). Available at: www.pediatrics.org/cgi/content/full/124/2/e294

13. Varan B, Tokel K, Yilmaz G. Malnutritionand growth failure in cyanotic andacyanotic congenital heart disease withand without pulmonary hypertension.Arch Dis Child. 1999;81(1):49–52

14. Cameron JW, Rosenthal A, Olson AD.Malnutrition in hospitalized childrenwith congenital heart disease. ArchPediatr Adolesc Med. 1995;149(10):1098–1102

15. Mitchell IM, Logan RW, Pollock JC,Jamieson MP. Nutritional status ofchildren with congenital heart disease.Br Heart J. 1995;73(3):277–283

16. Hehir DA, Ghanayem NS. Single-ventricleinfant home monitoring programs:outcomes and impact. Curr Opin Cardiol.2013;28(2):97–102

17. Ghanayem NS, Allen KR, Tabbutt S, et al;Pediatric Heart Network Investigators.Interstage mortality after the Norwoodprocedure: results of the multicenterSingle Ventricle Reconstruction trial.J Thorac Cardiovasc Surg. 2012;144(4):896–906

18. Anderson JB, Beekman RH III, Border WL,et al. Lower weight-for-age z scoreadversely affects hospital length of stayafter the bidirectional Glenn procedure in100 infants with a single ventricle. J ThoracCardiovasc Surg. 2009;138(2):397–404, e1

19. Ravishankar C, Zak V, Williams IA, et al;Pediatric Heart Network Investigators.Association of impaired linear growthand worse neurodevelopmental outcomein infants with single ventriclephysiology: a report from the pediatricheart network infant single ventricletrial. J Pediatr. 2013;162(2):250–256, e2

20. United Nations University, World HealthOrganization, and Food and AgricultureOrganization of the United States. HumanEnergy Requirements. Report of a JointFAO/WHO/UNU Expert Consultation (Foodand Nutrition Technical Report Series);pp. 11–19. Rome, October 17–27, 2011.Available at: http://www.fao.org/docrep/007/y5686e/y5686e00.htm. AccessedDecember 10, 2014

21. Jenkins KJ. Risk adjustment forcongenital heart surgery: the RACHS-1method. Semin Thorac Cardiovasc SurgPediatr Card Surg Annu. 2004;7:180–184

22. de Onis M and Blössner M. WHO GlobalDatabase on Child Growth andMalnutrition. Geneva, Switzerland:Programme of Nutrition, World HealthOrganization; 1997:50

23. Provost , LP, , Murray , S . The Health CareData Guide: Learning From Data forImprovement. San Francisco, CA: Jossey-Bass; 2011

24. Slicker J, Hehir DA, Horsely M, et.al.Nutrition algorithms for infants withhypoplastic left heart syndrome; birththrough the first interstage period.Congenit Heart Dis. 2013;8(2):89–102

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