Abstract
The study assesses the impact of a program using a model of knowledge transfer on the long-term development of a pediatric cardiac service in Lithuania. A team from the United Kingdom evaluated Lithuanian pediatric cardiac services and provided support in areas targeted for improvement. The total number of infant operations performed in Lithuania from 1990 to 2008, together with in-hospital mortality rates, was broken down into 3 time periods and analyzed to estimate the efficacy of the program: (1) 1990-1998, before the program; (2) 1999-2002, during the program; (3) 2003-2008, following the end of the program. Lithuanian results in children older than 1 year were comparable with other European centers. However, only 315 infant and neonatal cardiac procedures were performed between 1990 and 1998, and there was an in-hospital mortality of 34.2%. Between 1999 and 2002, the UK team performed 23 highly complex demonstration procedures (in-hospital mortality, 13%). During the same period the Lithuanian team performed 305 additional operations in neonates and infants, and in-hospital mortality decreased to 18.7%. From 2003 to 2008 results continued to improve—559 infant operations were performed, with in-hospital mortality of 11.3% (P < .0001). Knowledge transfer has led to substantial and sustainable long-term improvement in the results of infant cardiac surgery in Lithuania. Demonstrating techniques and care on a limited number of more complex cases is an efficient way of transferring knowledge and skills to the developing pediatric cardiac centers.
It has become widely accepted that collaborative programs with well-developed centers providing continuous educational support and know-how can be an effective to way to promote the growth of developing congenital cardiac centers. 1,2 Transfer of expertise and knowledge to the developing center, rather than transfer of patients to well-established centers for complex cardiac procedures, will eventually establish the basis for the solid programs in congenital cardiac surgery and enable developing centers to achieve standards close to those of leading world centers. In this article we share our experience with a knowledge transfer program aimed to improve results of pediatric cardiac surgery in Lithuania. Lithuania, with a population of 3.5 million, has a single congenital cardiac surgical unit, which is located in the capital city of Vilnius. Following the collapse of the Soviet Union and the regaining of independence in 1990, Lithuania gained an opportunity to modernize medical practice according to Western standards. The areas of practice requiring the most improvement were identified, and it was obvious that this area at Vilnius Heart Surgery Clinic was surgery in neonates and infants, as the results of procedures performed in neonates and infants were unsatisfactory. These results prompted a search for help to improve the situation with neonatal and infant cardiac surgery. Contacts were established with Wessex Cardiothoracic Centre, Southampton, United Kingdom, and those contacts developed into a 4-year collaborative program (1999-2002). The methods and results of this program are presented in the article.
Methods
Visits to Wessex Cardiothoracic Center by Lithuanian Team
As the initial step of the program, the Lithuanian team, consisting of the lead congenital cardiac surgeons, pediatric cardiologist, anesthesiologist, and intensive care unit (ICU) physician, was invited to visit the Wessex Cardiothoracic Centre, where they observed the way that the pediatric cardiac service was organized and saw the results achieved at the center. Following this initial visit, members of the Lithuanian congenital cardiac team (surgeons, cardiologists, anesthetists, ICU physicians, and ICU nurses) visited Southampton on a regular basis and stayed for 3 to 4 weeks at a time to learn about the delivery of the local pediatric cardiac services in detail.
Assessment of Vilnius Center by the British team
The Southampton team, consisting of congenital cardiac surgeon, anesthesiologist/ICU physician, and cardiologist, made an initial visit to Vilnius to assess the congenital cardiac service and the local facilities. The British team agreed to focus on neonatal and infant cardiac surgery. The surgical results in the neonatal and infant group were reviewed. The analysis of the results suggested that a major reason for high mortality was myocardial dysfunction following cardiopulmonary bypass (CPB), either causing immediate postoperative death or necessitating prolonged stay in the ICU resulting in infection and multiorgan failure. It was believed that the conduct of CPB and myocardial protection were important problems to be addressed. To identify all areas for improvement, all aspects of the perioperative management of pediatric patients were carefully assessed by the British team. The Southampton team was satisfied with the referral process of the Lithuanian children with congenital heart defects to the tertiary center, the way the neonates with congenital heart defects were transferred from the neonatal units to the cardiac center, and the accuracy of the final diagnosis. However, the British team identified several areas in the intraoperative and postoperative management strategies that could be improved. The key areas for the improvement were found to be conduct of CPB, myocardial protection, surgical techniques, transportation of the patients from operating room to ICU, and management in the ICU. Following this analysis, it was agreed that the most effective way to improve the results would be for the Southampton team visit Vilnius on a regular basis and work with the Lithuanian team while performing surgery on the most complex congenital cardiac cases. The Southampton team found local facilities to be satisfactory to proceed with complex cardiac procedures. It was also agreed that the perfusionist and ICU nurse had to be included in the visiting team.
Regular Visits of Southampton Team to Lithuania
The Southampton team initially consisted of the congenital cardiac surgeon, pediatric cardiac anesthesiologist/ICU physician, perfusionist, operating theater scrub nurse, and ICU nurse. They visited for 5 days on a regular basis approximately every 6 months. On the first day of each visit, the British team assessed the candidates for surgery. These had been discussed in advance of the visit. During the following 2 days, 3 to 4 complex cardiac procedures were performed together with the Lithuanian team. To ensure an optimal education process, each member of the British team was paired with his or her Lithuanian colleague. Learning was focused on the specific areas of perioperative management: (1) anesthesia, monitoring, and hemodynamic management of neonates and infants before and after CPB; (2) priming of the CPB circuit and conduct of CPB (ie, using fresh stored blood to prime the CPB circuit, maintaining high hematocrit levels during CPB); (3) cold blood cardioplegia for myocardial protection; (4) surgical technique, with special focus on the arterial switch operation; (5) transfer of the patient from operating room to ICU; and (6) fluid and inotropic drug management in ICU and ICU nursing care. After operative days, the team from Southampton stayed for another 2 days to be involved in the immediate postoperative care. This time was also used to analyze the management of the operations performed, identify new targets for improvement, and discuss other difficult patients referred to the Vilnius center. As the program progressed and the Lithuanian team became more used to the new practices, the visiting team from Southampton was reduced to 2 professionals—a congenital cardiac surgeon and a perfusionist. A perfusionist was maintained in the team because the role and responsibilities of the perfusionist during the period of CPB in British and Lithuanian systems were totally different. The perfusionist has responsibility with respect to all aspects of CPB in United Kingdom, whereas in Lithuania the perfusionist is a technician who operates the CPB machine and receives orders from the cardiac anesthesiologist, who has overall responsibility for CPB.
Most of the neonatal and infant operations performed by the UK team were performed during the first half of the program. As the Lithuanian team became more confident in performing neonatal and infant procedures without the help of the Southampton team, older patients were selected for the operations by the combined British and Lithuanian team. These cases were selected because the Lithuanian team had concerns about their complexity.
Financial Support for the Program
The UK team worked in Lithuania on charity basis. The costs of travel and lodging for both teams were covered by a private Lithuanian charity fund, Status—Vaikams (translation from Lithuanian—“Status for Children”) and the British Embassy in Lithuania. The total costs of the program were estimated at approximately 100 000 US dollars. Although the governmental institutions of Lithuania did not contribute to the program directly, the government of Lithuania has spent the equivalent of 6 million US dollars to renovate Vilnius Heart Surgery Center, including pediatric operating theaters and pediatric ICU.
Data Collection and Statistical Analysis
The primary objective of the collaborative program was to improve the results of neonatal and infant cardiac surgery in Lithuania. To understand whether the program has achieved this goal, the total number of operations performed in children younger than 1 year in Lithuania from 1990 to 2008, together with in-hospital mortality rates, were broken down into 3 time periods and were analyzed to estimate the efficacy of the program: (1) the first period from 1990 to 1998, before the beginning of the program; (2) the second period from 1999 to 2002, during the program; and (3) the third period from 2003 to 2008, following the end of the program. To describe the complexity of the case mix in each time period, all operations performed in patients younger than 1 year were also categorized using the Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) method. 3 To simplify analysis of the complexity of the case mix in each period, we combined the cases with the RACHS-1 scores of 1, 2, and 3 into one group (considered lower risk) and the cases with the RACHS-1 score of 4, 5, and 6 to another group (considered higher risk). The results of the operations performed together by Southampton and Vilnius teams in Lithuania are presented separately. The χ 2 test was used to compare in-hospital mortality rates and the complexity of the case mix in neonatal and infant group. The statistical software system SAS (version 9.2, Cary, NC) was used for statistical analysis. The total number of pediatric operations (patient age less than 18 years) performed at Vilnius Heart Surgery Center during the period from 1990 to 2008 was also collected.
Results
Operations Performed by Southampton and Vilnius Teams in Lithuania
Between 1999 and 2002, the Southampton team made 7 visits to Vilnius and together with the Lithuanian team performed 23 complex congenital cardiac procedures on 19 patients, with 13% in-hospital mortality. The procedures performed and the results are summarized in Tables 1 and 2 . Thirteen procedures were performed on children younger than 1 year, with a single in-hospital death. A 3-month-old boy died hours after the arterial switch procedure and closure of ventricular septal defect (VSD) because of severe unresponsive pulmonary hypertension. Postmortem examination revealed changes in pulmonary arteries consistent with grade IV of Heath-Edwards histological grading of pulmonary hypertension. Most of the procedures performed in the patients younger than 1 year were for isolated or complex transposition of great arteries (TGA). Before the start of the program, there was no medium-term survival following the arterial switch procedure in Lithuania, and most patients with TGA were treated with atrial switch procedures. Therefore, this group of patients received particular attention during the course of the program.
Operations Performed by British and Lithuanian Team in Children Younger Than 1 Year
BCPS, bidirectional cavopulmonary shunt; DORV, double-outlet right ventricle; mB-T, modified Blalock-Taussig; PA, pulmonary artery; PAH, pulmonary artery hypertension; S/P, status post; TGA, transposition of great arteries; TOF, tetralogy of Fallot; TV, tricuspid valve; VSD, ventricular septal defect.
Operations Performed by British and Lithuanian Team in Children Older Than 1 Year
Ao, aorta; AV, aortic valve; AVR, aortic valve replacement; BCPS, bidirectional cavopulmonary shunt; IVS, intraventricular septum; MAPCA, major aortopulmonary collateral arteries; MV, mitral valve; PA, pulmonary artery; PAH, pulmonary artery hypertension; PS, pulmonary stenosis; RPA, right pulmonary artery; S/P, status post; TGA, transposition of great arteries; TOF, tetralogy of Fallot; TV, tricuspid valve; VSD, ventricular septal defect.
Ten procedures were performed in children older than 1 year. Two in-hospital deaths occurred in this group. One patient died following the Rastelli procedure because of septic complications, and one patient died following a 1-1/2 ventricle repair that was complicated by pulmonary hemorrhage. One patient required reoperation because of late complications following aortic valve replacement with aortic root enlargement—the patch used to enlarge the aortic root through the subaortic curtain of the mitral valve dehisced, causing severe mitral regurgitation. The mitral valve was repaired at the time of the second procedure.
Results of Neonatal and Infant Cardiac Surgery in Lithuania
There were 3698 pediatric cardiac operations performed at Vilnius Cardiac Center between 1990 and 2008. Of these, 1179 operations were performed on neonates and infants. Although the total number of operations performed every year remained relatively static, there was a progressive increase in the proportion of neonatal and infant procedures (Figure 1 ). The case mix analysis performed using the RACHS-1 system for each time period is presented in Table 3 . The analysis revealed a progressive increase in the complexity of the operations performed (higher risk cases, 10.2%, 15.4%, and 16.1%, P = .04). Despite the trend for increasing complexity of the case mix, a significant reduction in mortality over the 3 time periods was noted in each individual RACHS-1 group as well as in the overall mortality rates (34.3%, 18.7%, and 11.3% for the 3 time periods; P < .0001) (Table 4 ).
Number of pediatric cardiac procedures performed in neonates and infants from 1990 to 2008 in Lithuania.
RACHS-1 Analysis of Case Mix (<1 Year)
Values are n (%). The complexity of the operations performed over the 3 time periods increased (10.2%, 15.4%, and 16.1%, respectively, P = .04, in the higher risk group).
In-Hospital Mortality (%) (<1 Year)
There was a significant reduction in the overall mortality comparing 3 time periods (34.3%, 18.7%, and 11.3%, respectively, P < .0001).
Discussion
Several strategies are available to help children with congenital heart defects in countries where congenital cardiac services are either absent or inadequate: (1) transferring children to well-developed cardiac centers for surgical treatment; (2) bringing in cardiac teams from other countries to perform surgery on a limited number of patients; and (3) establishing or improving local congenital cardiac programs.
1,2,4
The first 2 strategies, although beneficial for the selected individuals, have a very limited effect on the whole population of the selected country. The last option, in contrast, offers a more complete long-term solution for the problem. This concept is suggested by a Chinese proverb from the 6th century
In this article we describe an approach to improve the performance of existing congenital cardiac programs through the transfer of expertise and knowledge from a developed cardiac center. We found that expertise and knowledge can be successfully transferred from the developed center to the developing one by means of regular visits of the team from the developed center to perform selected complex cardiac procedures together with the local team. We believe that focusing on more complex cases is a much more beneficial experience for the learning team than performing straightforward cases. Selection of simple cases for the program would lead to a rather shallow learning curve, would require long-term commitments from the expert center, and could make the collaborative program very expensive. Even the limited number of complex procedures performed together can substantially improve the performance and results of the local center by exposing the learning team to inevitable challenging clinical situations. The program of collaboration between cardiac centers in Southampton, United Kingdom, and Vilnius, Lithuania, which lasted from 1999 to 2002, significantly improved the results of neonatal and infant cardiac surgery in Lithuania. Although only 23 operations were performed by the combined British and Lithuanian team in Vilnius, the program of collaboration reduced the overall mortality in neonates and infants undergoing cardiac surgery in Lithuania: from 34.3%, before the start of the program, to 18.7%, at the time of the program. More important, the results continued to improve further following the official end of the collaborative program. These results suggest that the effect of this form of knowledge transfer on the performance of the Vilnius pediatric cardiac program is long-lasting.
The improvement in the results may not be attributed solely to the effect of the program, as the knowledge and expertise could have been acquired in other ways in parallel to the collaborative program, for instance, visiting other centers, attending scientific meetings, and performing larger number of complex procedure. However, we believe that transferring the standards of practice from the developed center through repeated encounters and interactions had the biggest effect on changing local practice and improving the results at the Vilnius Heart Surgery Center.
Although the collaborative program between the Southampton and Vilnius cardiac centers proved to be very successful, some conditions have to be met to ensure that knowledge transfer in performing a limited number of complex congenital cardiac operations gives the desired result: (1) an infrastructure allowing performance of complex cardiac procedures in the local center; (2) the presence of adequately trained medical personal involved in perioperative management in the local center; (3) motivation of the local staff to accept and adapt to the new standards of practice; (4) enthusiasm about the program by all members of both teams; (5) financial support of the program; (6) evaluation of results and adjustment of direction for improvement; (7) a program duration that ensures stable performance and results of the local center; (8) selection of complex congenital cardiac cases for surgery by the combined team as they stimulate acquisition of new medical knowledge; and (9) maintenance of close connections so the teams can discuss the management of the most difficult cases. 5
If all these conditions are fulfilled, the model of knowledge transfer described in our article can prove to be a very effective and inexpensive way to improve the performance of the developing congenital cardiac center.
Conclusions
A targeted approach in the form of knowledge transfer has led to substantial and, most important, sustainable long-term improvement in the results of neonatal and infant cardiac surgery in Lithuania. Demonstrating techniques and care on a limited number of complex cases is an efficient way of transferring knowledge and skills to developing cardiac centers.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with financial interest in or financial conflict with subject matter or materials discussed in this manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants, and patents received or pending.
No writing assistance was used for this manuscript.