Use of a Learning Network to Improve Variation in Interstage Weight Gain after the Norwood Operation

BackgroundGrowth failure is common in infants with single ventricle. This study evaluated the use of a learning network, the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC), to spread optimized nutritional practices and improve infant growth. MethodsA previously identified Nutritional Bundle was spread among NPC-QIC sites. Primary outcome: interstage weight-for-age z-score change (WAZ) between discharge from stage 1 palliation (S1) and stage 2 surgical palliation (S2). Variation among sites in interstage WAZ was evaluated before (Period 1) and after (Period 2) spread of Nutritional Bundle. We performed an analysis of NPC-QIC registry infants presenting for S2 at sites previously shown to have significant variation in interstage patient growth. ResultsFour hundred seven infants from 15 sites underwent S2 between 2008 and 2013: 158 in Period 1 (December 2008-December 2010) and 249 in Period 2 (December 2010-April 2013). Median age at S2 was 4.9 months (2.6-12.8) with no difference between periods. There was significant variation in interstage WAZ among sites in Period 1 (P = .01) but not in Period 2 (P = .39). More patients had an interstage WAZ <0 in Period 1 (43%) than Period 2 (32%) (P = .03). In Period 1, the median interstage WAZ was <0 in six sites while in Period 2 no site had median interstage WAZ <0. Sites with the worst patient growth in Period 1 had marked improvement in Period 2 (P = .02, .06, and .06, respectively). ConclusionsSpread of optimal nutritional practices led to decreased variation in interstage growth with most improvement observed at sites with the worst baseline growth outcomes.