Transcription:
Pediatric Acute Care Cardiology Collaborative (PAC3)

Prakash Chandran: You are listening to Pediatric Insights, advances, and innovations with Children's Health, where we explore the latest in pediatric care and research.

Today, we're going to learn about the Pediatric Acute Care Cardiology Collaborative or PAC3, and how it's making life better for children with heart conditions. Joining us is the co-founder and Executive Director for the initiative, Dr. Nicholas Madsen. He's also the Co-director of the Heart Center and Chief of Cardiology at Children's Health and Associate Professor of Cardiology at UT Southwestern.

My name is Prakash Chandran, and thank you so much for being here. Dr. Madsen, it's great to have you. Let's get started by maybe you explaining what the Pediatric Acute Care Cardiology Collaborative is and how it got started.

Dr. Nicolas Madsen: Thanks so much for having me here today. PAC3 as it is commonly known is a collaborative in the sort of traditional sense. But in a more modern phrasing, we refer to it as a learning network. What that means is it's an alignment of stakeholders who have common interest along a path of caring for kids with heart conditions who are hospitalized.

We refer to it as acute care cardiology and what we mean by that is that phase of care between the cardiac ICU and going home. It was founded in 2014 by a group of cardiologists who saw an opportunity in that care of the hospitalized patient with a heart condition, that there was really room for improvement and there was a room for alignment of work, both research and clinical. And certainly, there was an opportunity to be transformative to the benefits of our patients and families.

Prakash Chandran: Yeah, that absolutely sounds wonderful. I know this might be a tough question to answer, but to date, what do you feel has been the biggest impact of PAC3?

Dr. Nicolas Madsen: I think, in a more qualitative way, the biggest impact is an acknowledgement that this phase of care, acute care cardiology, really deserves its own recognition and attention specifically from a collective group of people. Obviously, people have been practicing in the hospital for a long time, but never in a way that was unified and cutting across multiple centers where we were learning from each other quickly and really delivering new innovation and new practice patterns or practice care models to the patients as quickly as possible. So I think one of the true accomplishments is the coming together and the agreeing to work together despite covering 40 plus hospitals across north America.

I think in terms of more tangible or quantitative elements, we've had a number of terrific initiatives. We've changed the way that medications are managed after surgery, and we've done that across multiple centers. And very notably, we've changed the way that chest tubes, which are these tubes that are inserted in the chest after surgery and are very painful, we've changed the way those are managed. And what we've done is we've reduced the duration as measured by days that children have to have these chest tubes because we saw a new way of examining the safety and the effectiveness of our new processes. And so as we've talked to parents of children with heart disease and certainly children themselves, as they get older, this notion of getting that chest tube out days earlier has been really transformative.

Prakash Chandran: Yeah, all of that sounds really fascinating, especially hearing some of the impacts you've been able to have on these quantitative elements. And it's really just amazing when multiple stakeholders are able to get aligned, what can be accomplished. I want to move back to some of the qualitative impacts. I know that one of the things that PAC3 has also addressed is healthcare disparities and hospital-based inequity and outcomes. Can you maybe speak to this a little bit?

Dr. Nicolas Madsen: Yeah. Absolutely. i think healthcare is increasingly aware of our capacity to address health outcome inequities across different lines of disparity, be they racial, ethnic, socioeconomic. And PAC3 has really grabbed the bull by the horns in terms of trying to have a profound influence as we address these outcomes across multiple populations.

We are in the middle of a number of initiatives to both better study and better understand how some of these societal or hospital-based challenges, how they affect our patients and how in fact we can modify some of those effects to the benefit of patients. And right now, we are launching a new initiative across all of the centers of PAC3. That will be a two-year initiative to not only understand the outcomes, meaning when do you go home and do you experience complications, but some of the impacts as it relates to inequity across how far do you live from the hospital? What has your background been like? Is English your first language? Some of these other elements that we believe just by observation have had an impact. And so we're studying that in great detail, so that we can be more confident that we have some particular areas that we can address as a collective and, through this learning network, change our practice patterns to the benefit of all patients.

Prakash Chandran: You've mentioned the learning network a couple of times, and you alluded to this in the beginning, but maybe unpack a little bit more about how you all come together and learn from each other, even from a tactical standpoint.

Dr. Nicolas Madsen: Yeah, a learning network is a framework that is being used more and more across medicine in general, be it adult care or pediatric care. And the notion is really rather simple at its basic form. It is that why would we hoard best practice or why would we keep to ourselves knowledge that can be widely disseminated.

And so the commitment of a learning network is that you come together in person, virtually, digitally through email and any other conversation to address particular issues. And instead of assuming that you may have the right answer, you approach it with who else is working on this? What are their outcomes? What are their results? And maybe they are better than ours, despite our great attention to outcome X or process Y.

And I think the real notion or the real secret sauce of a learning network is the idea that you come to learn from others and that your ears and eyes are wide open. And I think that's really been a sea change in medicine. And PAC3 has certainly been very intentional in trying to harness those approaches as we unite in our common mission to improve the lives of the patients we care for.

Prakash Chandran: Yeah, absolutely. And just to understand a little bit more, in practice, does that mean brown bag sessions or Zoom webinars? Is there an online portal? How do you disseminate those learnings with one another?

Dr. Nicolas Madsen: All of the above. We traditionally had two conferences a year that are in person. And these are not conferences where somebody fancy gets up and stands at the podium for an hour and says everything that she or he knows. These are more "What are the projects we're working on?" Well, then let's break into groups that are representative of all of our different centers and let's work the problem." And so it's really more of a getting together and having a shared focus. And, of course, there are some folks who come in and maybe present on a topic and often outside of our field so that we are not just learning from each other, but we're learning from elsewhere. And so that has been an initiative since really 2014.

In addition to that, we have of course harnessed our learnings around teleconferences, Zoom, or otherwise. And so we have monthly gatherings and usually project-focused. There are those who are focused on quality improvement initiatives, those that are focused on research, those that are focused on how do we manage data. There are those that are focused on education and then we take those subcommittees and the work that they're doing, and we produce new education that's maybe for the nurses or maybe for the physician trainees or the advanced practice providers, or also we have patient and family action committee and that committee is specifically addressing both the patients and the families. And so it is really all of those approaches.

And lastly, of course we have a website and on the website, there is a SharePoint tool that allows person to ask a question and they'll receive an answer from 12 different institutions within a day. And all of a sudden, they are armed with all that experience, all that knowledge as they try to work a problem locally.

Prakash Chandran: From our conversation, this may seem obvious, but what opportunities do hospital systems who are not part of a learning network like PAC3 miss out on?

Dr. Nicolas Madsen: I think you miss out on several key elements. I think you miss out on the speed at which new opportunities are delivered to your patients. You miss out on new opportunities, being delivered without unintended introduced variability, meaning, "Well, I've read this paper, so I'm going to introduce something new at my site," but the paper may have a lot of information, but not all of the information.

And so having this network of colleagues and really friends, I think really improves the speed at which we do it and certainly improves the effectiveness.

Medicine for a very long time has made great discoveries, I mean, revolutionary discoveries. But the implementation of those discoveries has often been an afterthought. We invent a new medication and that's terrific and celebrated as it should be. But then do we really study if it's being used a hundred percent of the time when it's indicated? And I would argue, we would argue within a learning network and certainly within PAC3, that it's not enough to have the new medication, a new procedure. It should be applied to the right patient every time. That is part of the mission of PAC3, of learning networks in general. And we think it is again sort of that transformative part of bringing the best care to the right patient at the right time.

Prakash Chandran: Yeah, I think this is a good time also to ask, one of the things that I've heard is that PAC3 utilizes quality improvement science to drive its mission forward. So can you speak a little bit more about this?

Dr. Nicolas Madsen: Absolutely. I think it's one of the primary pillars of PAC3, the notion and field of quality improvement science. Improvement seems easy to all of us. But if we really pause and think about it, we realize that improving is hard. It doesn't take that long to think within one's own personal life and think, "Well, I'm trying to improve my level of fitness by exercising more," or "I'm trying to improve my health by drinking more water," how well is that sustained on a personal level? How often is everyone's successful a hundred percent of the time?

And I think most people are like myself, it's hard to make changes. It's hard to improve the quality of one's choices. So quality improvement science addresses exactly that. We know something is better, so how do we actually deliver it? How do we ensure that the system that is intended to deliver that improved quality does so every time? And if someone is new to quality improvement, usually when I ask how good are they at sticking to their exercise regimen, they sort of realize, "Well, yeah, you're right. Change is really hard," and I think quality improvement tackles that head on.

Prakash Chandran: Another thing that might be correlated to this is I know that there is a scientific review committee and research that's being done as well? Can you talk a little bit about that in PAC3?

Dr. Nicolas Madsen: Yeah, so that runs in parallel and overlapping with quality improvement, sort of the traditional aims of science and what PAC3 has done is it's established the largest ever registry of acute care cardiology patients and information about those patients. So each of the member sites that has a patient go through the hospital and through their acute care cardiology unit, there is a predetermined dataset that is collected relative to that patient. And of course, all personal health identifiers are removed, but we know in terms of the patient's condition and how long they were in the hospital and what medications they utilized and the like.

And that registry really forms the backbone of a more traditional approach to research and scientific inquiry where we then say, "Well, what does it mean to have X procedure? And what does that mean in terms of your likelihood of complication and what does that mean in terms of your likelihood of staying in the hospital longer?" And so it has allowed us to ask really pointed questions in terms of "Does the combination of X, Y, and Z lead to an increased readmission to the hospital rate?" Or maybe a common sort of legend within the hospital units, is "Well, if you always do A and B, then it clearly always leads to C." Well, maybe the data doesn't demonstrate that. And so instead of sort of just relying on anecdotal information, we're able to study it in fine detail and uniquely across all of north America, so across a large population base without sort of the bias that would be introduced if we were just looking at our own patients alone.

Prakash Chandran: Well, Dr. Madsen, this conversation has been fascinating. I mean, what a modern way for hospitals to work with one another and learn from each other. And it really just feels like the way things should be. Just before we close here today, is there anything else that you'd like to share before we sign off about PAC3 or anything else that we've discussed today?

Dr. Nicolas Madsen: Really just appreciate the opportunity to share. And PAC3 is one of these collaboratives and there are a number within the pediatric cardiology community. And I think that us working together for the benefit of patients and really to the betterment of all of us as we all come to work so committed to improving the outcomes of our patients. It is really the singular focus of every individual and that is certainly the case here at Children's Health and UT Southwestern.

And so I think being able to support this kind of collaborative and promote this kind of behavior has been a real privilege. And it's been an exciting first seven years for PAC3. And I have to say I'm even more excited and thrilled what the next seven years will hold as we utilize the momentum that we've gathered over last few years and we really become even more expansive in our efforts and in our ability to affect change.

Prakash Chandran: Absolutely. Well, thank you so much for your time today, Dr. Madsen.

Dr. Nicolas Madsen: Thank you. I really appreciate it.

Prakash Chandran: That's Dr. Nicolas Madsen, Co-director of the Heart Center and Chief of Cardiology at Children's Health and Associate Professor of Cardiology at UT Southwestern. Thank you for listening to Pediatric Insights. You can head to childrens.com/heart or pac3quality.org for more information. My name is Prakash Chandran, and we'll talk next time.