Nursing Editorial: Development of the Pediatric Cardiac Surgical Program at PGIMER, Chandigarh, India – Sustained Advocacy, Teamwork, and Global Collaborations are Keys to Success
The Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, is a government-funded tertiary care academic hospital in the Northern region of India. The specialty care services provided by the hospital cover a population of nearly 100 million spread over more than five administrative subdivisions of the country. The first pediatric cardiac surgery was performed here in 1975, and since then, the pediatric cardiac surgical care services have continually expanded. The expansion has been possible by overcoming technical, infrastructure, training, and financial limitations. Sustained advocacy, teamwork, and global collaborations were vital to the process.
The pediatric cardiac surgeries performed here have increased in both quantity and complexity, with the number of surgeries growing from ~10 a month in the year 2000 to more than 50 a month in 2019 (total 641 pediatric cardiac cases). The types of surgeries range from atrial and ventricular septal defect repairs to complex congenital surgeries including complete intra- cardiac repair of tetralogy of Fallot, arterial switch operation, truncus arteriosus repair, Fontan completion, and Total Anomalous Pulmonary Venous Connection repair. The proportion of patients undergoing complex cardiac surgery has increased over time, as has the number of neonates and infants undergoing cardiac surgery at our center (Figures 1 and 2). The outcomes have also steadily improved, with mortality decreasing from ~12% in 2013-14 to ~5% in 2019-20.
This growth spurt in volume and outcomes was greatly facilitated by establishing four upgraded cardiac operating rooms and a 13-bed postoperative care unit in 2009, and most recently, a new 10-bed dedicated pediatric cardiac ICU in 2019. However, infrastructure was not the sole contributor to the increase, especially since in 2013 we were doing only 30 cases per month. A critical milestone in 2013 was the beginning of a collaboration between PGIMER and Children’s Heartlink (USA) in staff training. Through this collaboration, cardiologists, surgeons, anesthesiologists, and critical care nurses received specialized training through lectures, simulations, hospital visits (partnership with Boston Children’s Hospital), and regular meetings, to prime the team for improving pediatric cardiac surgical outcomes. Presently, mortality following pediatric cardiac surgery at our hospital is around 5.5% and procedures in the Risk Adjustment for Congenital Heart Surgery (RACHS) score of 3 or more constitute 15-20% of all pediatric cardiac surgical procedures.
As a referral center, our program serves a large population of Northern India hence leading to prolonged wait-times. In addition, in the setting of prenatal detection being less common, the incidence of late presentation of congenital heart disease is high, as are preoperative infections. When these patients are received in the postoperative intensive care unit, pulmonary hypertension, ventricular dysfunction, and early sepsis often manifest and require increased vigilance and effort by the pediatric cardiac nursing team who are at the forefront of care for these critically ill patients. We have a well-trained and experienced cardiac nursing team, and 50% of all cardiac care nurses are trained to deliver pediatric cardiac care. Training and mentoring of the pediatric nursing team has been championed in collaboration with Ms. Anna Fisk, RN, Boston Children’s Hospital, who has been a mentor since 2013. We have regular clinical debriefs and teaching within the team and perform root cause analysis of issues and challenges we face. The cardiac nurses also share a close bond with the patients’ family, ensuring that the patient continues to receive good care after discharge.
Challenges remain in reducing wait times for surgery, reducing limitations induced by lack of financial support, and managing the sickest pediatric cardiac surgical patients. For example, the patients who would clinically be eligible for mechanical circulatory support but are unable to receive it due to unavailability of financial support remain a difficult group to manage. However, our growing clinical experience and improving outcomes have also enabled us to successfully perform two pediatric heart transplantations, one of them during the COVID-19 pandemic. We continue to build upon our experience in further improving the volume, efficiency, and outcomes of pediatric cardiac surgeries.
- Simsic JM, Cuadrado A, Kirshbom PM, Kanter KR. Risk adjustment for congenital heart surgery (RACHS): is it useful in a single-center series of newborns as a predictor of outcome in a high-risk population? Congenit Heart Dis. 2006 Jul;1(4):148-51. doi: 10.1111/j.1747-0803.2006.00026.x.
- First patient to survive heart transplant at PGIMER joins as hospital attendant [Internet]. Hindustan Times. 2022 [cited 30 June 2022]. Available from: https://www.hindustantimes.com/cities/chandigarh-news/first-patient-to-survive-heart-transplant-at-pgimer-joins-as-hospital-attendant-101650480105523.html
- 13-year-old boy discharged after heart transplant and recovering from coronavirus [Internet]. The Indian Express. 2022 [cited 30 June 2022]. Available from: https://indianexpress.com/article/cities/chandigarh/chandigarh-13-year-old-boy-discharged-after-heart-transplant-and-recovering-from-coronavirus-6578502/
Figure 1. Trends in Surgical Complexity Over Time at PGIMER, Chandigarh
Figure 2. Trends in Age Distribution of Pediatric Cardiac Surgical Patients Over Time at PGIMER, Chandigarh
Nursing Officer, Pediatric cardiac surgical intensive care unit, PGIMER, Chandigarh
Rajarajan Ganesan MD, DM
Assistant Professor, Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh