Improvement Through Collaboration: Inspiration and Growth through PC4


My involvement with the Pediatric Cardiac Critical Care Consortium (PC4) began in 2016 when Dr. Javier Lasa asked me to join him as a co-clinical champion at Texas Children’s Hospital.  Over the past 7 years, the opportunity to be involved with PC4 on a local and consortium-wide level has granted me foundational insights that in many ways inform how I think about the care we provide in the cardiac intensive care unit (CICU) and inspires me as I consider the ways we can continue to optimize this care.

PC4 was started in 2009 with the mission to enhance CICU medicine and improve the quality of care for all patients with critical congenital and pediatric acquired heart disease through high-impact science, collaborative learning, and identification and dissemination of evidence based best practices. Formed as a quality improvement collaborative within a clinical registry, PC4 has expanded from 5 initial institutions to now include 71 institutions (throughout North America as well as Pakistan).  The clinical registry contains over 171,000 cardiac ICU patient encounters to date, and data from the national PC4 registry has directly been utilized to produce at least 45 peer-reviewed manuscripts.

The core pillars of PC4 include:

  • timely performance feedback to centers with actionable high-quality data,
  • transparent data reporting,
  • an expectation of sharing wisdom among participants, and
  • promoting an environment which brings together a diverse group of leaders with the common vision of collaborative wide scholarship and improvement.

The clinical champion at each participating center has access to a web-based reporting platform detailing dozens of performance metrics, including risk-adjusted models for key metrics such as mortality, length of stay, and cardiac arrest rates.  The platform is updated daily, providing timely performance feedback as ICU encounters are entered into the database.   It allows for sites to benchmark performance against other CICUs in the consortium, identifying strengths but more importantly potential areas for improvement.  One key feature of PC4 is that once a site has passed an initial rigorous data audit (after approximately a year of data entry) the site can be “unblinded.”  This allows the clinical champion at each site to identify which specific other centers are performing at a high level across the various performance metrics.  This transparency promotes collaboration across the consortium as the clinical champion at any site may reach out to the clinical champion at a high-performing center in a clinical area they are looking to improve, to gain insights into how the high-performing site has achieved their outcomes.

While each individual participating center utilizes the PC4 database in its own unique way, since its inception we have compelling examples of how PC4 has succeeded in enhancing the quality of care provided to patients in the CICU.  An analysis published in 2019 examined post-surgical outcomes in centers participating in PC4 and found significant relative reduction in post-operative mortality, length of stay, major complications, and duration of mechanical ventilation following 2 years of participation in PC4.[1]  These improvements were not realized in other non-PC4 sites over the same time period.

Another example of network-wide quality improvement is the Cardiac Arrest Prevention project.  Fifteen participating centers implemented a low-technology cardiac arrest prevention practice bundle.  Participating sites achieved a 30% risk-adjusted relative decrease in cardiac arrest rate compared to the 12 months prior to implementation.[2]  PC4 sites not implementing the cardiac arrest prevention bundle, serving as control sites, did not exhibit a reduced rate of cardiac arrest.

These examples illustrate the potential of multi-center collaboration to facilitate meaningful positive impact on the care we provide in the CICU.  Personally, being an active member of PC4 has not only allowed me to experience this power of collaboration but also influenced the way I think about making improvements.  PC4 provides a powerful tool that allows us to insist upon a data-driven approach to assessing performance and implementing change.  It has opened my eyes to the aspects of excellent care being provided at centers of various sizes throughout the country and helped me feel closely connected to the CICU community outside the walls of my own institution.  As I’ve recently had the opportunity to assume the role of CICU medical director at Sunrise Children’s Hospital in Las Vegas, participation in PC4 was one of my most important stipulations, and I’m eager to dig into my site’s performance across all the domains tracked within PC4 to help guide and inform our efforts to optimize our practice.

If you are a PCICS member at a PC4 participating site, I hope that your ICU and Heart Center leadership is routinely utilizing and sharing PC4 data to assess performance and quality improvement initiatives.  If not, I would recommend you reach out to your PC4 site clinical champion and ask them to show you the data reporting platform and brainstorm potential ways you could utilize the data available to inform improvement initiatives in your CICU.  If your center is not currently participating in PC4, I’d encourage you to learn more about the consortium ( and talk to your ICU and hospital leadership about the benefits of joining.  We all know that providing critical care to children with heart disease is not easy, but PC4 has established the collaborative environment to help participants realize that we aren’t the only ones going through these struggles and we can leverage the lessons learned and expertise of the broader cardiac ICU community as we strive to constantly improve the care we provide.


  1. Gaies M, Pasquali SK, Banerjee M, Dimick JB, Birkmeyer JD, Zhang W, Alten JA, Chanani N, Cooper DS, Costello JM et al: Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration. J Am Coll Cardiol 2019, 74(22):2786-2795.
  2. Alten J, Cooper DS, Klugman D, et al: Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration. JAMA Pediatr 2022, 176(10):1027-1036.

Justin Elhoff MD

Medical Director, Cardiac ICU and Congenital Heart Disease Inpatient Services
Sunrise Children’s Hospital/Pediatrix Medical Group
Las Vegas, NV