# Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure

## TL;DR

Implementing postoperative guidelines for Fontan procedure patients significantly reduced hospital stays without increasing readmissions.

## Contribution

A quality improvement project successfully reduced hospital length of stay after Fontan procedures using standardized clinical guidelines.

## Key findings

- Hospital length of stay decreased from 23 to 7 days after implementing clinical practice guidelines.
- No significant change in 30-day readmission rates before and after guideline implementation.
- Guidelines included use of PleurX drains, fluid restriction, and pulmonary vasodilation.

## Abstract

Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely.

We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions.

One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86).

Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.