Andersons pediatric cardiology 2263
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technologyinclude,three-dimensionalechocardiography,hybridcath
lab–operatingtheatersuites,androboticsurgery.Theactualnumbersof
patientswheretheytrulymakeadifferencecouldbequitesmall,andit
maynotjustifytheoverheadcoststhatwillhavetobesharedbyall,
includingthevastmajorityinwhomthetechnologydoesnothavean
application.
7.Focusonsimplequalityimprovement(QI)measuresthatmakealarge
differenceinoutcome.ThefactthatanumberofsimpleandlowcostQI
measurescansignificantlyimproveoutcomeshasbeenamply
demonstratedbytheIQIConcongenitalheartsurgeryinthedeveloping
world.41TwospecificexamplesoftheseQImeasuresincludethe
establishmentofarobustinfectioncontrolandpreventionprogram62
andimplementationofasurgicalsafetychecklist.66
8.Willingnesstoeducate,train,andmentoravarietyofhealth
professionals.Educationandtrainingcaregiversatalllevelsisa
valuableinvestmentbecauseitempowersthem.Thisisparticularlytrue
fornurses.Nurseempowermentdirectlytranslatesintoimprovementsin
outcomesthroughimprovedvigil,betterinfectioncontrol,andgreater
motivationthroughasenseofownershipoftheresults.
9.Willingnesstosystematicallydocumentpracticesandresultsandshare
withothersthroughcontextuallyrelevantresearch.Systematic
documentationofvariousstrategiesadoptedtoenabledeliveryofcareat
alowercostwithoutcompromiseinqualityisimportant.Consistent
documentationofthesepracticesinmultiplecentersenableswider
acceptance.TheIQICisanexampleofacollectiveeffortto
systematicallyimprovesurgicaloutcomesinmultipleparticipating
centersinLMICs.53
10.Willingnesstoexploreavenuesforfundingindividualpatients.Inthe
absenceofuniversalhealthcoveragethroughhealthinsurance,itis
oftennecessarytoexploreavenuestoraiseresourcestofundindividual
patientsbyconnectingthemwithpotentialdonors,nongovernment
organizations(NGOs)andphilanthropicorganizations.
11.Developingarelationshipwiththehealthadministrators.Health
administratorsdonoteasilyunderstandthefactthatpediatriccardiac
careisresourceintensive,outcomescansometimesbequite
unpredictablewithindividualpatients,andthereturnsoninvestment
maynotbecomparablewithothermedicalorsurgicalspecialties.Itis
importanttopartnerwithadministrationandcommunicateregularly,
effectively,andconsistentlyaboutthespecificchallengesfacedwhile
takingcareofchildrenwithheartdisease.
12.Developingpartnerships.Inspiteofsubstantialdifferencesinpractice
environments,alotcanbelearnedfromtheexperienceofestablished
programsinhigh-incomenationsthroughinterinstitutionalpartnership
programs.67ThereareNGOssuchasChildren'sHeartLink
(www.childrensheartlink.org)thathavedemonstratedagreatdealof
successthroughcarefullynurturedpartnershipsbetweenestablished
programsinNorthAmericaandselectedprogramsinLMICsinAsia
andSouthAmerica.17Atamoreadvancedstage,partnershipand
mentoringneedtodevelopamongtheprogramsintheLMICS,with
sharedproblemsandchallenges.Partnershipsneednotnecessarilywork
inonedirection.Recognizingthepainfulconsequencesofrapidly
escalatinghealthcarecostsglobally,thereareperhapsvaluablelessons
thatadvancedcountriescanlearnfromthepracticeofpediatriccardiac
careintheresource-poorenvironmentsofLMICs.67Inaddition,these
programsofferuniqueopportunitiesforclinicaltrainingandresearchin
pediatriccardiacspecialties,giventhedecliningpatientvolumesin
manycentersofhigh-incomecountries.
EstablishingandSustainingPediatricHeart
ProgramsinLow-andMiddle-IncomeCountry
Settings
Startinganewpediatricheartprogramischallenging,especiallysoinalowresourceenvironment.Surgeryisinvariablythefinalcommonpathwayto
definitivecare,sotheresponsibilityoftenfallstoacardiacsurgeontrainedin
pediatricsurgery.Thefirststepinvolvesnegotiationwithahospitalthatis
willingtoinvestinapediatriccardiacprogram.Thehospitalwouldhavetobe
preparedtodedicateacertainnumberofhospitalbedsfortheprogramandto
investintherequiredequipment.Itismorelikelythatthiswouldsucceedina
hospitalrunninganactiveadultcardiacprogram.Thisisthereasonthat,inmost
LMICs,pediatriccardiacsurgicalprogramsaremoreoftenfoundinadultor
multispecialtyhospitalsthaninchildren'shospitals.Thenextchallengeistoput
togetherateam—cardiologist,anesthesiologist,intensivist,perfusionist,nurses,
andotherparamedicalstaff.Theelementsthatconstituteatypical
comprehensivepediatricheartprograminadvancednationsareshowninFig.
88.6.However,inLMICprograms,manyelementsarelikelytobemissing.
Thereisaneedtohaveindividualsskilledinmultiplesubspecialtiesand/orto
seekhelpfromadultservicestocoversomeofthemissingelements.For
example,inabsenceofdedicatedpediatriccardiacelectrophysiologists,pediatric
electrophysiologyservicesmayneedtobedeliveredwiththehelpofadult
cardiacelectrophysiologists.Aftertheinitialhurdleofidentifyingandrecruiting
thecoreteammembers,staffretentionisamajorprobleminthefaceofwork
stress,jobinsecurity,andaggressivepoachingbycompetingorganizations.
Nursesandtechnicalstaffareinconstantdemandinhigh-incomenations,and
thisisasourceofconstantshortfallasprogramsinLMICsmature.
FIG.88.6 Elementsandpersonnelthatconstituteacomprehensive
pediatriccardiacprogram.Inlow-andmiddle-incomecountry
environments,manyelementsaremissingmainlybecauseofthelackof
trainedpersonnelorbecausetheserviceisnotavailable(e.g.,transplant).
Keepingaprogramrunningsuccessfullyoftenrequiresacombinationof
extraordinaryclinicaladministrativeandfinancialskills.Inanenvironment
