Dr. Viviane Nasr - Toward Comprehensive Perioperative Risk Assessment in Children

Dr. Vivian Nasser. So she completed her initial medical school and anesthesia residency at the American University of Beirut. She then came to the United States and did a pediatric anesthesia fellowship at DC Children's followed by anesthesia residency at Tufts and then a pediatric cardiac anesthesia fellowship here at Children's. She's since stayed on as faculty and has now associate professor in the Department of Anesthesiology and Harvard Medical School. So she'll be speaking to us today on comprehensive parioperative resuscism in children. Please help me welcome Dr. Nasser. Good morning. Good morning everyone. Thank you Hester for a nice introduction there. Yes I did do residency twice once in Lebanon and once to be board-certified here. Just if there's any confusion about how that came up. I will be talking today about a comprehensive parioperative resuscism in children. It is interesting for me in particular because a lot of time we get a call from colleagues from residents fellows what's the risk of that patient and it's a little bit tricky sometimes to quantify it or really explain it. So I'm barked on an adventure of trying to determine this better. I have no disclosure. The objective would be to really discuss some of the risk factors of major parioperative adverse events in children and what has been published out there. Review some of the recent publications on risk stratification and introduce some novel scoring system that we are currently working on and we'll continue hopefully to work on. What is risk when we think about risk we think about the possibility of harm possibility or loss or danger in general. How many of you came today driving? How many came walking or even biking? This weather today? Wow good, you're courageous there. It was freezing. Everyone of us potentially took a risk this morning coming to work. Out of the leading causes of deaths, accidents is a third leading causes of deaths and not necessarily a car accident but accidents in general. And you can see here the fatalities of being inside a vehicle or outside a vehicle are steady throughout the year so there's always this risk for one person who bike this morning by looking at the risk factors of biking and injury, biking to work puts you at a higher risk when you're biking of an injury. So we all stick a risk. Even those who walked maybe from the parking lot like myself or from home, we have around 6,000 pedestrians that are killed every day in general and 2017. This is the data around 16 people a day which makes it around 115 people a week. Does that mean we're not going to come to work because there is a risk or we're not going to drive, we're not going to bike. No, we're going to try to understand it and maybe wear a helmet when we're biking or like Boston children that that bridge maybe this decreases the risk of pedestrians crossing the street and walking through the bridge. So we don't just decide not to do something because it carries a risk but maybe try to understand the risk and see how we can minimize it or prevent it. And that's what I think the thing is thought about risk for me means is not avoiding it but maybe try to face it and try to minimize it. So there is a risk in health care virtually all health care intervention carries some risk. Taking a low dose aspirin does have a risk even though we're trying to be protective of cardiovascular disease. It does have a risk maybe of anti-coagulation. The decision must balance risk of good outcome versus bad outcome. And when I think about risk there's many turns that come to mind. You think about risk as a facemist intensity of the risk, the severity, the complexity of the case, any comorbidities that the patient has or the health status. And so how do we really define it, measure it, quantify it and it's going to depend on what is the risk that we're measuring. When we think about health care we're thinking about the five-dease of outcomes, the death, the disease and this relate to the patients, the discomfort of a patient, their disability, their dissatisfaction potentially for us as a patient or as a family, and the risk of dollars for of insurance is in health and very much. And it depends also on who am I asking, are you asking an anesthesiologist or about the risk of induction or the risk of ICU admission after the case or are you asking a surgeon about the risk of bleeding? Are you asking an intensiveist about the outcome of my patient? Is he going to go okay, do well or is he going to come off ECMO, oncologist, primary care physician, everyone views risk a little different maybe. But in addition to clinicians, there are other health care providers in the system professionals, such as payers with the reimbursement, health policy makers, financial analysts, quality performance managers, regulators and everyone think about that risk. I'm going to focus on the risk of very operative process because I think it affects us and affects everyone in this room. The pre-op includes evaluation, diagnostic imaging, lab studies, and when we think about that there is a risk here, do they need anesthetic or do they not? Introperatively the procedure itself, the induction, the monitoring throughout the case that I need to put in a phase of monitoring or not, what is the operating room or should they be done offside? The post-op, the charge that they need to stay intimately or not, are they going to have a risk of mortality and what are the hemodynamics? And so the way I split it would be risk of mortality or risk of morbidity or other adverse events. So that I should try to think of when should I be worried, who should I be worried about and what am I worried about? Am I worried about the mortality or am I worried about some morbidity that they have? So if we put it all together here, I'm going to define the risk as a measure of probability. It's a statistical chance of an occurrence. It's a risk versus benefits. It can happen every day, every procedure when you guys finish ran around here, there is a risk of every patient that's of their waiting for us. And there is a different perspective whether it's the patient's viewing it, whether it's me looking at it or whether it's the insurances or the searcher. So risk adjustment is to account for pertinent attributes before making any inferences about the outcome of care. And we try to reduce the effect of confounding and try to be objective in our answer. And we want to produce results that appear credible. The risk of that certain procedure, that certain patient should be reproducible if possible. So if we think about 10 scenarios here, 10 months old Glenn for circumcision, we have the age, he's less than one year, and he has a congenital heart disease. So we got a call from our colleagues in the main or asking us, I do only cardiac anesthesia. So they would be asking us, what is the risk of this patient? He has a glenn, a glenn for those who might not know what it is. It's a connection of the superior veneciva to the pulmonary artery to allow pulmonary blood flow in the patient. And so if that patient comes to you, are you going to consider him high risk? The circumcision is a simple procedure, but he has congenital heart disease. How are you going to explain that? Next, creamy for hypospidial. A 16 year old who has a pulmonary hypertension who's coming for a brovia, or a pick line, and he has chemotherapy, so he has an A or plus, and he's pulmonary hypertensive. Or a 13 year old who's healthy for our trust, our trust, or a 13 year old who's healthy for spine fusion. And I know we can say they're moderate risk, they're high risk. I'm hopefully going to go back to these scenarios at the end and try to have some numbers there or put them in perspective. So now that I've described to you what is risk in general and how I think about it, we're going to go through some of the initiatives that have been done in terms from the anesthesia literature. They initiatives I'd been to try and identify and improve or prevent the certain adverse event. The wake-up safe is a quality improvement initiative. It is by the Society of Pediatric Amesthesia. It's a registry of serious adverse event for all pediatric patients who have an anesthetic. There is 34 major institutions that participate in it, and it is supported by the Anesthesia Patient Safety Foundation. The case load is around 500,000 anesthetic per year, and it's designated as the patient safety organization by the agency for healthcare research and quality. There is also another issue which is the pediatric-periocritic cardiac arrest registry, and they have shown that if you have the ASA physical status of 3 to 5, if you're an infant, if you're having an emergency procedure, you're a tyrus. But this is very broad, and the wake-up safe, I think, is a great initiative that it's collecting data and it has some results, which some of that goes along with some of the literature here. So there's different publications that have been done over the years. You can see from 1988, 1990, and then you have 2001 and 2004, and all of this have looked at patients with age range less than 16, or one of them doesn't state the exact age range. And they looked at type of events which are risk-peri-events, and they have shown that the risk factors which I underline there in red are infants, and ASA 3 to 5. And I think if you ask anyone what's my risk, and if they're an infant, or if they're ASA 3 to 5, you're going to say over there at high risk. The question is, how risk for risk-reparatory complications that they showed here, or you're thinking about risk when someone asks, okay, the ICU beds are tight, which has been very commonly linked in our institution. You say, well, do I need an ICU bed then should I cancel that case? And so I think when we think about that, we should think about what type of risk we're thinking. And so these studies have looked at risk factors for cardiac arrest, saying that ASA 3 to 5, but this is subjective, and we will discuss how it is subjective in pediatrics and particular. Age less than one year, emergency surgery. Other observations that that infants suffer predominantly risk-reparatory complications, and the vast of vomiting is common in other children. Similar major study done in Europe, it's called the APRICOT study. It's a prospective multi-center observational study where institution would have volunteered to participate. They had 261 institutions, 33 European countries involved, and they looked at adverse events, respiratory, cardiac, allergic, and neurologic complications. The incidence of total complications were around 5.2%. And they showed a higher incidence of severe critical infants in less than six years. So you can see here that different age groups, neonates as a highest risk of adverse events followed by infants, and then you have the older kids. And so it is all similar to other studies where infants and neonates might be at higher risk, and it's dependent on their medical history, on their comorbidities, on their ASA physical status. And you can see that the younger kids have higher cardiac complications than older kids where it's more respiratory complications. So I've mentioned that ASA is a big component of all these retrospective or prospective studies. However, the ASA for many of you who use it and reuse it, I think, in our institution is that it's not that reliable in pediatrics. And I'm going to take you through the next few slides trying to explain how I view ASA or many of us more recently. So the ASA physical status for those who may or may not know. In 1941 is when it was developed. And this is the American Society of Anesthesia. They asked the three particular people, which was Dr. Sakwa, and Droveinstein, and Ivan Tyler, to try and devise methods, which they would collect and terminate outcomes from anesthesia. And they came up with the ASA physical status classification. They described six classes, and they gave example to each one of those classes to try to help the provider understand what they are. In 1963, this ASA classification was adopted by the ASA American Society of Anesthesiology. Just to review it briefly, so that class one is a normal, healthy individual. Class two is someone with my systemic disease that may not be affecting him daily. Class three is a patient with severe systemic disease, but that is not incapacitating. Class four is a patient with incapacitating systemic disease, that is, it's conscious stress to life. Class five, it's a maribund patient who is not expected to survive 24 hour with or without the operation. And then the class E, which is added to any patient who's coming for an emergency. So you can see that it's a little gray, and there has been very little work that was done to try to provide this reliability or validity for the ASA. Twenty years after it was developed, no one has done anything for it. And then in 2014, they tried to look at evidence-based data to see, can we use really that ASA's four? And some of the studies listed there, they looked at it and showing that there is variability in the way people rated. If a diabetic was say, who's controlled on medication, does that mean I have systemic disease that is not incapacitating or does that mean I am incapacitated because I take the medication every day. So there is a little bit of rage how you would interpret that. And then they have looked at as well as this is in adults looking at ASA and how they each one rated. So they gave examples of cases and looking at, okay, how are you people rating it? And they showed that variability in fact, it is just there. And they showed that it does not reflect necessarily outcome. So it was not designed for prediction of preoperative risk. It was designed to describe the physical status of the patients. Now it was designed in adults. So does it apply to our pediatric population? And if we think about it, yes, it might be easy to describe it, describe our patients, systemic disease, no systemic disease, it makes it easy. However, it is used as a predictor of outcomes. As you saw in the other papers, they use it to define risk of adverse events, but it was never validated. They said that these are the risk factors, but there was never a validation about these rash factors. And they have been studied done in 2006, 2007, and more recently in 2009 by one of my colleague Dr. Ferrari, and she looked at the interrater variability of how people are really scoring the ASA. And it is integrated on our billing model. And that's why I think it's important to really understand it and maybe have a better tool if we're going to integrate it into our billing model. So this is a study by Stephanie Applin, and this is on Australia. They took 15 hypothetical scenarios in the geographic to see, well, maybe in pediatric, it works differently. But they show that just the respondent who are asked to grade the hypothetical patients there. They show that there is 55% of variants, and this variance was not necessarily due to the respondent, but more to the ASA physical status classification. And some of the some of the reasons might be in pediatric is that the ASA does not account for consumable abnormalities. It does not account for syndromes and does not account for developmental stage, which is something important for us in the pediatric population. So this is a study by Dr. Ferrari and some of other colleagues in the department, and they have 4,564 patients from our institution from in 2017. And they look to see how does patients, how does the ASA rating reflect the patient's condition? So all the patients have an ASA score in our pre-op evaluations. Taking all these pre-op evaluations ASA, and then looking at these patients, what kind of morbidities they have, and if the classification was correctly, correctly defined for each patient. And if you look here at the ASA, let's see if I can get the ASA one patient. So you think ASA one is a normal healthy. So if I ask the question, do you have a chronic condition, it should be 100%. No. However, 45% have a chronic condition, yet we have labeled them as ASA one. And if we look at multiple conditions here, 14% had a complex condition. ASA two, same thing, a chronic condition, yes, for 78% and 46% have a yes. I think for ASA four is where we mostly agreed that 100% had a chronic condition. So this variation not only impact the way we think about the patient, but since it isn't an integrated tool in our billing, if you're willing someone as ASA one, well, they have a chronic condition, they're actually losing. If you're willing someone as an ASA one who, as an ASA here with like the two, with no, but they have chronic condition, you're also under willing. So it does have implication not only on the way we assess the patient, but also on our VM person. So this was a proposal to have a pediatric ASA PS score. And the proposal was in kids to have six classification where you have a normal healthy patient. ASA two would be the patient with my systemic disease, no functional limitation and or no more than one control disease. And the addition in this proposal is you have examples so that people correct it's congenital heart disease when you have no other residual. You're not on medication. That could count as an ASA two. ASA three would be someone with congenital cardiac abnormalities with chronic heart disease on medication. ASA four with severe systemic disease such as an uncorrected, palliated patient, extreme prematurely, had a hypoxic in cell before. ASA five, it's a marvel, and it was not expected to survive. And the ASA six, brain, that patient was basically coming for organ harvesting. So this is the ASA classification and I hope I was able to make you think about it a little bit more as we try to think about the ASA. What I'm going to go through next is trying to think about risk testification a little bit outside the ASA. When we think about the patients, we think about the patient's chronic condition, which is what maybe some of the ASA tried to target too, but there's also the acute condition on where is the patient right now, how is the patient doing, and thinking about the intrinsic surgical risk of the surgery itself. Then we can decide on who's going to really do the procedure, where is it going to happen, what is the level of care do they need to be discharged home, do they need to be observed, do they need to go to the ICU, and then what is the potential outcome. So a few years ago I was not interested in this risk assessment and the first thing was an easy target to look at is mortality. At Versa Health Com we define them differently, we sometimes are not very good about how we think about them. So the first one to start ways was the mortality. I looked at 30-day mortality, working with Dr. Dinardo and Dr. Farone, who's now in seconds in Toronto. We looked at 183,000 children that were included in the 2012, 2013, and 2014 of the NESFIS database, the National Surgical Quality Improvement Program, the Pediatric Section. The incidence of mortality was 0.5%. We have the derivation cohort, and then we had a validation cohort, and the incidence in the validation cohort was 0.4%. Variables that were included in that logistic regression analysis included factors such as hematologic disorders, these were the ones that have actual significance in that slide. Pre-op, transfusion, congenital heart disease, neurologic disease, urgency, respiratory disease, acute kidney injury, pre-op CPR, less than 12-minds, mechanical ventilation, and neoplas. I think if every time a patient comes to you or a friend of a colleague is going to ask you about the risk of mortality, and if you have to think about all this, it would be a little bit tough to give an answer. So we tried to simplify it into five variables. The variables are urgency, which counts as a plus one, comorbidity, which include the kidney, respiratory, hematologic, neurologic, cardiac, that will give you a plus two. Critically ill will give you a plus three, and the age less than 12-minds will be a plus three, and the neoplasm, a plus four. So if you look at the slides showing the different transport distributions, and then the different transport distribution and the risk of mortality, you can see here around five or six of them. This is when your risk of mortality goes up. And the percentage distribution, a lot of our patients, thankfully, are in the lower risk scores, but it is something to keep in mind for those higher that the risk of mortality is high. So if you think about the pram, and we look at the ASA score, the ASA above or equal to four here, you would think they have a chronic condition. If someone have labeled you as an ASA four, you should have some comorbidity. But yet, a lot of the patients were in the zero one and two, which are at lower risk of mortality. So if we're going to think about the ASA being an assessment of mortality, I think we won't be able to get accurate data because we would have considered all these patients despite the fact that the lower risk of mortality based on the pram of a high risk. So after doing the NASCAR database, the question we came, well, is that valid if we use it in our institution? And maybe we should try and implement it here locally at Boston Children. So what we have done is we have a great name, steam. I'm very thankful for working with them, and we implemented the perioperative risk assessment score, which I call the pram, into the anesthetic records. And every provider would be able to fill these factors urgent, particularly health, comorbidity, and the neoplasm and the age of the patients. And when you go, we collected that data prospectively over, it's still being collected, but that does the data of a year worth of data. 13,530 surgical cases in our external validation cohort were included. There was no missing pram data because we made it mandatory to be filled out otherwise the provider won't have a closed record. Thanks to Dr. Hicking for implementing that as being mandatory. And the incidence of mortality was 0.21%. Yes, our risk of mortality was lower than the NASCAR mortality database. And maybe because we do a very good job about preparing these patients, our pre-op evaluation. And so the risk of mortality might not be the same. However, the pram prediction of mortality in our cohort at the CAH looked as good as the NASCAR, the derivation and validation cohort, and with an area under the curve of 0.95. So we can say that the pram has an excellent prediction of 30-day mortality in our patients. And we again looked at the ASA, since these ASA scores work by us as providers here, collected at Boston Children, and looked at the pram distribution. And you can say similarly that there is really a wide distribution of how the ASA4 includes prams of 0. And prams the ASA less than 3 includes prams of 9. And if I think about mortality in these patients, so we did a gray zone approach where we tried to say what is the cutoff of the pram where you are really at a high risk of mortality? And where does the risk of mortality start decreasing? And a pram above 6 is when your mortality starts really increasing. A pram less than 3, your mortality goes down. So between 3 and 6, there were around 600 patients there, where your mortality is really not at the high risk or at the low risk, or potentially could be defined a little bit better. The incidence of mortality in the patients with ASA less than 3E was shown as 0.06%. However, some of those patients, as I've shown, have a prams score that was higher than 6. And if your prams score is higher than 6, your mortality is around 0.49%, which is 8-fold higher. So if you're going to use the ASA to really describe mortality, you might be underestimating the risk of a patient. So I've talked about the acute condition. They're coming, they're critically ill. What is their condition right now? The current status is that in your treatment or not. But that is only one box of risk assessment. They're going to comment, they're going to have a surgical procedure that might change their status intraocatively or depending on what's happened. Surgical procedure can have physiological changes, mechanical changes. The outcome might be different. So then NESPRABITSELF has done a pediatric surgical risk calculator and some of the surgeons who are here at Boston Children was involved at Ferengal. And they have qualified 18 risk factors to look at that. And they have a post-operative outcome. So this calculator is available online. Google it, you can put in the factors of the patients. They also have a risk modification that can be done by the surgeon where you can go up or down on the risk that shows up based on the surgeon. The only thing with the development and evaluation of the article is that you don't really know how does each risk factor work in the post-operative outcomes. There is no definition of how this algorithm really wants to divide. The methods is there but I don't know what's the odds ratio of each of those outcomes. So we try to look at the intrinsic surgical risk by surgeries. And we use the NASCARP again to have a derivation and evaluation for heart. And we use four years for derivation and evaluation in 2017. And we looked at all CPT codes. There were 659 of them. And among these cases there were 0.34% 30-day mortality. All of the CPT codes were categorized into four intrinsic risk quartiles based on the mortality there. And when we looked at the predicted 30-day mortality in these patients, you can see that the low surgical risk patients have 4.7%. If you have five comorbidities, your ears are around 4.7% to have mortality. If you have a high risk procedure, you're 46.7%. And the procedures were four quartiles, one, two, three, four. And you can see here in that multivariate model that you have weight loss and five, ASA, the substances, Inotropic support and pre-op ventilator, which are factors that we have shown before that could be impactful in terms of comorbidities. And you can see that the intrinsic risk by itself has a risk of mortality here. Even for the same patient with five comorbidities, you're just just like doing a different procedure. You're increasing your risk of mortality. So one factor that doesn't show up, which is very important for me, is the patient with Continental Heart Disease. And they did not show that this is significant, which was a little surprising. But then we use it in this model as a yes, no. Do you have Continental Heart Disease or you don't? And maybe that's not the right way of doing it. And that is based on other studies that we've done that I'm going to share with you. And maybe Continental Heart Disease should be classified as minor major and severe. And maybe we would have shown some significance there. So Continental Heart Disease undergoing noncardiac is something we get called for. There's every day one of us is cardiac anesthesia as a consultant that anyone can call us to say, this is the patient going to the OR. Can we help with him on the schedule? Who should be doing the case? What are consideration? Him or dynamics? We even put notes in the pre-op, try to find the provider and give them advice. We sometimes come in and help you. And maybe that's why I haven't seen many of you. Thankfully, not thankfully that I haven't seen you. Thankfully, I wasn't called for a risk of patients. So Continental Heart Disease are important because every time there is a study in looking at mortality, it shows up that it is one of the high risk factors that shows. The influence of CHD here, twofold increase in mortality in neonates and infants. Very operative cardiac arrest in children between 1980 and 2005, 88% of these patients had CHD. Post-op mortality in children looking at tertiary pediatric hospitals, 50% had pulmonary hypertension. So CHD always comes out as a major risk factor in patients who are undergoing non-partiac procedure. Even looking at the pediatric cardiac registry that I mentioned earlier, they showed that 34% congenital or acquired heart disease among the patients who have had cardiac arrest. Single ventricle has been one of the major regions and 50% more than 50% are in the general OR. They are patients that are undergoing non-partiac procedure. So this is done by my colleagues, Dr. Denardo, Dr. Farone and other members of the Department of anesthesia. They looked at post-op outcome in children with and without congenital heart disease to see what is the impact of CHD. And they used the classification of minor, major, and severe CHD. Minor CHD being a cardiac condition with or without medication. So for example, a small ASTV, ASTV repaired. Major CHD is a repaired congenital heart disease, but they still have a residual hemodynamic instability. And the severe is someone who is uncharacter tionotic heart disease. And when they looked at the outcomes of 30-day mortality, the outcome of overall mortality and re-intimation, they showed that severe CHD are at high risk. And then if you look at overall and re-intimation, even major CHD will be at risk. And as I mentioned in the intrinsic risk, just use CHD as yes and no. And this is when you, if most of the CHD are minor, it's not going to come out as a predictor there. So we tried to develop risk or stratification for scoring in patients undergoing non-cardiac because if I'm going to tell you, main or major severe ametris, but what is actually the risk of these patients? And we looked at the risk stratification to predict as well post-op mortality, emergency procedures, single ventricle, surgery within 30 days, severe CHD, Inotropic support, and acute kidney injury or chronic mechanical ventilation. So some of the common theme become Inotropy, mechanical ventilation, acute or chronic kidney injury. And then in this particular patient's of CHD, severe CHD are single ventricle. And the scores less than three are associated with the lowest of mortality. Scores ranging from 4 to 6, you see that your odds ratio become as 4.19. And the scores above 7, they are associated with the high risk of odds ratio of 22. So we took that intrinsic surgical risk of mortality and we took our CHD population and tried to see if there is an impact of intrinsic risk, surgical risk in patients with CHD. We looked at 37,000 children with CHD just to keep in mind this is still in review. And if they're undergoing non-cardiac surgery with the incidence of overall mortality of 1.7%, you can see that the overall mortality of patients in CHD is higher than the regular NASCOV database that I showed earlier is at 1.4.5%. And we looked at a validation cohort. And you can see here that patients with CHD, whether you are having a low risk or a high risk surgery, you have the same risk of mortality. So really it is not your surgical procedure, your surgical risk that is playing a role. You can see that here with the risks for we put it as a zero. It doesn't matter what procedure you're doing. It matters very functional status of their cardiac region is more important in patients with CHD. So we looked at chronic condition and we tried to define mortality in that. We looked at surgical risk and tried to define mortality of that. But I'm sure many of you are thinking, well what's important? The patient is not going to come asking me, am I going to die today? Or the family is not going to ask you the question, is my patient is my child going to die today? They're more going to ask you, is my patient going to need ICU? How many days I'm in a state in the hospital? Are they going to stay intubated? And so these are the questions I think that might be more important for a family, but also for providers or even for intensivists who are trying to look at the bed capacity and which case need to go and which cannot go. So then the group started growing here. We had Steve with us, who's here. I had a gym in order. We had David Farone, but now we extended more Dr. Farone, Dr. J. Barry, and we involved other people and we started thinking more about the chronic conditions of the patient and what are the real outcome of these patients trying to make it more comprehensive. And we looked at the outcomes, there is a composite morbidity outcome that we came up with, but also if you look at them separately, we wanted to see how many patient get transferred to a higher level of ICU care. How many get re-admitted within 30 days? How many of them are post-operatively ventilated, hemodynamic instability, acute neurologic decomposition or respiratory decomposition? How many have acute respiratory failure that requires non-invasive support or intubation? How many have cardiac arrests? And this is what we did is because we had our cram data being collected respectively. We used another data, another year of data, so that was around 18 months of patients, where we looked at their outcomes, prospectively collecting all this and looking, you can see that the incidence of these outcomes separately is very low. We have very few patients that really have major hemodynamic instability. And that was one of the reasons where we decided to do it as a composite morbidity outcome instead of looking at each one. Although when you look at the area under the curve for transferred to higher level of ICU, it's 0.8, acute neurologic decomposition 0.8, so it is really a good predictor even just for some of these factors, but as a composite, it is even better. And the idea is to come up with a model that will predict these outcomes. And the model that we came up with is age less than five years. So we always talk about age less than one year or infants or neonates, but when we're thinking about these risks or many of the studies before, they have looked at cardiac arrest, we have looked at mortality. And so this is more looking at morbidity and maybe the morbidity in these kids and adverse events are in age less than five years. In fact, the Africa study that I mentioned earlier, their cutoff for age and high risk was around five as well, 4.6. And so anything well as then 4.6 was the cutoff for also other adverse events including respiratory. Urgent procedure, intrinsic surgical quartile risk of 3 or 4, even though developed from mortality, it helps true for these outcomes. And the chronic condition indicator, and chronic condition for those of you who may not know what it is, it's we look at the organ system and if you have diseases that affect your organs, such as neoplasms, circulatory, neurologic, cardiovascular, they are just there. And we have to find some of them as a significant CCI, which had a higher risk than others and the ones that are significant, I'm listening there, started to name some of them, neoplasms, circulatory, neurologic, respiratory, digestive, genetic, optic, and mosquito skeletal. And the CCI above, if you have four of them, any of them, you're at the risk. If you have two of those significant ones, you have also a risk. And so the same, we tried to put a simple, easy point system here for the provider to use. And you can see that we call the traps, the risk assessment, it's morbidity, impingiatrics, surgery, and you can see that, and this is as well in review. And you can see that as your risk increases here, the ramp score increases your risk of morbidity for that composite outcome increases. So if you have two of those significant CCI, your ramp score is going to be a five. So you're here at risk of 14% of having any of those morbidities. Yes. How are you defining intrinsic surgical risk portal? So this is the one that I showed earlier by the intrinsic risk here. So this is what the intrinsic surgical risk was. So we've used the NASCOB database and divided into four quartiles of risk of mortality. And each quartile had a specific risk of point 14, and this is how we define the four risk quartiles. So we used that same risk when we had our CPT codes from internally here at the hospital. What the CPT codes in the NASCOB was in one of those quartiles. So using that same surgical definition, we assign each CPT a risk quartile. So they are not patient that actually have died in our hospital, but with that CPT, that would have been their risk in the NASCOB database. So we use that same risk to define their morbidity in that model. So the going back to some of our scenarios. So we had 10 months old Glenn for circumcision, the first one. So if I think about it, we're going to try to give them a prime score or give them a ramp score. So this patient has comorbidity, which is the cardiac condition. He's less than 12 months. The prime is five. And as I said earlier, the prime between five and four was not very like a high increase of mortality, but you are right before the cutoff of mortality. So you're fine there. And then your ramps, you have a circumcision, which is the entrance to the Christoph one and just then five years is the one. So you have a ramps off tool. So I think in terms of morbidity, I think we can all agree that Glenn is one of the most stable stages in single ventricle physiology. And he's coming for a circumcision. I would say that these foreings looks okay there. And the X-premier for hypospatial, he's a plus three just because of age, but he doesn't have other comorbidities. And then he would be a plus three. If he had other comorbidities, then we would have kidney disease or anything, then we'd have been different similarly for ramps for that patient. This is I think the interesting one who's 16 year old pulmonary hypertension. He's in the unit for a brovia or a pick line for chemotherapy. So his comorbidity has a two of his pulmonary hypertension. He's critically ill disease in the ICU. And he has a neoplasm and this is he's coming for chemotherapy. So this puts him at a high risk of pram of mortality. Same thing for the ramps. He has an intrinsic risk of the procedure is simple. It's a one this chronic condition of five and then your ramp score becomes six. So you are at a higher risk of potentially having morbidity. This is a 13 year old. So this is the same patient coming for a troscopy or for a spine fusion. Based on the nescoop, the spine fusion is a higher risk procedure. Our troscopy is a low risk and so there is no mortality in these patients, which is expected not to have any mortality. But if you look at their morbidity, potentially, this one has a one. This one has a three. So this is just putting numbers for things that maybe over time and with experience, you can have an answer for this. But if you want to quantify it to the patient, then we might have better numbers to quantify it with. So I think in terms of classification, stratification there, we have targeted their acute condition of the patient, the intrinsic surgical risk, which I put tonsils up there because the tonsils are not part of NASQV. And so it was very difficult to try to put a surgical risk. So they have not been part of that for any or L in the field, which my husband was disappointed, but we are not included in here. But this is something that is subset of patients that we will look at separately. Patient's chronic condition and CHD, genetics, and dermal primary hypertension. And by putting all this together, maybe we can have an answer on who should take care of the patient, where should this patient be cared for, and what is the outcome. So in summary, I would say the ASAPS continues to be widely used. And maybe it is time for an updated version. The Fram score and intrinsic surgical risk are predictors of mortality. The ramps is predictive of post-operative outcomes. But this is not the end. And the reason I'm saying that is just the beginning, because our team continues to grow. This is a picture I took in the Bryce National Park. And the team continues to grow starting off with Dr. Dinhardo or Dr. Farone. And then we have Dr. Farare, Jay, Zabella, our statistical health. We can do anything without you guys. And Ellie, Dr. Valenciaga, I want our critical care fellows. And the AIMS team, honestly, have been instrumental in trying to put, prospectively, the PrAM into the records, collecting some of the outcomes and the data. And the future would be to try to use that PrAMS in implementing it into our medical record, try to apply it maybe outside VCH, since it was developed here, and try to see if it does work at other institutions. What is the role of the provider? I mean, the patient comes, but different people take care of him. And so what is the level of provider or experience that that make a difference? Does it make a difference where are we offside or in the operating room? Does it matter if it's a volume center that is big or high? And how does that impact the ramps? So there is a lot of more question to answer. And that's why I'm saying it's just the beginning. And I'm hoping to work with many of you throughout the years as we do that. Thank you. Dr. Nesta, thank you. That was an excellent presentation. I think we all struggle when we're talking with the families of our patients preoperatively as far as, you know, what the reported risk is for the different procedures. And I think we all take a much more qualitative approach to it than your nice quantitative assessment, which may help us. The one thing I was going to ask you didn't break out, sort of in your studies, the various contendent heart lesions. And it certainly strikes me that if you've got, you know, single ventricle or synodic disease, that would be different from an ASD or a VSD. Have you, and you may have shown it in your study, and I just missed it. But if you've broken down the relative risk of the different, different cardiac lesions. Yeah. So this is the one that they broke down minor major and severe. And so it looks at the not the lesion itself, but the functional status of the lesion. So if you have an ASD or a VSD and you're considered a minor CHD, you can see that there is no difference in your 30-day mortality overall or reintegration. If you look at major CHD like tetralogy of follow that are unmedication, they still have some residual lesion, then it might be worse overall mortality. If you look at severe CHD, then yes, you have a higher risk of mortality. So there is a difference in CHD. The thing we are trying to look at right now is because CHD, when we collect them, we put the lesion. Not every patient has an echo, not every patient has a calf prior. So this data retrospectively to look at it and try to come up with a very granular risk for CHD patient has not been very easy. We have looked at it through this one and we showed that single ventricle strikes out as a lesion, which is similar to other previous studies that have been done. Prospectively, what we're trying to do is have a few multi-institutional centers. We have a few that have agreed to collect prospect of the data on CHD patients coming for non-cardiac and have their echo data and the granularity about not just the lesion, but also the functional status to try to predict their outcomes better. Maybe I'll come back in a couple of years and give that answer more. It'd be good. And the other thing that I just underlined in your one study you showed that there was a statistically increased risk up the age of five. And most of the studies you mentioned previously had shown it really just looked at two as it cut off. But clearly you looked at higher ages to see if there was still a significant difference. So the studies that looked at cardiac arrest and our studies looked at mortality have shown less than one, like the neonates and infants and less than two are at higher risk. So when we looked at the ramps, which is not cardiac arrest, it was more morbidity and outcomes. Similarly to the apricots European study that looked at respiratory complication, not just cardiac arrest and mortality, the cutoff of age becomes around five. So yes, we're used to think about neonates and infants because we think about mortality and arrest. But if you think about morbidity, it seems that we have shown that five is the cutoff. Similarly to the European study that shows 4.6 of the cutoff for respiratory and other morbidity. Certainly we need to address some of our discussions. Are there other questions? Dr. Jellies. Awesome. Awesome talk. Thank you. But I might say that from my perspective, you missed half the equation. I missed half. Half the equation. The half the two missed. The half that you missed is the surgeon and the anesthesia team and the ICU team and all of that because in cardiac surgery, you do a great job. You can drill down to the surgeon and the outcomes in it's nationally available. I don't know if anybody else or we certainly would not do that. I don't want you to know my herni outcomes. And so how do you factor that in because we all know, I mean, if I have a conversation with you and we have a really, really sick kid who needs a complicated reconstruction, there's a certain group of anesthesiologists and certain group of surgeons you're going to choose because you know it's going to be better up. And how do you factor all those non-mengeon details into something like this because it's in my mind, in my perspective, it's critically important. Oh yeah, it is important. That's why I said there's some future there with the role of the provider. But the Africa study in Europe, they looked at the experience of the anesthesiologist because they were collecting prospectively a strainy or anesthesiologist and they saw they saw that the experience of the anesthesiologist had a better outcome and they reported that unannomously. So I agree with you. I think it is a big part of the equation. Maybe not have given me some credit there, but I think it is important to look at the role of the provider, but also the volume center I think should be affected. And maybe it will show that there is no difference based on the center that you are. Everyone is equally competent, but I agree with you. Even when we consult for cardiac patients coming for non-cariag, there's a subset of patients of providers that are comfortable, though in these cases, and we don't commend them to be taking care of those patients. Just look at one correlation. A couple years ago, I read a white paper that was an industrial paper, so it wasn't published. And it was very clear that a huge insurance institution followed the outcome of the venture patients. And there's a sharp demarcation, the outcomes of the patients who went to a tertiary care center were traveled to a tertiary care center to get their outcome, their procedures, or whatever it was, as opposed to those who got local care. And the result through that it was a marketer, more expensive, descendant of the tertiary care center for the first year, but after the first year was much cheaper because their complication rate was less, and their outcome for better. And so I think the team that takes care of matters. And when we published data like this, we sort of gloss over, and somebody in a small town in Arkansas said, oh, this is great. I only have a point five percent mortality. Yeah, I agree. Thank you. I was looking for you. I didn't spot you back to show. That was a great talk. Unfortunately, I missed the last 20 minutes because I was ironically over your staff meeting, presenting on something that was similar to this. But I just agree with with my partner Rusty over there where you didn't miss half the equation to refining what the equation is and what we have to look for. What Rusty brought up is really the other side, right? So once we really have a good sense of what issues and what characteristics really are higher risk for bad outcomes, then you have to figure out, well, what's the minimal standards that you need? And so the ACS, you spend a lot of time talking about the ACS measurement program, NESQ, but there's also the verification program, which is a baller of the past five years to try to figure out what resources hospitals need, personnel, infrastructure, the way they work together in a multidisciplinary fashion to treat these high risk patients. And so it's a critical, it's very critical, but it's a little bit of a different issue that the ACS is working on at the same time. So what's really exciting, I think, is you may or may not know, but the folks on Wake Up Safe do work with us in NESQ and ACS verification to further refine what those risk factors are. So every year these models are becoming more powerful and more prescriptive in terms of what kind of resources you need. And so again, it's important, but it's a different issue. But I think whatever one needs to know is that there is a lot of collaborative work between the OPASO or Society of Pediatric Anesthesia in the ACS to really move this forward. So we really can figure out not only who these high risk patients are, and a lot of the modeling you're doing is really pushing us forward and really knowing which kids, particularly neonates are at high risk. But in the next five to 10 years, I really think that this is going to be a tremendous improvement in terms of not only identifying who these patients are, but to Rusty's point where they need to go to get the best care. So great work. Thank you. Thank you. I think the last SBA meeting I was invited to come because some of the NESQ representatives over there discussing the adding the anesthetic management and the procedure to the data collection. The additional questions for Dr. Neser. Dr. Neser. No, thanks very much for your informal talk. Thank you.