Abstract
IntroductionThe value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes. Materials and methodsPatients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses. ResultsBetween 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0–4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay. ConclusionThis study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction.
Highlights
The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned
The survey needed to be completed by one surgeon on behalf of the hospital and consisted of 14 questions on standard hospital policy regarding length of direct postoperative ICU stay after MIE, reasons for possible protocol deviations, and estimated protocol compliance rates
The survey was conducted to gain more insight into the different hospital protocols and did distinguish between ICU and medium care unit (MCU). This nationwide, retrospective cohort study showed significant hospital variation in terms of direct postoperative length of ICU stay after minimally invasive esophagectomy for cancer
Summary
The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes. Some studies showed that ICU admission policy after esophageal cancer surgery varied between hospitals, with no impact on short-term mortality rates [4,6]. Verification of these results in the era of MIE and immediate extubation in the operating room is necessary as prolonged ICU admission of patients without vital ICU indication can be considered a misplaced use of scarce resources and impacts hospital finances and, possibly, ICU capacity [7]. The audit aims to improve the quality of Dutch upper gastrointestinal cancer care by identifying and reducing hospital variation in treatment, outcomes and clinical care pathways [9]
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