ROUTINE ICU ADMISSION IS NOT REQUIRED AFTER CARDIAC SURGERY

Abstract

S82 INTRODUCTION: Efficient resource utilization has resulted in a change in the way care is delivered to patients having cardiac surgery. [1] "Fasttrack" cardiac anesthesia allows early extubation and is part of any multidisciplinary "fasttrack" cardiac surgery program. Routine admission to ICU remains part of most "fasttrack" programs. Most patients are admitted because they are intubated and require cardiac monitoring. We present data that suggests that the admission to ICU after cardiac surgery is not required in the majority of cases. METHODS: In 1995, a "fasttrack" cardiac surgery protocol (we called our program a Facilitated Recovery Program; "fasttrack" may have some pejorative connotations) was developed in order to expand the program at our Centre. This includes "fasttrack" anesthesia, an initial 4-6 hour PACU-based recovery directed by both the Anesthesiologist and Cardiac Surgeon, elimination of routine ICU admission, and further recovery in a cardiac surgery stepdown unit (no facilities for IV vasodilators, vasopressors, mechanical ventilation, PA catheters, and maximum nurse:patient ratio 1:2). For this paradigm to become accepted, it was gradually introduced. In 1996, we initially selected 1 patient/week; by January 1997, most patients were being considered for this program. Final determination of recovery site is made after separation from CPB, and in some cases, after initial admission to PACU. We reviewed our OR, Health Records, ICU, and Cardiac Anesthesia databases for the years 1994-1997 for the pertinent data. Chi-square, Wilcoxon rank-sum, Mantel-Haenzel trend test, and ANOVA were used where appropriate to analyze the data. RESULTS: Most patients are extubated within 2 hours; the reintubation rate is low. There is a large reduction in ICU utilization (Table 1), shown as the % admissions and ICUdays/100cases/year (p<0.001, 1997 vs. all previous years and trend). The chance of ICU admission from stepdown is low. As expected, ICU LOS in 1997 was longer than in 1996 (p<0.01). APACHE II increased (p<0.01, 1997 vs. all previous yrs. as well as trend). There has been no significant change in mortality.Table 1DISCUSSION: A multidisciplinary program for cardiac surgery based on early extubation and PACU/stepdown-based recovery can dramatically and safely reduce ICU use. The acuity and LOS of patients admitted to the ICU increases, possibly reflecting a more prudent use of ICU resources. There may be large potential cost savings with this model of care. The majority of cardiac surgery patients can be considered for this type of Facilitated Recovery Program. As the number of patients in this study is relatively small, a ongoing analysis of the risk factors that may predict ICU admission is being done.