Resource utilization in on- and off-pump coronary artery surgery: Factors influencing postoperative length of stay—an experience of 1,746 consecutive patients undergoing fast-track cardiac anesthesia

A Comparison of Patients Undergoing On- vs. Off-Pump Coronary Artery Bypass Surgery Managed with a Fast-Track Protocol

The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55-120) min vs. off-pump 80 (55-120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate.

Effect of a Perioperative Intra-Aortic Balloon Pump in High-Risk Cardiac Surgery Patients: A Randomized Clinical Trial

OBJECTIVES

The aim of this study was to evaluate the efficacy of perioperative intra-aortic balloon pump use in high-risk cardiac surgery patients.

DESIGN

A single-center randomized controlled trial and a meta-analysis of randomized controlled trials.

SETTING

Heart Institute of São Paulo University.

PATIENTS

High-risk patients undergoing elective coronary artery bypass surgery.

INTERVENTION

Patients were randomized to receive preskin incision intra-aortic balloon pump insertion after anesthesia induction versus no intra-aortic balloon pump use.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite endpoint of 30-day mortality and major morbidity (cardiogenic shock, stroke, acute renal failure, mediastinitis, prolonged mechanical ventilation, and a need for reoperation). A total of 181 patients (mean [SD] age 65.4 [9.4] yr; 32% female) were randomized. The primary outcome was observed in 43 patients (47.8%) in the intra-aortic balloon pump group and 42 patients (46.2%) in the control group (p = 0.46). The median duration of inotrope use (51 hr [interquartile range, 32-94 hr] vs 39 hr [interquartile range, 25-66 hr]; p = 0.007) and the ICU length of stay (5 d [interquartile range, 3-8 d] vs 4 d [interquartile range, 3-6 d]; p = 0.035) were longer in the intra-aortic balloon pump group than in the control group. A meta-analysis of 11 randomized controlled trials confirmed a lack of survival improvement in high-risk cardiac surgery patients with perioperative intra-aortic balloon pump use.

CONCLUSIONS

In high-risk patients undergoing cardiac surgery, the perioperative use of an intra-aortic balloon pump did not reduce the occurrence of a composite outcome of 30-day mortality and major complications compared with usual care alone.

Effects of nurse-led clinical pathway in coronary artery bypass graft surgery: A quasi-experimental study

AIMS AND OBJECTIVES

To develop and evaluate the effects of a nurse-led clinical pathway for patients undergoing coronary artery bypass graft surgery.

BACKGROUND

A clinical pathway is a multidisciplinary care plan, based on evidence and guidelines to provide consistent, quality care to patients and improve outcomes.

DESIGN

Prospective, quasi-experimental design.

METHODS

Patients hospitalised for coronary artery bypass graft between April 2014-November 2015 in a hospital in Turkey were studied. First 42 usual care patients were enrolled to determine outcomes and plan for the development of the clinical pathway followed by 40 patients in the newly developed clinical pathway. The primary outcome was length of stay and secondary outcomes related to recovery from surgery (e.g., time to extubation, first feeding).

RESULTS

The mean age for the clinical pathway group was 60 and for usual care was 63 years. Most were male (CP = 78%, UC = 69%). There were significant differences between groups for the primary outcome. Length of stay in the intensive care unit was 38.9 hr for CP and 50.7 hr for usual care patients p < .01. Total hospital time was 144.4 hr for clinical pathway and 162.2 hr for usual care, p < .05. For secondary measures, the following times were less for the clinical pathway group than for the usual care: time to extubation and nasogastric tube removal (5.7 vs. 8.6 hr, p < .01), first oral feeding (4.7 vs. 10.9 hr, p < .001), first mobilisation (8.4 vs. 22.9 hr, p < .001) and first bowel movement (69.8 vs. 85.9 hr, p < .01). There were no statistically significant differences in the 3-month readmission rates and complication rates between the groups, except the renal complication rates were higher in the usual care (n = 16, 38%) than in the clinical pathway (n = 7, 17.5%) (p < .05).

CONCLUSION

The nurse-led clinical pathway was effective in improving length of stay in both the ICU and hospital as well as the secondary outcomes.

RELEVANCE TO CLINICAL PRACTICE

This study contributes to previous studies supporting clinical pathway use can improve the length of stay and quality of care in patients undergoing coronary artery bypass graft surgery.

Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet?

Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.

Factors associated with prolonged length of stay following cardiac surgery in a major referral hospital in Oman: a retrospective observational study

OBJECTIVES

Two objectives were set for this study. The first was to identify factors influencing prolonged postoperative length of stay (LOS) following cardiac surgery. The second was to devise a predictive model for prolonged LOS in the cardiac intensive care unit (CICU) based on preoperative factors available at admission and to compare it against two existing cardiac stratification systems.

DESIGN

Observational retrospective study.

SETTINGS

A tertiary hospital in Oman.

PARTICIPANTS

All adult patients who underwent cardiac surgery at a major referral hospital in Oman between 2009 and 2013.

RESULTS

30.5% of the patients had prolonged LOS (≥11 days) after surgery, while 17% experienced prolonged ICU LOS (≥5 days). Factors that were identified to prolong CICU LOS were non-elective surgery, current congestive heart failure (CHF), renal failure, combined coronary artery bypass graft (CABG) and valve surgery, and other non-isolated valve or CABG surgery. Patients were divided into three groups based on their scores. The probabilities of prolonged CICU LOS were 11%, 26% and 28% for group 1, 2 and 3, respectively. The predictive model had an area under the curve of 0.75. Factors associated with prolonged overall postoperative LOS included the body mass index, the type of surgery, cardiopulmonary bypass machine use, packed red blood cells use, non-elective surgery and number of complications. The latter was the most important determinant of postoperative LOS.

CONCLUSIONS

Patient management can be tailored for individual patient based on their treatments and personal attributes to optimise resource allocation. Moreover, a simple predictive score system to enable identification of patients at risk of prolonged CICU stay can be developed using data that are routinely collected by most hospitals.

Clinical and economic outcomes associated with blood transfusions among elderly Americans following coronary artery bypass graft surgery requiring cardiopulmonary bypass

BACKGROUND

Blood transfusion occurring during hospitalisation for heart surgery has been shown to be associated with increased morbidity and mortality and with increased time spent in hospital, use of healthcare services, and costs. The objective of this study was to assess how perioperative blood transfusion among adults 65 years and older who underwent coronary artery bypass graft surgery requiring cardiopulmonary bypass in the United States is associated with immediate and longer term clinical and economic outcomes.

MATERIALS AND METHODS

Using data from a 5% random sample of Medicare patients who underwent their first (within 2 years) coronary artery bypass graft requiring cardiopulmonary bypass procedure in 2005 or 2006, this study estimated associations (hazard ratios and regression coefficients) between transfusion status (received or not) and complications after surgery, serious adverse events, death, and costs using Cox proportional hazard and generalised linear models adjusting for patients' demographic and clinical characteristics.

RESULTS

Adjusted hazard ratios were statistically significant (P<0.05) for risks of complications (1.20), serious adverse events (1.58), and death (1.49). There was also a statistically significantly (P≤0.01) and strong relationship between receiving transfused blood and Medicare payments over the subsequent 45 months following discharge ($5,778 per calendar quarter for those receiving transfusion vs $5,197; all costs are measured in 2011 USD).

CONCLUSION

Blood transfusion during hospitalisation for coronary artery bypass graft requiring cardiopulmonary bypass was significantly associated with increased long-term post-operative morbidity, mortality, and overall healthcare costs. This study contributes to the evidence demonstrating an association between transfusion and adverse clinical and economic outcomes by using a nationally representative longitudinal cost and utilisation database.

Miniaturized extracorporeal circulation vs. off-pump coronary artery bypass grafting: What the evidence shows?

Recognition of the potentially deleterious effects of esxtracorporeal circulation led to off-pump coronary artery surgery (OPCAB) experiencing a surge in popularity in the initial decade after its conception. However, OPCAB has its own limitations and technical difficulties, such as coronary access, increased left ventricular size and reduced function, which may lead to the potential for suboptimal revascularization. As an alternative technique, miniaturized extracorporeal circulation (mECC) may provide a more controlled operative field in which the heart may be manipulated whilst minimizing the inflammatory, coagulopathic and haemodilutional effects of cardiopulmonary bypass. In this review, we outline the proposed benefits of the mECC system, discuss the pitfalls associated with mECC, and directly compare mECC to ‘off-pump’ coronary surgery for a variety of clinical and non-clinical outcomes.

Epidural anesthesia and postoperative analgesia with ropivacaine and fentanyl in off-pump coronary artery bypass grafting: a randomized, controlled study

Background

Our aim was to assess the efficacy of thoracic epidural anesthesia (EA) followed by postoperative epidural infusion (EI) and patient-controlled epidural analgesia (PCEA) with ropivacaine/fentanyl in off-pump coronary artery bypass grafting (OPCAB).

Methods

In a prospective study, 93 patients were scheduled for OPCAB under propofol/fentanyl anesthesia and randomized to three postoperative analgesia regimens aiming at a visual analog scale (VAS) score < 30 mm at rest. The control group (n = 31) received intravenous fentanyl 10 μg/ml postoperatively 3-8 mL/h. After placement of an epidural catheter at the level of Th₂-Th₄ before OPCAB, a thoracic EI group (n = 31) received EA intraoperatively with ropivacaine 0.75% 1 mg/kg and fentanyl 1 μg/kg followed by continuous EI of ropivacaine 0.2% 3-8 mL/h and fentanyl 2 μg/mL postoperatively. The PCEA group (n = 31), in addition to EA and EI, received PCEA (ropivacaine/fentanyl bolus 1 mL, lock-out interval 12 min) postoperatively. Hemodynamics and blood gases were measured throughout 24 h after OPCAB.

Results

During OPCAB, EA decreased arterial pressure transiently, counteracted changes in global ejection fraction and accumulation of extravascular lung water, and reduced the consumption of propofol by 15%, fentanyl by 50% and nitroglycerin by a 7-fold, but increased the requirements in colloids and vasopressors by 2- and 3-fold, respectively (P < 0.05). After OPCAB, PCEA increased PaO₂/FiO₂ at 18 h and decreased the duration of mechanical ventilation by 32% compared with the control group (P < 0.05).

Conclusions

In OPCAB, EA with ropivacaine/fentanyl decreases arterial pressure transiently, optimizes myocardial performance and influences the perioperative fluid and vasoactive therapy. Postoperative EI combined with PCEA improves lung function and reduces time to extubation.

Trial Registration

NCT01384175

Cost-effectiveness of clinical pathway in coronary artery bypass surgery

Few studies have been devoted to the exploration of the effect of clinical pathways on coronary artery diseases treated with coronary artery bypass (CAB) surgery. This study was aimed to investigate the cost and effectiveness of the clinical pathway on CAB surgery in a medical center. With a retrospective dataset in 2003-2007, 212 CAB surgery patients were included. Data of the costs and postoperative complication occurrence and length of stays were the focus and patient demographics, surgical risk indicator EuroSCORE, surgical conditions were collected. It revealed that there was differentiation across specified cost items in beating heart CAB surgery patients, but not for heart arrest CAB surgery patients with and without clinical pathways enrolled. In addition, there was no difference in postoperative complication occurrence in CAB surgery patients enrolled into clinical pathways. However, robotic beating heart CAB surgery patients enrolled clinical pathways were shown to have less postoperative ordinary ward stay than those not enrolled clinical pathways. CAB surgery patients' age and surgical risks were related to their postoperative lengths of stay to some extent.

Sex differences in resource use after on-pump and off-pump coronary artery bypass surgery: a propensity score-matched cohort

BACKGROUND

Previous studies have demonstrated that off-pump coronary artery bypass surgery (OPCAB) is associated with less use of hospital resources compared with on-pump coronary artery bypass surgery (ONCAB).

OBJECTIVE

To determine whether there is a sex effect between the two procedures regarding resource utilization.

METHODS

Between 1996 and 2004, 13,522 patients (10,637 men and 2885 women) underwent coronary artery bypass grafting surgery at the Toronto General Hospital (Toronto, Ontario). Among the men, 10,121 patients underwent ONCAB and 516 underwent OPCAB. The female population consisted of 2723 ONCAB and 162 OPCAB patients. Both groups were matched to standard preoperative risk factors. A propensity score macro-matched 471 OPCAB men to 471 ONCAB men, and 148 OPCAB women to 148 ONCAB women.

RESULTS

The mean (+/- SD) postoperative length of stay (7.5+/-6.5 days versus 6.4+/-5.5 days; P<0.0001) was significantly higher in ONCAB compared with OPCAB in the male population. The mean length of stay in the intensive care unit and the mean ventilation time was similar between the groups. However, in the female population, there were no differences in mean postoperative length of stay (8+/-5.9 days versus 8+/-6 days; P=0.4), mean length of stay in the intensive care unit (43+/-38 h versus 53+/-81 h; P=0.4) or mean ventilation time (9.8+/-9.7 h versus 11+/-13 h; P=0.8).

CONCLUSION

These results suggest that the benefits of OPCAB in terms of hospital resource use are influenced by sex. The potential beneficial effects are not demonstrated in the female population.

Current Status of Off-Pump Coronary Artery Bypass Surgery

The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.

Economic stress and misaligned incentives in critical care medicine in the United States

OBJECTIVES

This review will provide an overview of issues with economic ramifications intrinsic to the management of intensive care resources and identify some of the external pressures that ultimately influence the provision of intensive care services.

DESIGN

A review of the current literature was performed.

RESULTS

Economic stress is a reality of the management of intensive care resources. The nature of critical care medicine as a technologically heavy, labor intensive, high-cost, limited resource, combined with a projected increase in demand in an era of cost containment, presents an array of challenges.

CONCLUSIONS

It is in the best interest of the care of our patients that critical care providers increase awareness of the many factors influencing our practice economically. It is through such understanding that challenges can be met, solutions can be found, and the quality of intensive care can be improved in a financially sustainable environment.

Gender Differences for Rapid After Bypass Back Into Telemetry Tract Following Cardiac Surgery

The Rapid After Bypass Back Into Telemetry program is based on a simple clinical algorithm to predict same-day transfer of patients to the cardiac telemetry unit following cardiac surgery. This program proved to be an excellent predictor for decreased postoperative complications, shorter intensive care unit and hospital stay, and lower costs. We believe that any candidate for cardiac surgery should be screened for eligibility to participate in the program with special focus on female patients to further improve their outcomes.

Making a Business Case for Quality by Regional Information Sharing Involving Cardiothoracic Surgery

A consortium of cardiac surgeons, nurses, and administrators in Virginia has developed a clinical/financial database to identify sites with best outcomes and replicate best practices statewide. The financial value of quality improvements is estimated from the incremental savings gained by reducing postoperative complications. The group studied 7,417 coronary artery bypass graft cases in 2003-2004. The average costs of atrial fibrillation, stroke, mediastinitis, renal failure, reoperation for bleeding, and prolonged use of ventilation were measured using charge data and ratios of costs-to-charges. Costs ranged from 18,093 US dollars to 28,136 US dollars in eight hospitals. Lower-cost hospitals had lower standardized mortality ratios. Average total costs were 19,049 US dollars for cases with no complications. Cases with postoperative atrial fibrillation were 21,415 US dollars, an incremental cost of 2,366 US dollars (p<0.0001), and reached 54,671 US dollars for mediastinitis (deep sternal wound infections) and 57,360 US dollars for renal failure. Overall, 16.1% of 5,230 coronary artery bypass graft patients developed atrial fibrillation in 2003. Incidence ranged from <5% to nearly 30% across 14 hospitals. Reducing the incidence of complications by small fractions can yield significant savings. Paying for performance may lead to more comparative analysis, peer-to-peer collaboration, and new approaches to quality improvement and efficiency measurement.