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Eur J Cardiothorac Surg 2002;21:377-384
© 2002 Elsevier Science NL

Day 0 intensive care unit discharge — risk or benefit for the patient who undergoes myocardial revascularization?

Department of Cardiology and Cardiac Surgery, ‘G. D'Annunzio’ University, Chieti, Italy

Received 12 September 2001; received in revised form 11 December 2001; accepted 11 December 2001.

* Corresponding address. Department of Cardiac Surgery, ‘San Camillo de' Lellis’ Hospital, Via Forlanini 50, 66100 Chieti, Italy. Tel.: +39-871-358653; fax: +39-871-402239
e-mail: calafiore{at}unich.it

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 
Objective: Day 0 intensive care unit (ICU) discharge allows to use one ICU bed for two patients. Results of this policy were analysed. Methods: From January 1998 to June 2001, 1194 patients who had myocardial revascularization in the morning were discharged on the same day (Group 0, n=647), or one (Group 1, n=521) or many days (Group 2, n=26) after surgery. Criteria for day 0 discharge were: early extubation with at least 2 h of observation, stable hemodynamic status, no significant bleeding, no arrhythmias, normal EKG and normal neurological evolution. Results: Mean ICU stay was 4.0±1.2 h in Group 0, 17.5±4.0 h in Group 1 and 65.8±46.6 h in Group 2 (P₁, among Groups, <0.001; P₂, between Groups 0 and 1, <0.001). In 613 cases (94.7% of patients in Group 0) the same ICU bed was used for another patient. Postoperative in-hospital stay was 4.1±2.3 d in Group 0, 4.9±3.1 d in Group 1 and 7.4±6.8 in Group 2 (P₁<0.001; P₂<0.001). Fifteen patients (1.2%) were readmitted to the ICU, seven in Group 0 (1.1%), five in Group 1 (1.0%) and three (11.5%) in Group 2 (P₁<0.001, P₂ n.s.), because of bleeding (five cases in Group 0, two in Group 1, none in Group 2; P₁<0.001, P₂), cerebrovascular accident (two cases in Group 0, none in Group 1, three in Group 2; P₁<0.001, P₂ n.s.), acute myocardial infarction (no case in Groups 0 and 2, two in Group 1; P₁ n.s., P₂ n.s.) and acute renal failure (no case in Group 0 and 2, one case in Group 1; P₁ n.s., P₂ n.s.). Nine patients (0.8%) died (three, 0.5%, in Group 0, three, 0.6%, in Group 1 and three, 11.5%, in Group 2; P₁<0.001, P₂ n.s.), four (one in Group 0, two in Group 1 and one in Group 2, P₁ 0.006, P₂ n.s.) in the hospital (two from cardiac and two from non-cardiac causes) and five (two in Group 0, one in Group 1 and two in Group 2, P₁<0.001, P₂ n.s.) outside the hospital within the 30th day of surgery (one from cardiac and four from non-cardiac causes). No patient in Group 0 died from cardiac causes. Conclusions: Day 0 ICU discharge can be obtained in selected patients without an increased risk of death or of ICU readmission. The impact in terms of resource saving is striking.

Key Words: Fast track • Myocardial revascularization • ICU discharge in day 0

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 
Reduction of in-hospital stay became a crucial point in saving resources in cardiac surgery. The first step was early extubation of the patient; the concept of patient's fast track was thus mainly related to the presence or not of the endotracheal tube [1–3].

Initially, many authors focused the applicability of these protocols on younger and low risk patients, documenting the potential for cost containment [4,5]. Subsequently, Cheng et al. [6] demonstrated that fast track protocols could enhance patient outcome without increasing mortality and morbidity rates. Recent studies focused the feasibility and safety of fast track protocols in the elderly population as well [7,8].

Our concept of rapid recovery of patients from the intensive care unit (ICU) was not related to his early extubation, that, in our opinion, is not influent, but to the length of ICU stay, that, in selected cases, could be reduced to only a few hours.

We reviewed our clinical experience in patients who underwent myocardial revascularization, wherein our protocol for ICU discharge on the same day of surgery was applied, independent of age, ventricular function or preoperative high risk factors. Only the patients operated on with median sternotomy were evaluated and, among them, only those who had surgery in the morning, as only in this situation could the same ICU bed be used for two patients. The aim of our study is to evaluate if there is any risk of increased morbidity or mortality in these patients, when compared to those discharged from the ICU one or many days after surgery.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 
From January 1998 to June 2001, 1214 patients had myocardial revascularization via a median sternotomy and were operated on in the morning (first operation of the theatre). Patients who died in the operating room (OR) or in the ICU (n=20, 1.6%) were not considered. Therefore, only 1194 patients who were discharged from the ICU are included in this study. Patients were operated on with and without cardiopulmonary bypass (CPB); patients converted from no CPB to CPB (n=24) were considered as no CPB (according intention to treat).

Three groups were considered:

Group 0 (n=647): patients discharged from ICU on the same day of ICU admission.

Group 1 (n=521): patients discharged from ICU on the day after ICU admission.

Group 2 (n=26): patients discharged from ICU on 2 or more days after ICU admission.

Preoperative data of these groups are listed in Table 1.

2.1. Surgical technique
Anesthesia was induced with fentanyl (2 µg/kg) and propofol (2.0–2.5 mg/kg) and was maintained with fentanyl in bolus (0.8 µg/kg) and propofol (0.4–1.2 µg/kg) in continuous infusion. Muscular relaxation was obtained with atracurium besilatum. During the closure of the chest, the infusion of propofol was reduced and then stopped, to achieve a rapid awakening of the patient and, if possible, his disconnection from mechanical ventilation. As soon as the chest was closed, a continuous infusion of antalgic agents (ketoralac, 90 mg/24 h, metoclopramide, 10 mg/24 h and tramadol, 200 mg/24 h) was started for at least 24 h.

Surgical techniques for CPB or off pump procedures were previously reported [9,10].

2.2. Group selection
All the patients admitted in the ICU were discharged on the same day of admission if they met the following criteria: early extubation with at least 2 h of observation, stable hemodynamic status, no significant bleeding, no arrhythmias, normal EKG and normal neurological evolution. All the patients discharged from the ICU were admitted into regular wards with the drains and were connected to a telemetry. Readmission to ICU, for any case, 30 days mortality and morbidity were recorded.

2.3. Definitions
Need for inotropes: infusion of dobutamine >5 µg/kg/min or epinephrine or norepinephrine any dose for more than 12 h. Cerebrovascular accident (CVA): global or focal neurological deficit, lasting less (transient ischemic attack, TIA) or more (stroke) than 24 h, that could be evident after emergence from anesthesia or after first awakening without any neurological deficits. CVA was diagnosed by a neurologist and confirmed by a brain computerized tomography (CT) scan. Acute myocardial infarction (AMI): enzymatic elevation, EKG sign of necrosis, new akinetic segment(s) at echocardiogram, ventricular arrhythmias non-K⁺ related. Acute renal failure: postoperative creatinine value >2.0 mg/dl for more than 24 h if preoperative value was 1.4 mg/dl, or an increase of one unit of creatinine, if preoperative value was >2.0 mg/dl.

2.4. Statistical analysis
Results are expressed as mean value±SD unless otherwise indicated. Statistical analysis comparing two groups was performed with unpaired two-tailed t test for the means or ² test for categorical variables. P<0.05 was considered significant. A multivariate analysis (stepwise logistic regression) was used to identify independent factors that can predict ICU discharge on day 0, ICU readmission and 30 day mortality, and included all the univariate variables with a P0.2. Variables included in the analysis are listed in Appendix A. In the final regression model, independent variables were expressed as odds ratio (OR) with the 95% confidence limit (CL); the related P value was also reported. Three year survival and event free survival (first month excluded) were obtained with the Kaplan–Meier method. The statistical significance was calculated with the log–rank test. SPSS software (Chicago, IL, USA) was used.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 
Operative data are listed in Table 2. Patients in Group 0 had less anastomoses per patient and a lower use of multiple arterial conduits. In this group more patients were operated on without CPB. Globally, out of 573 patients who had myocardial revascularization without CPB, 66.7% (382 cases) were discharged from the ICU on day 0 versus 42.7% (265/621) who had myocardial revascularization with CPB, P<0.001.

Two patients in Group 1 needed IABP and inotropes; in both cases, IABP was removed after 20 h and the patients were discharged from the ICU (in one case inotropic support was discontinued) and had an uneventful recovery.

Five patients (0.4%) had a myocardial infarction, without any difference between Groups 0 and 1. One patient (in Group 1) died, as previously reported.

Ten patients (0.8%), five during ICU stay and five in the ward, had a postoperative CVA, with the same incidence in Groups 0 and 1. Three of them died after being transferred to a neurologic hospital.

Four patients (0.3%) had an acute renal failure, two in the ICU (none in Group 0) and two in the ward (one in Group 0). None of them needed ultrafiltration or hemodialysis.

Thirty-two patients (2.7%) underwent surgical revision for bleeding, 25 (2.1%) during ICU stay (eight in Group 0 and 16 in Group 1) and seven after ICU discharge (five in Group 0). All of them had an uneventful recovery.

3.2. ICU readmission
Fifteen patients (1.2%) were readmitted to the ICU, seven in Group 0. Table 6 shows the causes of ICU readmission. In Group 0, five patients were readmitted because of excessive bleeding needing surgical revision, four on the same day 0 and one on day 1. All of them were again discharged from ICU on the same day of readmission. The remaining two had a postoperative CVA. In Group 1, two patients were readmitted because of the need for surgical revision for bleeding (redischarged on the same day), one for acute renal failure and the last one for myocardial infarction (both redischarged the day after). All the three patients in Group 2 were readmitted because of CVA and all of them, in different periods, died.

View larger version (17K): [in this window] [in a new window]   Fig. 1. Three year actuarial survival according to different groups (first month excluded).

View larger version (17K): [in this window] [in a new window]   Fig. 2. Three year event free survival according to different groups (first month excluded).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

Different teams promoted the so-called fast track, to reduce ICU stay. However, everything was focused on early extubation and this aspect was dominant in all the definitions [1–3].

On the contrary, we explored the possibility of discharging the patient from the ICU on the same day of the procedure, with the purpose of utilizing the same ICU bed for two patients. This was possible for 53.3% of the patients included in this study. If all the coronary patients are considered, independent of the surgical approach, day 0 ICU discharge was possible in 59.1% of the cases. However, this protocol was used not only for coronary patients, but also for patients who underwent other kinds of surgery. Out of 453 patients operated on in the morning for non-isolated coronary surgery during the time frame of this study, 162 (35.8%) were discharged from the ICU on the same day of surgery. Globally, 53.5% of the 1885 patients who had surgery as the first operation of the day were discharged on the same day of surgery from the ICU.

Safety of this strategy is demonstrated by univariate analysis that showed that patients discharged on day 0 had no higher incidence of adverse events in the ward (Table 4B). Moreover, multivariate analysis failed to demonstrate that day 0 ICU discharge was an independent predictor of higher 30 day mortality or ICU readmission.

Table 7 shows the profile of patients who can be discharged on day 0. They undergo mainly elective surgery, are operated on without CPB, have no renal failure, the operation is not a redo, they have not had CVA or contemporary carotid endoarteriectomy and are not revascularized with multiple arterial conduits. This latter point is true mainly when CPB is used. In fact, out of 379 patients who had two or more arterial conduits with CPB, only 156 (41.2%) were discharged on day 0. However, out of 284 patients who had the same operation without CPB, 175 (61.6%) had day 0 discharge (P<0.001).

Independent predictors of ICU readmission were contemporary carotid endoarteriectomy, because of some related postoperative CVA, and use of inotropes during ICU stay. Indeed, these patients were at risk of further ischemic events during in-hospital stay. It is noteworthy that out of 26 patients who had some inotropic support (two also had IABP), two (7.7%) died (P=0.003 versus the remaining patients).

Five patients discharged on day 0 (0.8%) were readmitted because of the need of surgical revision for bleeding. All of them had an uneventful recovery. These events did not modify the global benefit of the strategy of day 0 discharge and did not add any adjunctive risk.

In conclusion, day 0 discharge can be obtained in selected patients and allows the use of the same ICU bed for two patients. This does not represent a risk for the patient, but is crucial in terms of resource saving.

	Footnotes

 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.

	Appendix A. List and definition of the variables

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 
Preoperative

Age

Continuous (years)

Age75 years

Dichotomous

Sex

Dichotomous

Body weight

kg

History of hypertension

Need for medical treatment (Ca²⁺ blockers, ß-blockers, ACE inhibitors).

History of smoking

More than 10 cigarettes a day smoked at least for 10 years.

Hypercholesterolemia

History or at present cholesterol value higher than 200 mg/dl.

Preoperative chronic renal failure

Creatinine value higher than 2.0 mg/dl.

Chronic hepatic failure

Bilirubin value higher than 2.0 mg/dl.

COPD

FEV1 lesser than 75% of predicted value, air pO₂ lower than 60 mmHg or chronic medical treatment.

Unstable angina

Presence of angina at rest, stable angina with worsening pattern or de novo angina.

Chronic heart failure

Heart failure in the history or at the present admission, without angina.

AMI<24 h

Acute myocardial infarction 24 h before surgery.

Preoperative IABP

Use of IABP for cardiogenic shock or to stabilize an unstable angina.

Previous atrial fibrillation

Dichotomous

Urgency

Any condition (unstable angina, cardiogenic shock, critical left main stenosis, etc.) that prevents the patient from being discharged from the hospital.

Diabetes

Medical treatment for hyperglycemia at rest.

IT (insulin treatment)

Insulin dependent diabetes.

OT (oral treatment)

Diabetes on oral treatment.

Redo

Previous CABG operation.

Ventricular arrhythmia

In the history or requiring medical treatment at admission.

Peripheral vasculopathy

Symptoms or angiographic or echographic evidence of dilation or reduction of flow (stenosis or occlusion) of any artery, with the exclusion of carotid arteries.

Carotid disease

Presence of a fibrocalcific plaque with a stenosis 50% or of a soft plaque conditioning any degree of stenosis.

Previous CVA

History of previous cerebrovas-cular accident with or without persistent neurological defect.

Previous AMI

EKG sign of previous myocardial infarction or documented non-Q infarction.

Left main stem lesion

Stenosis 50% or more.

Ejection fraction (EF)

Continuous

EF 35%

Dichotomous

Inotropes

Need of inotropic support at admission in OR.

Nitroglycerin e.v.

Need of nitroglycerin e.v. at admission in OR.

Perioperative

Use of CPB

Dichotomous

Simultaneous carotid surgery

Dichotomous

Untouchable ascending aorta

Detected before the operation or when the chest is open.

	Appendix B. Conference discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 
Dr B. Messmer (Aachen, Germany): Can you tell me only one thing, who is taking care of the intensive care, is that you or is that the anesthesiologist?

Dr Calafiore: The anesthesiologist.

Dr Messmer: Well, I think one problem is a little bit with the neurologic complications because they do not have to come immediately after surgery but they can come within 24–48 h, and that is probably a little bit of a problem to rely on discharge neurologic problems, yes or no, because you often do not see them in the very beginning.

Dr Calafiore: We cannot prevent a neurologic complication if a patient remains 1 or 2 days more in the ICU. Fifty percent of the postoperative CVA happens after a normal first neurologic examination. A CVA that happens on the first or on the second or on the third postoperative day is not prevented by a longer ICU stay. Anyway we were able to treat appropriately the patients, even if they were in the ward and not in the ICU.

Dr A. Mazzucco (Verona, Italy): If I may ask a clarification about your plans, after discharge from ICU, how is the nursing of the patient done, because in our experience the decision to discharge an operated patient from the ICU is mostly influenced by the shortage of nurse staff in the common ward, so that early discharge is conceivable only for the most straightforward patients who can be left alone in the common ward. So how did you get rid of this limiting factor, nurse's availability?

Dr Calafiore: Patients are discharged to the regular ward, where they have telemetry. They are followed by our nurses and by the surgeon on duty in the ward. This is not a real problem because the great majority of patients has no necessity to remain in ICU if they are extubated.

Dr Mazzucco: As stated before, there are quite a few complications which are not immediately postop but they come a little later, so aren't you concerned about medico-legal issues?

Dr Calafiore: The purpose of this paper is to demonstrate that ICU discharge on day 0 is as safe as discharge on day 1. The complications we had were the same. More or less the same percentage of patients were readmitted in ICU or died. Day 0 ICU discharge was not an incremental risk for morbidity or mortality. Anyway, in our Division we have five ICU beds for a workload of 900 to 1000 cases. The ultra-fast track protocol started with the MIDCAB and later on it was applied to patients operated on via a median sternotomy, with and without cardiopulmonary bypass.

Dr R. Mohr (Tel Aviv, Israel): Why do you think there is a connection between extensive arterial revascularization and longer ICU stay?

Dr Calafiore: This was just a statistical finding. The percentage of extensive arterial revascularization was 52% in patients discharged on day 0 and nearly 70% in patients discharged on day 1. Multivariate analysis showed that extensive arterial revascularization was a factor that limited day 0 discharge, but the percentage of such patients was anyway high.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. List and... Appendix B. Conference... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Antonio Maria Calafiore Giovanni Teodori Gabriele Di Giammarco Giuseppe Vitolla Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Calafiore, A. M. Articles by Vitolla, G. Search for Related Content PubMed PubMed Citation Articles by Calafiore, A. M. Articles by Vitolla, G. Related Collections Coronary disease