Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol

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.

Effects of acute-phase multidisciplinary rehabilitation on unplanned readmissions after cardiac surgery

OBJECTIVES

The provision of inpatient programs that reduce the incidence of readmission after cardiac surgery remains challenging. Investigators have focused on multidisciplinary cardiac rehabilitation (CR) because it reduces the postoperative readmission rate; however, most previous studies used outpatient models (phase II CR). We retrospectively investigated the effect of comprehensive multidisciplinary interventions in the acute inpatient phase (phase I CR) on unplanned hospital readmission.

METHODS

In a retrospective cohort study, we compared consecutive patients after cardiac surgery. We divided them into the multidisciplinary CR (multi-CR) group or conventional exercise-based CR (conv-CR) group according to their postoperative intervention during phase I CR. Multi-CR included psychological and educational intervention and individualized counseling in addition to conv-CR. The primary outcome was unplanned readmission rates between the groups. A propensity score-matching analysis was performed to minimize selection biases and the differences in clinical characteristics.

RESULTS

In our cohort (n = 341), 56 (18.3%) patients had unplanned readmission during the follow-up period (median, 419 days). Compared with the conv-CR group, the multi-CR group had a significantly lower unplanned readmission rate (multivariable regression analysis; hazard ratio, 0.520; 95% confidence interval, 0.28-0.95; P = .024). A Kaplan-Meier analysis of our propensity score-matched cohort showed that, compared with the conv-CR group, the multi-CR group had a significantly lower incidence of readmission (stratified log-rank test, P = .041).

CONCLUSIONS

In phase I, compared to conv-CR alone, multi-CR reduced the incidence of unplanned readmission. Early multidisciplinary CR can reduce hospitalizations and improve long-term prognosis after cardiac surgery.

Early Rehospitalization After Prolonged Intensive Care Unit Stay Post Cardiac Surgery: Outcomes and Modifiable Risk Factors

Background

Prolonged intensive care unit length of stay (prICULOS) following cardiac surgery (CS) in older adults is increasingly common but rehospitalization characteristics and outcomes are understudied. We sought to describe the rehospitalization characteristics and subsequent non‐institutionalized survival of prICULOS (ICULOS ≥5 days) patients and identify modifiable risk factors to decrease 30‐day rehospitalization.

Methods and Results

Consecutive patients from January 1, 2000 to December 31, 2011 were analyzed utilizing linked clinical and administrative databases. Logistic regression was used to identify risk factors associated with 30‐day rehospitalization. Out of 9210 consecutive patients discharged from the hospital alive, 596 (6.5%) experienced prICULOS. Cumulative incidence of rehospitalization for the prICULOS cohort at 30 and 365 days was 17.5% and 45.6% versus 11.4% and 28.1% for non‐prICULOS (P<0.01). Over 40% of rehospitalizations for the entire cohort occurred within 30 days of discharge costing over $12 million. The most common reasons for rehospitalization were heart failure (in prICULOS) and infection (in non‐prICULOS). Rehospitalization within 30 days was associated with a 2.29‐fold risk of poor 1‐year noninstitutionalized survival for the entire cohort. Potentially modifiable factors affecting 30‐day rehospitalization included lack of physician visits within 30 days of discharge (odds ratio 2.11; P=0.01), and preoperative anxiety diagnosis (odds ratio 2.20; P=0.01).

Conclusions

PrICULOS patients have high rates of rehospitalization that is associated with an increased rate of poor noninstitutionalized survival. Addressing modifiable risk factors including early postdischarge access to physician services, as well as access to mental health services may improve patient outcomes.

Establishing an Early Discharge Protocol After Cardiac Surgery in Korea

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

Readmission to the Intensive Care Unit in Times of Minimally Invasive Cardiac Surgery: Does Size Matter?

<p><b>Objectives:</b> It is well known that patients who undergo readmission to an intensive care unit (ICU) after cardiac surgery face an increased risk of morbidity and mortality. The present study sought to evaluate whether less invasive procedures might be associated with a reduction of this economically as well as individually important problem. The role of the quantity of ICU and intermediate care (IMC) beds was investigated as well.</p><p><b>Methods:</b> Altogether, we reviewed 5,333 patients who underwent cardiac surgery in our department between 2005 and 2010. The incidence of and reasons for readmission were determined with regard to individual subgroups, particularly comparing minimally invasive procedures with conventional strategies.</p><p><b>Results:</b> A total of 5,132 patients were primarily discharged from the ICU. Out of this group, 293 patients were readmitted to the ICU at least once. After readmission, the average length of stay in the hospital was 21.9 � 11.3 days compared to 12.8 � 5.0 days in all other patients. Comparing the readmission rate in separate years, it was evident that this rate decreased with a growing ICU and IMC capacity. In patients who underwent less invasive cardiac surgery (ie, minimally invasive cardiac surgery, off-pump coronary artery bypass grafting), the readmission rates were significantly lower than in the entirety of patients studied.</p><p><b>Conclusion:</b> Readmission to the ICU after cardiac surgery is associated with impaired outcome. Extended resources in terms of ICU and IMC capacity may positively influence this problem by decreasing the number of readmissions. Modern surgical strategies with less invasive procedures may be associated with a reduced incidence of readmission as well.</p>

Incidence and predictors of readmission to the cardiac surgery intensive care unit: A retrospective cohort study in Greece

INTRODUCTION:

Readmission in the intensive care unit (ICU) is a significant morbidity index, which has been related to poor patient outcomes

AIM:

To identify the preoperative and intraoperative risk factors for readmission in the cardiac surgery ICU.

METHODS:

We conducted a retrospective cohort study of 595 consecutive patients who were admitted to the cardiac surgery ICU of a tertiary hospital of Athens — Greece during the one-year period (September 2011-September 2012). Data collection was carried out, retrospectively, by the use of a short questionnaire and based on the review of medical and nursing patient records at December 2012.

RESULTS:

The incidence of ICU readmission was 3.7% (22/595). Respiratory disorders were the main reason for readmission (45.4%). Readmitted patients had a significantly higher in-hospital mortality compared to those requiring no readmission (P < 0.001). Multivariate analysis revealed that female gender [for males odds ratio (OR) 0.37, 95% confidence interval (CI) 0.15-0.89], high logistic EuroSCORE (OR 1.02, 95% CI 1.00-1.04), prolonged cardiopulmonary (CPB) duration (OR 1.01, 95% CI 1.00-1.02) and preoperative renal failure (OR 1.02, 95% CI 1.00-1.05) were the independent risk factors for readmission to the cardiac surgery ICU.

CONCLUSIONS:

One intraoperative and three preoperative variables are associated strongly with higher probability for ICU readmission. Shorter CPB duration could contribute to lower ICU readmission incidence. In addition, the early identification of high risk patients for readmission in the cardiac surgery ICU could encourage both the more efficient healthcare planning and resources allocation.

Risk factors of prolonged mechanical ventilation following open heart surgery: what has changed over the last decade?

OBJECTIVE

To identify the risk factors for prolonged invasive mechanical ventilation after open heart surgery in Pakistan.

DESIGN

This study is based on retrospective analysis of database.

PLACE AND DURATION

We conducted study of all patients who underwent open heart surgery at CPE Institute of Cardiology, Multan from March 2009 to May 2011.

PATIENTS & METHODS

The data was retrieved from the database in the form of electronic spreadsheet which was then analyzed using SPSS software. The patients with incomplete data entries were removed from the analysis resulting in a set of 1,617 patients. The data of each patient consisted of 65 preoperative, operative and postoperative variables. The data was summarized as means, medians and standard deviations for numeric variables and frequencies and percentages or categoric variables. These risk factors were compared using Chi-sqaure test. Their ODDs ratios and 95% confidence intervals of ODD's Ratios and P values were calculated.

RESULTS

Out of a total of 1,617 patients, 77 patients (4.76%) had prolonged ventilation for a cumulated duration of more than over 24 hours. Preoperative renal failure, emphysema, low EF (<30%), urgent operation, preoperative critical state, prolonged bypass time, prolonged cross clamp time, complex surgical procedures and peri-operative myocardial infarction were found to be risk factors for PIMV. Old age, female gender, advanced ASA class, advanced NYHA class, diabetes mellitus, smoking, history of COPD, redo surgery, left main stenosis, obesity and use of intra-aortic balloon pump were not found to have significant ODDs ratios for PIMV. The patients with prolonged ventilation had significantly high mortality i.e. 32.47% while the normal ventilation group had 0.32% overall mortality.

CONCLUSIONS

Many of the previously considered risk factors for prolonged ventilation after open heart study are no more significant risk factors. However, prolonged ventilation continues to be associated with very high mortality.

Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: a systematic review

The current health care system is discharging elderly patients "quicker" and "sicker" from acute care facilities. Consequently, hospital readmission is common; however, readmission may be only one aspect of adverse outcomes of importance to social work discharge planners. The early recognition of risk factors might ensure a successful transition from the hospital to the home. A systematic review was conducted to identify factors associated with adverse outcomes in older patients discharged from hospital to home. Using a content analysis, factors were characterized in five domains: demographic factors, patient characteristics, medical and biological factors, social factors, and discharge factors. The most frequently reported risks were depression, poor cognition, comorbidities, length of hospital stay, prior hospital admission, functional status, patient age, multiple medications, and lack of social support. A systematic search identified four discharge assessment tools for use with the general population of elderly patients. Practice and research implications are offered.

Risk factors for mediastinitis and endocarditis after cardiac surgery

A prospective open-cohort study was performed in 838 adults undergoing coronary revascularization or valve surgery to define the risk factors for development of surgical site infections. Patients diagnosed with mediastinitis or endocarditis during follow-up were compared with patients with no such infection. After 1 year of follow-up, 22 (2.6%) patients had developed mediastinitis or endocarditis. No preoperative or intraoperative variables were identified as risk factors. By multivariate analysis of postoperative variables, respiratory insufficiency, microorganisms in blood cultures, and intensive care unit stay were independent risk factors for the development of these complications. The type of antibiotic prophylaxis had no influence on the incidence of organ or space infections after cardiac surgery.

Effect of an episode of critical illness on subsequent hospitalisation: a linked data study

Healthcare utilisation can affect quality of life and is important in assessing the cost-effectiveness of medical interventions. A clinical database was linked to two Australian state administrative databases to assess the difference in incidence of healthcare utilisation of 19,921 patients who survived their first episode of critical illness. The number of hospital admissions and days of hospitalisation per patient-year was respectively 150% and 220% greater after than before an episode of critical illness (assessed over the same time period). This was the case regardless of age or type of surgery (i.e. cardiac vs non-cardiac). After adjusting for the ageing effect of the cohort as a whole, there was still an unexplained two to four-fold increase in hospital admissions per patient-year after an episode of critical illness. We conclude that an episode of critical illness is a robust predictor of subsequent healthcare utilisation.

Feasibility of the fast-track recovery program after cardiac surgery in Japan

OBJECTIVES

The purpose of this study was to determine if a fast-track recovery protocol that is applied in other countries can be used in the present Japanese medical system. Second, we wanted to evaluate the differences if the protocol was adapted from the viewpoint of cost saving, postoperative hospital stay, and adverse complications.

METHODS

We retrospectively analyzed 94 consecutive patients who underwent cardiovascular surgery with conventional techniques on cardiac arrest requiring cardiopulmonary bypass between July 1, 2004 and June 30, 2006. We started our fast-track recovery protocol from July 1, 2005. We compared the results of the conventional group (before July 1, 2005) and the fast-track recovery protocol group (after July 1, 2005). Moreover, we used a unique questionnaire and investigated how the patients in the fast-track group felt about the short hospital stay postoperatively.

RESULTS

The mean postoperative hospital stay was 36.7 +/- 6.0 days for the conventional group and 15.0 +/- 12.4 days for the fast-track group, with a statistically significant difference (P = 0.01). The mean cost fell by almost half, from 712545 yen to 383268 yen (P = 0.038). The difference in complication rates was not statistically significant.

CONCLUSION

A fast-track recovery protocol can be safely adapted to patients in the Japanese system without increasing the mortality or morbidity rate. Based on our unique questionnaires, the most important factor was sufficient and repeated explanations preoperatively to the patients and their family members. Second, good pain control with routine use of acetaminophen and sporadic morphine orally has a great effect on the patients' recovery.