Dollars and sense: the economics and outcomes of patients undergoing carotid endarterectomy at Royal Adelaide Hospital

Carotid endarterectomy: What difference does a clinical protocol make?

BACKGROUND

The initial eight hours after carotid endarterectomy (CEA) are crucial to patient outcome as many potential complications can occur during this period. Hypotension is one of the most common issues observed after patients have returned to the surgical ward. Postoperative management of patients undergoing CEA varies between facilities, with reported direct intensive care unit or surgical high dependence unit admission. Patients that underwent a CEA procedure at the study hospital were monitored in the Recovery Unit for a minimum of four hours before being transferred to the surgical ward. Episodes of hypotension, on return to the surgical ward, were one of the main issues identified. This observation resulted in revision of the CEA management policy with collaboration from all specialties involved in the care of patients undergoing a CEA. The aim of this study was to compare whether there was any difference in short-term clinical outcomes between preupdate and postupdate of the carotid management policy in a tertiary referral hospital in New South Wales.

METHODOLOGY

Retrospective review of health care records was undertaken for the following two time intervals: prepolicy change from July 2008 to June 2009; postpolicy change from June 2011 to May 2012. Hypotension was defined as a systolic blood pressure less than 90 mm Hg. State SE 12.1 was used for data analysis.

RESULTS

After assessing for potential confounding factors-such as postoperative heart rate, risk factors, gender, and age-patients from the postpolicy change group were less likely to receive vasoactive medications to manage blood pressure deviation (OR, 0.33; 95% CI, 0.12-0.91; P = 0.026), the odds of receiving vasoactive medications was 0.33 times lower than that of the pre-policy change group patients, and is 95% confident that the true association lies between 0.12 and 0.91 in the underlying population. Over 90% of intensive care unit admission was avoided in patients from the postpolicy change group with estimated cost saving of $807 Australian dollars per patient.

CONCLUSIONS

The study hospital postoperative carotid surgery management policy has driven practice change with an extended Recovery Unit observation. This is a cost effective and safer management method. The Clinical Nurse Consultant was essential for clinical policy development, implementation, and evaluation.

[Early transfer from intensive care does not influence clinical results of carotid endarterectomy]

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

Comparison of short-term clinical postoperative outcomes in patients who underwent carotid endarterectomy: Intensive care unit versus the ward high-dependency unit

The objective of this research was to examine the routine postoperative management of patients who have undergone carotid endarterectomy and compare the intensive care unit (ICU) with the ward high-dependency unit (HDU) in terms of the number, type, severity, or management of postoperative clinical events within a 48-hour time frame. Two of the vascular surgeons routinely admitted patients to the ICU, and 1 vascular surgeon routinely admitted patients to the ward HDU. This research determines whether there was a difference in outcomes between the 2 groups with the intention of changing the practice of the 2 vascular surgeons who routinely admitted their patients to the ICU. This was a nonexperimental, descriptive, prospective study of all patients who underwent carotid endarterectomy during an 18-month period between August 1999 and January 2000. A total of 104 patients were recruited to the study. There were 84 patients in the ICU cohort; 59 were male and 25 were female, with a mean age of 72 years. There were 20 patients in the ward HDU cohort; 12 were male and 8 were female, with a mean age of 66 years. Major complications occurred in 3 patients. One patient from the ICU group was returned to the operating room for evacuation of a hematoma, and 2 patients from the ward HDU group were transferred to the ICU for an inotropic infusion. During the first 24 hours, hypertension developed in 37 patients in the ICU cohort, 12 of whom did not require intervention. Hypertension requiring intervention developed in 3 patients in the ward group. Chi-square cross-tabulation revealed a chi 2 value of 1.4 and a P value of.01, which is a significant difference in the number of hypertensive events in the ICU versus the ward HDU. Hypotension occurred in 41 patients in the ICU group and in 9 patients in the ward cohort. The same chi 2 test was used to reveal a chi 2 value of 0.026 and a P value of.87, which are nonsignificant results. There was no difference in the number of hypotensive events in the ICU versus the ward HDU. There were no reported incidents of tachycardia. Bradycardia was reported in 64 patients in the ICU group and in 12 patients in the HDU group. There was no significant difference in the number of patients with bradycardia in either group of patients. Chi-square analysis revealed a chi 2 value of 1.4 and a P value of.23 during the first 24 hours postoperatively. We believe that careful selection of patients to the ward HDU is safe and cost-effective.