PURPOSE: Evidence- based practice and cost containment are vital in critical care delivery; 24/7 in- house intensivist coverage of Surgical ICU (SICU) is increasingly required. We questioned whether outcomes in cardiac surgery patients were compromised by a staffing model without intensivists or housestaff?.
METHODS: Retrospective analysis of prospectively gathered mandatory data from the New York State Cardiac Surgery Reporting System 1994 - 2009 (NYS). Annual outcomes in one center (care delivered by one group of cardiac surgeons and nurses staffing a dedicated cardiac surgery unit) are compared to NYS data.
RESULTS: 5493 patients had isolated coronary artery bypass (CABG). Mortality 1.44% (range 0- 2.78%) vs NYS (range 1.61 - 2.58). Complication incidence: Stroke 1.67 vs 1.48; Reoperation 2.14 vs 2.11; Renal 1.66 vs 1.16; Respiratory 3.84 vs 4.10; Sternal infection 1.31 vs 1.02; Sepsis 2.06 vs 0.92 and Gastrointestinal(GI) 0.6 vs 0.82. 3273 patients underwent Cardiac operations "OTHER " (than isolated CABG). Mortality 6.39% (range 1.89 - 9.79). Complications (%): Stroke 2.44; Reoperation 2.84; Renal 4.4; Respiratory 8.95; Sternal 1.31; Sepsis 4.89 and GI 1.00. Fatality rate (%) for major complication after CABG vs OTHER : Stroke 9.8/ 39; Reoperation 6 / 19; Renal 32/ 53; Respiratory 22/ 36; Sternal 11/ 21; Sepsis 27/ 45; GI 53/ 45. Hospital stay (LOS) trended longer (range 6.8-9.6 days); Excluding patients staying > 15 days (3-12%) increased LOS by 1 day (5.8 - 6.7). Fewer than 5% of deaths were classified "Postoperative" and "Avoidable". Extending our SICU coverage 24/7 costs $773 600 annually.
CONCLUSION: Mortality, risk adjusted mortality, complication rates and lethality were within state average/ range consistently 1994-2006. Unpredicted life-threatening postoperative emergencies were very rare. Occasional SICU emergency support for Cardiac Surgery patients did not affect individual outcomes. Patients with complications consume disproportionate resources.
CLINICAL IMPLICATIONS: A model of care for Cardiac Surgery patients without intensivists is supported by the data but depends on expertise and dedication of surgeons and nurses and attention to evidence based practices.
DISCLOSURE: Darryl Hoffman, No Financial Disclosure Information; No Product/Research Disclosure Information