Evaluation of predicted and actual length of stay in 22 Scottish intensive care units using the APACHE III system. Acute Physiology and Chronic Health Evaluation

The most recent edition of the Acute Physiology and Chronic Health Evaluation provides a prediction of intensive care unit length of stay in addition to the probability of hospital mortality. Intensive care length of stay is an important determinant of intensive care costs and may be an important indicator of quality of care. Data were collected from 22 Scottish intensive care units over a 2-year period to allow comparison of actual intensive care unit length of stay with that predicted by the Acute Physiology and Chronic Health Evaluation III system. Correlation between actual and predicted stay for individual patients was poor. However, performance of the model for patients, grouped either by predicted length of stay or by intensive care unit, indicated that the model stratified patient groups appropriately while demonstrating a consistent bias. Length of stay in Scottish intensive care units was found to be consistently lower than that predicted by a model which is based on intensive care practice in the USA. Variations in severity of illness in intensive care unit populations cannot readily explain differences in intensive care unit length of stay. The availability of a model capable of predicting length of intensive care stay, based on data reflecting practice in the UK, would compliment current methods of assessing effectiveness of intensive care.     

How DRGs hurt academic health systems.

BACKGROUND: Academic health centers continue their mission of clinical care, education, and research. This mission predisposes them to accept patients regardless of their individual clinical variation and financial risk. The purpose of this study is to assess the variation in costs and the attendant financial risk associated with these patients. In addition, we propose a new reimbursement methodology for academic health center high-end DRGs that better aligns financial risks. STUDY DESIGN: We reviewed clinical and financial data from the University of Michigan data warehouse for FY1999 (n = 39,804). The diagnosis-related groups were classified by volume (group 1, low volume to group 4, high volume). The coefficient of variation for total cost per admission was then calculated for each DRG classification. A regression analysis was also performed to assess how costs in the first 3 days estimated total costs. A hybrid methodology to estimate costs was then determined and its accuracy benchmarked against actual Medicare and Blue Cross reimbursements. RESULTS: Low-volume DRGs (< 75 annual admissions) had the highest coefficient of variation relative to each of the three other DRG classifications (moderate to high volume, groups 2, 3, and 4). The regression analysis accurately estimated costs (within 25% of actual costs) in 64.7% of patients with a length of stay > or = 4 days (n = 16,287). This regression fared well compared with actual FY 1999 DRG-based Medicare and Blue Cross reimbursements (n = 9,085 with length of stay > or = 4 days), which accurately reimbursed the University of Michigan Health System in only 43.9% of cases. CONCLUSIONS: Academic health centers receive a disproportionate number of admissions to low-volume, high-variation DRGs. This clinical variation translates into financial risk. Traditional risk management strategies are difficult to use in health care settings. The application of our proposed reimbursement methodology better distributes risk between payers and providers, and reduces adverse selection and incentive problems ("moral hazard").     

Incidence and clinical outcomes of ventilator-associated pneumonia in liver transplant and non-liver transplant surgical patients

The aim of this study was to compare the incidence of ventilator-associated pneumonia (VAP) and clinical outcome among patients undergoing orthotopic liver transplantation (OLT) admitted to our surgical intensive care unit (ICU). Patients with an ICU stay longer than 4 days who had undergone surgery within 48 hours of admission were included in the study. Patients were subdivided into a liver transplant group (OLT) and no-liver transplant group (noLT). Diagnosis of VAP was based on microbiological data with a positive culture from a sample collected >or=48 hours after admission. VAP was defined as early if the positive culture occurred within the 4th day of admission, and late if after the 4th day. Three hundred seventy-three noLT and 71 OLT patients showed no differences in sex, mean severity score on admission (SAPS II), length of stay, and outcomes. The incidence of VAP was also similar in the 2 groups (27.3% in the noLT group vs 25.3% in the OLT group). Both in the OLT and noLT groups, the VAP patients showed higher (P< .05) SAPS II scores on admission, length of ICU stay, and mortality rates than the non-VAP patients, without any difference between the 2 groups. VAP is a frequent complication in ICU surgical patients, particularly those with high severity scores on admission. In an ICU surgical population, liver transplantation per se does not seem to increase the patients' risk either for VAP acquisition or for bad outcomes.     

Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries

BACKGROUND: Optimal timing of femur fracture fixation remains controversial. This study examines the association between the timing of femur fracture fixation and outcome in patients with concomitant chest and head injuries. METHODS: A retrospective review of registry data from a Level I trauma center identified 1362 patients with a femoral shaft fracture over a 12-year period. Patients were categorized into five groups by timing of femur fracture fixation: Group 1, within 24 hours; Group 2, 24 to 48 hours; Group 3, 48 to 120 hours; Group 4, > 120 hours; and Group 5, patients with no operative fixation. Primary outcome measures included morbidity (specifically, pulmonary complications) and mortality. Secondary outcome measures were hospital length of stay, intensive care unit length of stay, and discharge Glasgow Coma Scale score. Subsets of patients were examined including all patients with multiple injuries (Injury Severity Score > 15), chest trauma (Chest Abbreviated Injury Scale score > or = 2), and head trauma (Head Abbreviated Injury Scale score > or = 2). RESULTS: Acute respiratory distress syndrome, pneumonia, hospital length of stay, and intensive care unit length of stay were lowest in the group fixed within 24 hours, even in patients with concomitant head or chest trauma. Fixation between 2 and 5 days was associated with a significantly increased incidence of acute respiratory distress syndrome, pneumonia, and fat embolization syndrome in patients with concurrent chest trauma (p < 0.0001). In head-injured patients, discharge Glasgow Coma Scale score was highest in the group fixed within 24 hours. Timing of operative fixation did not affect mortality. CONCLUSION: Our data show that early femur fracture fixation (< 24 hours) is associated with an improved outcome, even in patients with coexistent head and/or chest trauma. Fixation of femur fractures at 2 to 5 days was associated with a significant increase in pulmonary complications, particularly with concomitant head or chest trauma, and length of stay. Chest and head trauma are not contraindications to early fixation with reamed intramedullary nailing.     

The use of epidural anesthesia and analgesia in aortic surgery.

During a 3-year period, sixty-four consecutive patients, who had elective aortic reconstruction were investigated to determine whether epidural anesthesia and analgesia, combined with light general anesthesia, would lower the rate of perioperative complications in this high-risk group of patients. The epidural group comprised 32 consecutive patients who had surgery during the 20-month period from July 1986 to December 1987. These patients were compared with the previous 32 patients who had aortic reconstruction at Huntington Memorial Hospital (Pasadena, CA) using conventional general anesthetic techniques. Cardiovascular and respiratory morbidity, length of hospital stay, length of intensive care unit stay, and duration of endotracheal intubation were compared. There was no statistically significant difference in cardiovascular morbidity, length of hospital stay, or intensive care unit stay between the two groups. There was however, a striking decrease in respiratory complications and length of intubation in the epidural anesthesia group (P less than 0.005). The authors conclude that epidural anesthesia and analgesia, combined with a light general anesthetic may confer benefits over conventional general anesthesia in patients undergoing aortic surgery.     

A prospective randomized study of abdominal aortic surgery without postoperative nasogastric decompression

Nasogastric decompression following abdominal aortic aneurysmectomy or bypass, for 3–4 days, is a routine part of postoperative care in many centers. A prospective randomized study of 80 patients undergoing abdominal aortic surgery was performed in order to determine the necessity of prolonged nasogastric decompression. Patients were divided evenly between removal of the nasogastric tube upon tracheal extubation and retention of the tube until the passage of flatus. Preoperative risk factors, aortic cross-clamp time, estimated blood loss, length of procedure, length of intensive care unit stay, numbers of days with nasogastric tube, number of days until clear liquid and regular diets commenced, and the length of hospital stay were recorded for all patients. There were no significant differences in any of the measured variables between the two groups. The length of hospital stay was similar in both groups and three patients in each group required a nasogastric tube or reinsertion of one. In conclusion, the routine postoperative use of nasogastric tubes for abdominal aortic procedures is unnecessary. Copyright © 1996 The International Society for Cardiovascular Surgery.     

The influence of perioperative factors on outcomes in children aged less than 18 months after repair of tetralogy of Fallot

OBJECTIVES: To determine the impact of age at repair in patients with tetralogy of Fallot on early postoperative morbidity. METHODS: All patients less than 19 months of age (median age, 8 months; range, 36 days-18.5 months) who underwent complete repair of tetralogy of Fallot between January 1997 and December 1999 were reviewed. Data were analyzed on the preoperative clinical and anatomical characteristics, operative procedure and postoperative course in the intensive care unit. Independent factors associated with intensive care unit stay were sought using Cox's proportionate hazard modeling. In addition, independent factors associated with an intensive care unit stay of more than 2 days were sought in multiple logistic regression analysis. RESULTS: Seventy-eight patients underwent surgical repair; 3 had (4%) had a previous systemic to pulmonary arterial shunt. There was no operative mortality. One late death occurred. The median intensive care unit length of stay and mechanical ventilation time were 2 days (range, 1-14) and 16.2 hours (range, 0-267), respectively. Age less than 3 months was associated with increased use of vasoactive drugs, higher postoperative fluid requirement, and a higher incidence of organ dysfunction but no patient required renal replacement therapy. The duration of ventilator support and the intensive care unit length of stay were also longer in this age group. CONCLUSIONS: Primary repair at an early age has excellent short-term outcome. Patients less than 3 months of age have an increased but transient intensive care unit morbidity.     

Intensive care unit stay not required for patients with obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass

BackgroundMany programs admit morbidly obese patients with obstructive sleep apnea (OSA) to the intensive care unit after laparoscopic gastric bypass (LGB), fearing pulmonary complications. Our practice has been to admit these patients to the surgical floor. Our objective was to compare the perioperative course and outcomes in morbidly obese patients with OSA to those of patients without OSA undergoing LGB in a physician-led health system with a 325-bed community teaching hospital serving 19 counties.MethodsWe retrospectively reviewed the medical records of 650 patients who had undergone LGB from 2001 to 2008 and divided them into 2 groups: patients with OSA as confirmed by polysomnography (OSA group) and those without OSA (non-OSA group). The patients who reported a diagnosis of OSA without documentation confirming the diagnosis were excluded. The statistical analysis included t tests and chi-square tests.ResultsA total of 217 patients met the inclusion criteria for the OSA cohort and 368 for the non-OSA cohort. Of the 650 patients, 65 reported a history of OSA without confirmation and were excluded from the present study, leaving 585 patients. The demographic data were similar between the 2 groups, and no difference was found between the OSA and non-OSA groups for the length of postanesthesia care unit stay (105.4 versus 106.3 minutes), length of hospital stay (2.2 days for both groups), and 30-day major complication rate (3.7% versus 5.2%). No deaths and no intensive care unit admissions for pulmonary complications occurred in either group.ConclusionThe results of our study have shown that morbidly obese patients with OSA undergoing LGB have a perioperative course and postoperative pulmonary complication rate similar to that of patients without OSA. Thus, routine admission to the intensive care unit after LGB in patients with OSA is not indicated.     

Eight-year follow-up on the effect of a hip fracture service on patient care and outcome

The purpose of this study was to evaluate the 8-year effect of a hip fracture service on time to surgery; duration of surgery; length of stay in acute care, intensive care, and rehabilitation unit; and incidence of postoperative complications and in-hospital mortality. The study group consisted of 50 female patients 65 years of age or older who were treated for hip fractures in 1999 and 50 case-, age-, and American Society of Anesthesiologists score-matched female patients treated in 2006. Group differences were compared via the Student paired t test and χ2 analysis (statistical significance, p ≤ .05). The 2006 group had a significantly shorter mean surgical time than did the 1999 group, but time to surgery did not change. The 2006 group showed improvements (but not statistically significant ones) in length of stay in acute care, intensive care, and rehabilitation unit, and in the incidence of complications and in-hospital mortality.     

A comparison of fentanyl, sufentanil, and remifentanil for fast-track cardiac anesthesia

Cardiac surgery is estimated to cost $27 billion annually in the United States. In an attempt to decrease the costs of cardiac surgery, fast-track programs have become popular. The purpose of this study was to compare the effects of three different opioid techniques for cardiac surgery on postoperative pain, time to extubation, time to intensive care unit discharge, time to hospital discharge, and cost. Ninety adult patients undergoing cardiac surgery were randomized to a fentanyl-based, sufentanil-based, or remifentanil-based anesthetic. Postoperative pain was measured at 30 min after extubation and at 6:30 AM on the first postoperative day. Pain scores at both times were similar in all three groups (P > 0.05). Median ventilator times of 167, 285, and 234 min (P > 0.05), intensive care unit stays of 18.8, 19.8, and 21.5 h (P > 0.05), and hospital stays of 5, 5, and 5 days (P > 0.05) for the Fentanyl, Sufentanil, and Remifentanil groups did not differ. Three patients needed to be tracheally reintubated: two in the Sufentanil group and one in the Fentanyl group. Median anesthetic costs were largest in the Remifentanil group ($140.54 [$113.54-$179.29]) and smallest in the Fentanyl group ($43.33 [$39.36-$56.48]) (P < or = 0.01), but hospital costs were similar in the three groups: $7841 (Fentanyl), $5943 (Sufentanil), and $6286 (Remifentanil) (P > 0.05). We conclude that the more expensive but shorter-acting opioids, sufentanil and remifentanil, produced equally rapid extubation, similar stays, and similar costs to fentanyl, indicating that any of these opioids can be recommended for fast-track cardiac surgery. IMPLICATIONS: To conserve resources for cardiac surgery, fentanyl-, sufentanil-, and remifentanil-based anesthetics were compared for duration of mechanical ventilation, intensive care unit length of stay, hospital length of stay, and cost. The shorter-acting anesthetics, sufentanil and remifentanil, produced equally rapid extubation, similar stays, and similar costs to fentanyl; thus, any of these opioids can be recommended for fast-track cardiac surgery.     

The effect of preoperative clopidogrel on bleeding after coronary artery bypass surgery

INTRODUCTION: Clopidogrel treatment is associated with a reduction in thrombotic complications in coronary stent placement, improved outcome after acute coronary syndromes, and decreased mortality in patients with coronary artery disease. The purpose of this study was to analyze the effect of preoperative clopidogrel exposure on bleeding complications, blood transfusions requirements, and reoperations in patients undergoing coronary artery bypass grafting (CABG). PATIENTS AND METHODS: This study included 320 patients from a single institution that underwent an isolated CABG who were discharged between July 2003 and June 2004. The cohort of 320 patients was classified into 3 groups. The control group consisted of 255 patients that did not receive clopidogrel or stopped clopidogrel 7 days before surgery but were treated with aspirin instead. Clopidogrel I consisted of 25 patients that were taking clopidogrel within 3 days of surgery, and Clopidogrel II consisted of 40 patients that were taking clopidogrel 4 to 7 days before surgery. Patients were compared based on preoperative data (age, gender, use of clopidogrel, preoperative hemoglobin, and ejection fraction), intraoperative data (cross-clamp time), postoperative data (chest tube output, rate of reoperation, units of transfused blood, length of stay in the intensive care unit, and length of intubation). RESULT: There were no significant differences among the 3 groups concerning age, sex, ejection fraction, or preoperative hemoglobin. There were no differences in length of intensive care unit stay and length of intubation among the 3 groups of patients. Patients in the clopidogrel I group had more units of blood transfused than either the control or the Clopidogrel II group (p=0.027). There is also a trend toward more chest tube output in clopidogrel I group compared with the control group. Fifteen patients (4.6%) of the total group required reoperation secondary to bleeding: 2 (8.0%) in the Clopidogrel I group, 2 (5%) in the clopidogrel II group, and 11 (4.3%) in the control group (p=0.41). CONCLUSION: This study demonstrated that clopidogrel within 3 days preoperatively increases the requirement for blood transfusion in patients undergoing CABG. Waiting more than 3 days after the last dose of clopidogrel decreases blood transfusion requirements. There is also a trend toward more postoperative bleeding for those patients that took clopidogrel within 3 days before their CABG. The reoperation rate of patients that took clopidogrel within 3 days of their procedure required almost twice as many reoperations as the patients that did not take clopidogrel.     

Relationship between intra- and postoperative oxygen transport and prolonged intensive care after cardiac surgery: a prospective study

Background: Prolonged intensive care is a rare but serious complication of cardiac surgery. It is required in less than 10% of operated patients but they use more than 30% of all the intensive care resources needed for cardiac surgery. The aim of our study was to describe the clinical course of the patients who need prolonged intensive care following cardiac surgery and to assess whether the intra- and postoperative oxygen transport variables are different in these patients as compared to patients with an uncomplicated course.
Methods: The study patients were divided into two groups according to the length of stay in the intensive care unit (ICU) after the operation: Group I, n=241, ICU-stay 5 days and Group II, n=20, ICU-stay≥5 days. Hemodynamic and oxygen transport data were prospectively obtained intra- and postoperatively and postoperative organ dysfunctions were recorded.
Results: The patients in the prolonged intensive care group tended to be older, have lower ejection fraction and longer cardiopulmonary bypass time. Postoperatively, this group had significantly increased oxygen extraction rate ( P =0.035, repeated measures for ANOVA). In the logistic regression analysis, in creased oxygen extraction (31% in Group I vs. 36% in Group II, P < 0.005) at 6 hours after arrival at the intensive care unit had the strongest independent association with the need for prolonged intensive care.
Conclusions: There was no significant relationship between the factors conventionally assumed to be risk factors for prolonged intensive care. Instead, an increase in whole body oygen extraction, reflecting a mismatch between the whole body oxygen demand and supply, was associated with the need for prolonged intensive care. Oxygen extraction increased to compensate for the reduced oxygen delivery, which in turn was caused by a lower arterial oxygen content.     

Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients

Background>Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units.MethodsWe performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL.ResultsOf the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D–deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant (P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D–deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D–deficient group, which also was clinically significant (P = .027). More importantly, the mortality rate for the severe vitamin D–deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group (P = .125). Because no deaths occurred in the mildly or normal vitamin D–deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups (P = .047).ConclusionsIn univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D–deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.     

Does ICU length of stay influence quality of life?

BACKGROUND: Patients with prolonged stay in the intensive care unit (ICU) use a disproportionate share of resources. However, it is not known if such treatment results in impaired quality of life (QOL) as compared to patients with a short length of stay (LOS) when taking into account the initial severity of illness. METHODS: Prospective, observational case-control study in a university hospital surgical and trauma adult ICU. All patients admitted to the ICU during a 1-year period were included. Patients with a cumulative LOS in the ICU > 7 days, surviving up to 1 year after ICU admission and consenting were identified (group L, n = 75) and matched to individuals with a shorter stay (group S). Matching criteria were diagnostic group and severity of illness. Health-related quality of life (HRQOL) was assessed 1 year after admission using the short-form 36 (SF-36) and was compared between groups and to the general population. Further, overall QOL was estimated using a visual analogue scale (VAS) and willingness to consent to future intensive care, and was compared between groups L and S. RESULTS: Based on ANCOVA, a significant difference between groups L and S was noted for two out of eight scales: role physical (P = 0.033) and vitality (P = 0.041). No differences were found for the physical component summary (P = 0.065), the mental component summary (P = 0.267) or the VAS (P = 0.316). Further, there was no difference in expectation to consent to future intensive care (P = 0.149). As compared to the general population, we found similar scores for the mental component summary and for three of eight scales in group L and five of eight scales in group S. CONCLUSIONS: When taking into account severity of illness, HRQOL 1 year after intensive care is comparable between patients with a short and a long LOS in the ICU. Thus, prolonged stay in the ICU per se must not be taken as an indicator of future poorer HRQOL. However, as compared to the general population, significant differences, mostly in physical aspects of QOL, were found for both groups of patients.     

Caudal anesthesia in pediatric cardiac surgery: does it affect outcome?

OBJECTIVE: The purpose of this study was to examine the influence of caudal anesthesia on outcomes (pediatric intensive care unit [PICU] length of stay, hospital length of stay, ventilatory time, early extubation rate) in pediatric patients undergoing congenital heart disease repair requiring cardiopulmonary bypass (CPB). DESIGN: Retrospective. SETTING: University teaching hospital. PARTICIPANTS: Pediatric patients undergoing surgery to treat congenital heart disease between 1999 and 2002. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients with atrial septal defect (ASD), 37 with ventricular septal defect, and 46 with tetralogy of Fallot (TOF) were included in the analysis. No differences were found in preoperative and intraoperative data between caudal and noncaudal group for each disorder. There was no difference between caudal and noncaudal groups in PICU and hospital stay. A statistically significant difference was found in the postoperative ventilatory time in patients with ASD and TOF between caudal and noncaudal groups. The early extubation rate was higher in the TOF caudal group compared with the noncaudal group. CONCLUSIONS: This retrospective study demonstrated that postinduction placement of caudal anesthesia does not affect PICU or hospital length of stay. A well-controlled prospective study is needed to confirm these findings.     

A Comparison between Minilaparotomy and Standard Median Laparotomy for Reconstruction of Aorto-Iliac Occlusive Disease

Objective : Minimally invasive surgical procedures have become increasingly used in all surgical branches. In this respect we compared the minilaparotomy (ML) technique with standard median laparotomy (SML) for the surgical treatment of aorto-iliac occlusive disease .

Methods : 120 patients were included in this prospective study, with 60 patients in the minilaparotomy group and 60 patients in standard median laparotomy group. The two approaches were used within the same time period. Both groups were compared in terms of operating and aortic cross clamp time, the amount of blood transfusion, length of stay in the intensive care unit and hospital, and time for normalization of bowel functions.

Results : There were no significant differences in terms of the amount of blood transfusion, or aortic cross clamp time. The minilaparotomy approach has the advantages of less operating time, earlier return to a general diet, decreased length of stay in the intensive care unit and hospital and reduced cost.

Conclusions : As a conclusion, we believe that the minilaparotomy technique will be the standard treatment of choice for aorto-iliac occlusive disease in the future with reduced use of facilities and lower cost than the laparoscopic or the standard technique.     

Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A

BACKGROUND: Operative mortality after acute aortic dissection type A is still high, and prolonged stay at the intensive care unit is common. Little has been documented about factors influencing the intensive care unit length of stay. The aim of this study was to determine such variables. METHODS: During a 10-year period, 67 patients (47 male, 20 female) were operated on for acute aortic dissection type A. In 42 patients (63%), an ascending aortic replacement was performed, 23 patients (34%) underwent a Bentall procedure, and 2 patients (3%) received a valve-sparing David type of operation. In 14 of these cases (20%), an additional partial or total arch replacement was performed. RESULTS: Hospital mortality was 9 of 67 (14%). Median postoperative intensive care unit length of stay was 5 days (range, 1 to 72 days). Intensive care unit stay was in univariate analysis significantly influenced by the following factors: age (p = 0.008), body mass index (p = 0.039), cardiopulmonary bypass time (p = 0.018), aortic cross-clamp time (p = 0.031), postoperative low cardiac output syndrome (p < 0.001), and postoperative lactate levels (p = 0.01). By multivariate analysis, age (p = 0.012), cardiopulmonary bypass time (p = 0.037), and the presence of a postoperative low cardiac output syndrome (p < 0.001) significantly influenced intensive care unit stay. CONCLUSIONS: Stay in the intensive care unit after operation for acute aortic dissection type A seems to be determined by age, cardiopulmonary bypass time, and the postoperative presence of a low cardiac output syndrome.     

Incidence and significance of lobar atelectasis in thoracic surgical patients

Lobar atelectasis, defined by complete lobar collapse and mediastinal shift on chest roentgenogram, represents one extreme form of postoperative atelectasis. We have evaluated the incidence and clinical significance of lobar atelectasis in a thoracic surgical patient group. A retrospective review was done of patients who underwent pulmonary resection over a 2-year period to determine patient characteristics, contributing comorbidities, and associated perioperative care factors. Lung resections were performed for both benign and malignant disease through open or video-assisted techniques. One hundred eighty patients had pulmonary resection, 101 males and 79 females, and they were divided into three groups: I, no complications (112 patients, 62%); II, complications unrelated to lobar atelectasis (60 patients, 33%); and III, complications of lobar atelectasis (8 patients, 5%). There was one death in the series, in the lobar atelectasis group (III). Mean age for the entire group was 64.5 +/- 12.5 years; however, patients in Groups II (67.3 years) and III (69.6 years) were significantly older than in Group I (P < 0.02). Mean hospital length of stay in Group I was 6 +/- 3 days, whereas that in Group II was 13 +/- 12 days (P < 0.001), and in Group III it was 27 +/- 31 days (P < 0.001). In addition, patients who developed lobar atelectasis were more likely to be male (88% vs 48%, P = 0.034), had a longer ICU length of stay (P < 0.001), were more likely to have two or more comorbidities (P < 0.05), and had a lower forced expiratory volume in 1 second (2.34 +/- 0.90 vs 1.96 +/- 0.63). All patients in the lobar atelectasis group were operated on for malignancy, but this was not significantly different from the other groups. None of the 16 patients who had thoracoscopy developed lobar atelectasis, but this also was not a significant finding. We conclude that severe postoperative atelectasis occurs as lobar atelectasis in approximately 5 per cent of patients who undergo pulmonary resection and significantly adds to the intensive care unit and hospital length of stay. The etiology of lobar atelectasis appears to be multifactorial and warrants further study to define mechanisms of occurrence and their prevention.     

„Statistische Prozesskontrolle“ als Monitoring-Tool zur Evaluierung von Reorganisationsmaßnahmen

INTRODUCTION: The German health care system is currently in a constant state of flux owing to enhanced competition and to the increasing focus on economic aspects. Medical services, especially treatment processes, are being reorganised in an attempt to adapt them to the new economic challenges. Ideally, radical reorganisation and streamlining of medical therapy processes should be accompanied by controlling and quality management systems. The purpose of this is to monitor the intensity of any economic and any patient-related (side)-effects. Business management techniques are needed that allow online and long-term performance reviews of reorganisation measures once initiated. METHODS: In industry, the method applied for this purpose is statistical process control (SPC). The present study demonstrates for the first time that use of this monitoring tool can be extended to the medical sector. In an intensive care unit (ICU) the following process parameters were monitored: duration of sedation, time to persisting spontaneous breathing, length of stay in ICU, length of stay in hospital, patient mortality in ICU and in the next 30 days after admission to the ICU. Group 1 was made up of 87 patients examined before and group 2, 93 patients after process optimisation. The main feature of the reorganisation was application of a new analgo-sedation technique and of the weaning concept. RESULTS: In group 2 duration of sedation, time to spontaneous breathing and length of stay on the ICU were significantly shorter than in group 1. The length of stay in hospital, patient mortality in the ICU and 30 days after the initiation of intensive care did not differ significantly between the two groups. CONCLUSION: Economic and patient-related key figures can be evaluated with SPC. It allows online assessment both before and during process optimisation, and especially in the long term afterprocess optimisation.     

Getting back to zero with nucleated red blood cells: following trends is not necessarily a bad thing

BackgroundThe presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma.MethodsWe retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality.ResultsGroup A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality.ConclusionsAny positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.