Placing intensivists who specialize in cardiothoracic surgery in the cardiac ICU could potentially enhance post-operative care efficiencies, which could decrease length of stay, according to a study published in the November issue of the Archives of Surgery. With nearly 500,000 patients undergoing open heart surgery per year in the U.S., this could equate to a savings of nearly hundreds of millions of dollars, the researchers estimated.
“Evidence suggests that critical care physicians (intensivists) make a significant difference in the care of the critically ill, with reported decreased mortality, time to extubation, infectious complications, and length of stay (LOS), as well as increased use of quality indicators,” Glenn J.R. Whitman, MD, of the Johns Hopkins Hospital in Baltimore, and colleagues wrote.
While some previous studies have shown that hospitals with intensivist-managed ICUs can see as much as a 40 percent reduction in ICU mortality, others have shown that mortality is higher for patients cared for by critical care physicians.
To better understand whether post-op cardiac care performed by cardiothoracic surgeons in a semi-closed ICU model can be distinguished by care provided by non-board certified intensivists in cardiothoracic surgery, Whitman et al evaluated cardiac operations over two periods: those who were managed by non-cardiothoracic intensivists (period one; 168 patients) or cardiothoracic surgeons (period two; 272 patients).
The researchers used observed and expected mortality, central venous line infections, ventilator-acquired pneumonia, red blood cell exposure, adherence to blood glucose level targets, length of stay and ICU pharmacy costs as the study’s primary endpoint.
Mortality rates did not change significantly from period one to period two, and rates of ventilator-acquired pneumonia dropped from 7.6 per 1,000 device-days to 4.2 per 1,000 device-days, the authors noted. The incidence of central venous line infections did not change significantly between the two periods, 1.3 per 1,000 device-days vs. 1.6 per 1,000 device-days, respectively.
Surprisingly, the mean total hospital LOS during period two decreased by 2.2 days, from 13.4 to 11.2 days; post-op LOS dropped from 9.8 days to 8.3 days, respectively.
“When applied to a population of approximately 300 patients per year who undergo open heart surgery, a 2.2-day decrease in LOS translates into as many as 660 new inpatient-days,” the authors wrote. “With an average hospital LOS of six days, as seen at our institution, this represents approximately 110 new admissions per year. At current reimbursement levels, this would increase the hospital’s contribution margin by approximately $800,000.
“The crux of the issue regarding the improvement in LOS and cost savings is whether they are attributable to the insight and teamwork resulting from similarly trained surgeons working together or simply because of the efficiency measures that were concurrently implemented at the commencement of P2 [period two],” the authors wrote.
“It is possible that this sense of belonging to the same group felt by the surgeons and intensivists present during P2 enabled the intensivists to address apparent opportunities for improvement and institute new plans for patient care,” according to the authors.
“The change in group dynamics, wherein both surgeons and intensivists were similarly trained and board certified, may have been responsible for the success of the performance improvement initiatives that was associated with increased efficiency of care delivered,” the authors summed.
“Whether or not intensivits improve outcomes is debatable,” wrote David A. Fullerton, MD, of the University of Colorado School of Medicine in Aurora, Colo., in an accompanied editorial. “Lost in this debate, however, is the fact that many surgical subspecialists are, in fact, well-trained critical care physicians. Obvious examples include trauma surgeons, burn surgeons and cardiothoracic surgeons.”
Fullerton congratulated Whitman et al on their study and said that these data demonstrate that critical care provided by cardiothoracic surgeons led to better surgical outcomes.