Extubating heart surgery patients in OR safe with lower costs

Extubating low- and moderate-risk patients in the operating room (OR) after cardiac surgeries can lower costs and shorten lengths of stay at no added risk, according to a study published in the December issue of the Journal of Thoracic and Cardiovascular Surgery.

Vinay Badhwar, MD, of the Heart and Vascular Institute at the University of Pittsburgh Medical Center, and colleagues conducted a propensity-matched analysis of patients who underwent cardiac operations and who were extubated within 12 hours. They assessed three groups: those extubated in the OR (165 patients), those extubated in the intensive care unit within 12 hours (487 patients, group one) and those extubated in the intensive care unit within 6 hours (356 patients, group two).

They enrolled patients between January 2012 and June 2013; the start date coincided with the expansion of a standardized protocol for anesthesia for cardiac surgical procedures to include all nonemergency operations. “[O]ur clinical quality improvement objective was to apply the principles of preoperative and intraoperative protocolized care pathways of extubation to all operations and assess the benefits of OR extubation,” they wrote.

In the propensity-matched analysis, they found no difference in operating times between the three groups. There was a non-statistically significant trend toward a decrease in the overall complication rate with OR extubation and no difference in the reintubation rate. The overall 30-day mortality rate was very low.

Patients extubated in the OR had shorter postoperative ICU times compared with groups one and two (median 26.3 vs. 29 hours with group one and 27 vs. 29 hours with group two) and a shorter length of stay from surgery completion to discharge (median five vs. six days for both groups).

Rates of discharge directly to home without skilled nursing rehabilitation were about 15 percentage points higher for patients extubated in the OR compared with groups one and two. And overall costs with OR extubation came in lower, at a median $3,055 vs. $3,977 compared with group one and $3,025 vs. $3,877 compared with group two.

“[W]e found that not only was OR extubation safe in terms of no difference in the low reintubation rates compared with ICU extubation, but also OR extubation was associated with significant improvements in patient mobilization, pulmonary toilet, and a return to physiologic baseline as manifested by the shorter ICU times and reductions in LOS [length of stay], without the sequelae of an increased incidence of complications,” Badhwar et al wrote.

With a postoperative cost reduction of about 20 percent, extubation in the OR offered value without compromising safety, they added. The study was observational and retrospective, but it supports the practice of extubation in the OR, they proposed.