Conserving resources after carotid endarterectomy: Selective use of the intensive care unit

doi:10.1067/mva.1991.33418

Journal of Vascular Surgery

Volume 14, Issue 6, December 1991, Pages 796-800

Presented at the Fifth Annual Meeting of the Eastern Vascular Society, Pittsburgh Pa., May 2-5, 1991.

https://doi.org/10.1067/mva.1991.33418 Get rights and content

Abstract

A retrospective review was undertaken of a random sample (N = 73) comprising 50% of carotid endarterectomies performed during 1986 to evaluate the necessity of routine postoperative intensive care unit (ICU) admission after carotid endarterectomy. Severity of illness was determined with use of the Acute Physiology Score of the APACHE II system. The Therapeutic Index Scoring System was used to quantify postoperative services used. Postoperative morbidity was analyzed. Financial impact was extrapolated with use of 1990 billing data. Length of ICU stay was 24.5 hours. Only 13 of 73 patients (18%) required ICU services. In 10 (77%) of these patients therapy was initiated in the recovery room and discontinued in six patients within 3 hours of ICU admission. Only two patients required ICU services for 16 hours after surgery. The mean Acute Physiology Score was low (4.96) and could not identify patients who required unique ICU services. Neurologic deficits were seen in five patients (6.9%). In three cases deficits were recognized in the recovery room; deficits developed in two patients after discharge from the ICU. Observation in the recovery room with transfer of stable patients would have eliminated ICU admission in 60 patients (82%). In 1990 the incremental ICU charge was $720/patient day. This represents 12.5% of the hospital charges for carotid endarterectomy. The ICU is an expensive and highly used hospital resource. Only a few patients need unique ICU services after carotid endarterectomy, and this is usually apparent within 2 hours of surgery. Prolonged recovery room observation or use of intermediate care units can avoid ICU admission for most patients undergoing carotid endarterectomy thereby conserving this precious hospital resource. (J VASC SURG 1991;14:796-802.)

Section snippets

Methods

A retrospective medical review of a random sample comprising 50% (N = 73) of all CEAs performed at a university medical center during 1986 was completed. Severity of illness was determined by use of the Acute Physiology Score (APS) of the Acute Physiology and Health Evaluation6, 7 tool (APACHE II). The Therapeutic Index Scoring System7, 8 (TISS) was used to describe and quantify postoperative services used. Preoperative risk factors and postoperative morbidity were examined. The frequency of

Results

Thirty-seven (51%) of the 73 subjects studied were men. The mean age was 65 years, with a range of 43 to 83 years. Hypertension was the most common risk factor, found in 74% of subjects. Other risk factors included smoking (52%), coronary artery disease (43%), previous vascular surgery (35%), peripheral vascular disease (26%), and diabetes mellitus (25%). These preoperative characteristics were examined and appeared to be representative of patients undergoing CEA at the study institution.

Discussion

This study demonstrates that most patients after operation for CEA have minimal physiologic derangement, and rarely use unique ICU services. The mean APS (4.96) of patients undergoing CEA in the sample is consistent with scores reported for low-risk monitor admissions. Knaus et al.⁹ suggested that ICU admission may not be warranted in patients with APS less than 5 who do not receive active therapy. By use of those standards, 48.3% of the sample would not have required ICU admission. The mean

Acknowledgements

Special thanks to Barbara Peterangelo for her help with the manuscript and to Richard Green, MD, and James DeWeese, MD, for permission to study their patients.

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Carotid endarterectomy: What difference does a clinical protocol make?
2016, Journal of Vascular Nursing
Citation Excerpt :
The patient was taken back to theater for emergency evacuation of hematoma in the afternoon as he had developed stridor that caused airway compromise. As illustrated by previous studies,4,6,7,9–11 admitting patients to ICU routinely after undergoing CEA is not warranted. The findings from this review are similar to other studies.10,24
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.
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.
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.
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.
Critical pathways can improve results with carotid endarterectomy
2004, Seminars in Vascular Surgery
Approximately 10 years ago, the Section of Vascular Surgery at Pennsylvania Hospital reported results of critical pathways that we developed for all major vascular operations, including carotid endarterectomy (CEA). After implementing these pathways, we then developed a specific five-step protocol to further improve results and decrease costs for elective CEA. With the advent of carotid artery balloon angioplasty and stenting (CABAS), CEA has come under increasing attack by endovascular interventionalists. We believe our regimen remains the gold-standard against which CABAS should be compared. Our five-step CEA protocol includes: (1) duplex ultrasonography performed in an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of surgery, (3) cervical block anesthesia to eliminate intraoperative electroencephalographic monitoring and other costly intraoperative monitoring tests, (4) transfer from the recovery room after a short observation period to the vascular ward, and (5) discharge the first postoperative morning. Since this 5-step protocol was implemented several years ago, we have found it to be safe and cost-effective, and now represents the standard against which CABAS should be compared.
Carotid endarterectomy: Experience in 5425 cases
2004, Annals of Vascular Surgery
From 1992 to December 2002, 3967 patients (2619 males; 1348 females) with a mean age of 68.4 years (range 32–92) underwent 5425 carotid endarterectomy (CE) procedures at our institute. Neurological history was positive for stroke in 1130 cases (21%) and for transient ischemic attack (TIA) in 2121 cases (39%). In 2174 cases (40%) patients were neurologically asymptomatic or presented nonspecific symptoms. Our current clinical protocol has been designed to optimize resources and reduce complications. Some of the major features, along with the respective percentages in this series, are as follows. Duplex scanning was performed at a validated laboratory as the principal preoperative exam (86.9%). Locoregional anesthesia and neurological monitoring were performed during carotid cross-clamping (96.3%). Selective shunting was carried out with a Javid shunt (10.7%). The choice of surgical technique was made according to carotid anatomy and cerebral tolerance of cross-clamping. Those used were a standard technique (now abandoned, 12.1%), synthetic patching (46.4%), and eversion endarterectomy (41.5%). Intraoperative completion arteriography was routinely performed for eversion endarterectomy and only in dubious cases with other techniques. The option of staying in an postoperative intensive care unit (ICU) was available (selective use, 2%). In uncomplicated cases, early discharge (after 1.5 postoperative days) was conisdered safe. The overall perioperative mortality was 0.37% (20/5425). Causes of death were myocardial infarction in seven cases, ischemic stroke in six cases, hemorrhagic stroke in five cases, respiratory failure caused by cervical hematoma in one case, and wound infection in one case. Perioperative neurological morbidity was 1.31% (71/5425); there were 43 major and 28 minor strokes. In conclusion, CE is effective for stroke prevention when there is significant symptomatic and asymptomatic carotid stenosis, as low mortality and morbidity may be achieved in an experienced center. At our institute, the reduction of costs did not have negative consequences on the quality of the surgical care.
Dollars and sense: The economics and outcomes of patients undergoing carotid endarterectomy at Royal Adelaide Hospital
2002, Journal of Vascular Nursing
Citation Excerpt :
If these patients had had an extended observation time (at least 2 hours) in the recovery room, those that required ICU could have been identified and the remaining patients could have been transferred directly to the ward.4 The use of regional anesthesia, selective use of ICU, and early hospital discharge is a safe and cost-effective method of treatment for patients undergoing carotid endarterectomy.5 In summary, the literature suggests that the efficient use of ICU areas will ultimately prove beneficial to patients and hospitals because it will effectively match resources to patients' needs and ensure optimal clinical outcomes and cost-effective medical care.1
This study examined the costs and outcomes of patients undergoing carotid endarterectomy who returned directly to the vascular unit after surgery rather than to the intensive care unit (ICU)/high dependency unit (HDU). The ICU/HDU is for critically ill patients. HDU is the step-down area from the ICU. The nurse-to-patient ratio for these patients is 1:2 and senior medical staff are available 24 hours a day. To prepare staff for the change in practice, an intense educational program was provided and protocols for patient management were developed and implemented. Outcomes were then monitored for the group of patients who returned directly to the vascular unit. Case notes audits, informal patient interviews, daily monitoring of patient outcomes, and an analysis of costing data from Australian Diagnostic Related Groups demonstrated that 50% of patients required transfer to the ICU/HDU after surgery for respiratory, hemodynamic, or neurologic management. The remaining 50% of patients returned directly to the vascular unit with no major complications and had better outcomes with less intensive nursing care overall. The length of hospital stay and the management costs were reduced significantly. (J Vasc Nurs 2002;20:6-13)
The vascular project: Using data to improve processes and outcomes
2001, Journal of Vascular Nursing
Fiscal accountability by health care providers has become a theme in health care delivery systems; however, evaluation of outcomes on the basis of cost alone may minimize the importance of patient needs and the quality of the care delivered. Mechanisms related to resource identification and allocation has to be driven by internal data and information systems that consider clinical, financial, administrative, and patient satisfaction data. This article will define processes, outcomes and outcomes measurement, and management. Various nursing-sensitive outcomes will be presented and their establishment, tracking, interpretation, and effect on the delivery of patient care in a newly opened vascular unit will be highlighted. (J Vasc Nurs 2001;19:80-6)
Timing of postcarotid complications: A guide to safe discharge planning
2001, Journal of Vascular Surgery
Citation Excerpt :
However, again numerous studies undertaken during the 1990s demonstrated that most ICU stays were not necessary, whereas others demonstrated the safety of discharging patients on the first postoperative day. As a result of these studies, many physicians changed their patient care algorithm by transferring patients to the floor after postanesthesia monitoring in the RR5-7 and discharging patients from the hospital the next day. The above changes instituted in the perioperative care of CEA patients over the past decade beg the question, how has the patient fared?
Objectives: Currently, our standard of practice is that patients undergoing carotid endarterectomy (CEA) may be safely discharged on the first postoperative day. Because many patients do not appear to require overnight observation, we wanted to determine the safety and feasibility of same-evening discharge by establishing the timing of postoperative complications, which may potentially require operative intervention. Methods: A total of 835 consecutive patients undergoing CEA were retrospectively reviewed. Sixty-two patients had a postoperative wound hematoma or neurologic deficit (ND) (transient ischemic attack or stroke) within 24 hours of their operation, complications potentially requiring a second operation. Excluded were 64 patients not eligible for same-day discharge because of other reasons (eg, heparinization, CEA with coronary artery bypass grafting). Results: Sixty-two patients (8.0%) had ND (26 [3.4%]) or neck hematoma (NH) (36 [4.7%]) within 24 hours of their CEA. Nineteen (73%) of the NDs were diagnosed in the operating room or recovery room, 5 (19%) within 8 hours of the operation, and 2 (7.7%) after 8 hours but in less than 24 hours. Of the NHs, 23 (66%) were diagnosed in the recovery room, 11 (31%) within 8 hours, and 1 (2.7%) after 8 hours. Of the outliers, one patient experienced a blowout of the vein graft occurring on postoperative day 1, one patient had a delayed ipsilateral stroke, and one had a vertebrobasilar stroke. Overall, only three of 773 (0.4%) patients undergoing CEA had a complication occurring more than 8 hours after operation. Conclusion: NDs and NHs in post-CEA patients occurred within 8 hours of operation in 95% of those patients experiencing these complications or 99.6% of all CEA patients. These data indicate that same-evening discharge may be safely performed without increasing the adverse effects of stroke or hematoma. This plan has cautiously been initiated at this institution. (J Vasc Surg 2001;34:13-6.)

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^☆: Reprint requests: John J. Ricotta, MD, Department of Surgery, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209.

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Original Articles from the Eastern Vascular SocietyConserving resources after carotid endarterectomy: Selective use of the intensive care unit☆

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

J Vasc Surg

Benefits and cost of intensive care

Image: J Nurs Scholar

The range of intensive care services today

JAMA

The use of intensive care: new research initiatives and their implications for national health policy

Milbank Memorial Fund, Quarterly/Health and Society

The role of an intensive care unit in a community hospital: a ten-year review with observations on utilization past, present, and future

Arch Surg

Identification of low-risk monitor patients within a medical-surgical intensive care unit

Med Care

Original Articles from the Eastern Vascular Society
Conserving resources after carotid endarterectomy: Selective use of the intensive care unit☆