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Ann Thorac Surg 1995;60:127-132
© 1995 The Society of Thoracic Surgeons

Cost-Effectiveness and Predictors of Early Extubation

Minneapolis Heart Institute, Minneapolis, Minnesota

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. This study examined predictors and cost-effectiveness of early extubation after coronary artery bypass grafting.

Methods. Six hundred forty-five patients admitted to intensive care units after coronary artery bypass grafting at our institutions in 1993 were reviewed. There were 455 male and 190 female patients, which included all patients in DRG 106 and DRG 107. The patients were categorized into three groups: group A (269 patients) were extubated in less than 12 hours (7.55 ± 2.5 hours), group B (291 patients) were extubated between 12 and 24 hours (16.85 ± 3.3 hours), and group C (376 patients) were extubated any time after 12 hours.

Results. The reintubation rate for the entire group was less than 1%. Univariate preoperative analyses revealed small differences between groups A and B: only 6 of 25 variables were found to reach statistical significance. Stepwise logistic regression analyses were carried out in 269 patients of group A and 376 patients of group C. Older patients (log of age, p = 0.0001), female sex (p = 0.0129; odds ratio = 1.634), use of preoperative diuretics (p = 0.0010; odds ratio = 1.965) and unstable angina (p = 0.0301; odds ratio = 1.544) were noted to be clinical factors associated with late extubation (12 hours). Early extubation was accomplished in 42%; however, further analysis revealed that many patients who were intubated overnight should have been extubated sooner.

Conclusions. Early extubation shortened the postoperative length of stay, resulting in reduction of cost and resource utilization. The average hospital charge per patient was approximately $6,000 less in the early extubation group.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 132.

The sedation and ventilation of cardiac surgical patients overnight has been standard practice for several decades. Justifications for this practice are to avoid the respiratory insufficiency that commonly occurs in the immediate postoperative period and to minimize the increased myocardial oxygen demands secondary to spontaneous ventilation or the stress response after cardiopulmonary bypass that may lead to myocardial ischemia [1].

The past decade has seen a substantial increase in the demand for cardiac operations, principally through the acknowledged benefits of myocardial revascularization [2]. Cardiac surgery proves cost-effective in terms of quality-adjusted life years by improving capacity for work, longevity, and quality of life in all age groups. This is, however, an expensive specialty, and coronary artery bypass grafting has become one of leading procedures that contributes to high health care costs in the United States.

The single factor that differentiates open heart operations from other procedures is cardiopulmonary bypass. Cardiac surgical patients traditionally require beds in the intensive care unit (ICU) for up to 36 hours because of the damaging effects of cardiopulmonary bypass and prolonged anesthesia. Improvement in extracorporeal tech-nology with membrane oxygenation, centrifugal perfusion, ultrafiltration, and blood-sparing techniques have reduced the cerebral, pulmonary, renal, and bleeding complications of cardiopulmonary bypass. Changing perfusion techniques and using ``inhalation-based anesthesia'' allows for early extubation (within hours after operation) of many post–cardiopulmonary bypass patients [3], leading to a rapid stepdown from the ICU with subsequent lowering of costs. However, progress in postoperative management has not kept pace with intraoperative advances.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We reviewed 645 consecutive patients admitted to ICUs after coronary artery bypass procedures at our institutions in 1993. There were 455 male and 190 female patients, which included all of the patients in diagnostic-related group (DRG) 106 (coronary artery bypass grafting with coronary angiographic study done on the same admission) and DRG 107 (coronary artery bypass grafting without coronary angiographic study done on the same admission). Patient demographic data are listed in Table 1. The patients were categorized into three nondiscrete groups according to the time of extubation: less than 12 hours (group A), 12 to 24 hours (group B), and 12 hours or more (group C). These patients were operated on by the same group of surgeons and same group of anesthesiologists.

After arriving in the ICU patients were ventilated mechanically with either intermittent mandatory ventilation or the assist control mode. Arterial and venous blood pressure routinely were monitored continuously. In the more seriously ill patients, or those with poor left ventricular function, a pulmonary artery catheter was used to determine cardiac output on a continuous or an intermittent basis. Parameters recorded during the intraoperative and postoperative period are listed in Tables 2 and 3. All patients were entered in the clinical pathway and followed the following extubation criteria:

1. Patients are awake and alert with cerebral function adequate for patient cooperation
   
2. Forced vital capacity greater than 11 mL/kg
   
3. Spontaneous ventilation at a rate of not more than 30 breaths/min with a good respiratory pattern
   
4. Arterial carbon dioxide tension less than 55 mm Hg
   
5. Arterial oxygen tension greater than 80 mm Hg on an inspired oxygen fraction of 0.50
   
6. Stable hemodynamic parameters; mean arterial pressure greater than 70 mm Hg with a normal filling pressure and heart rate of 80 to 100 beats/min
   
7. Adequate hemostasis (chest drainage less than 100 mL in 60 minutes)
   The patients were weaned from ventilatory support as soon as hemodynamic stability was established. The patients remained intubated until satisfactory gas exchange was achieved as confirmed by serial arterial blood gas analysis. The decision to wean and extubate patients was initiated by specially trained nursing staff. Throughout the weaning process and after extubation, arterial blood gas analysis and pulse oximetry were monitored closely.
   After extubation, close monitoring was continued as before. Specific attention was given to adequacy of respiratory effort. The analgesia during the recover period included morphine sulfate, 1 to 2 mg given intravenously every 30 to 60 minutes, or Toradol (Ketoralac), 60 mg given intramuscularly initially and then 30 mg every 6 hours for the next 48 hours if the patient was younger than 65 years and had normal renal function.
   Group A included 269 patients (42%) who were extubated in less than 12 hours (7.55 ± 2.5 hours), and group B consisted of another 291 patients (45%) who were extubated between 12 and 24 hours (16.85 ± 3.3 hours). Group C included 376 patients who were extubated any time at 12 hours or greater. The reintubation rate for all groups was less than 1%. The 12-hour dividing point was selected prospectively before the conduction of any analysis.
   The data were analyzed using univariate and multivariate analysis techniques. Pearson correlation analyses were used to determine preliminary relationships between clinical variables and extubation groupings. The ² (or, where appropriate, Fisher's exact test) and unpaired t tests were used to conduct univariate analyses for discrete and continuous variables, respectively. Stepwise logistic regression was used to conduct multivariate analyses of the independent predictors of extubation groupings. Values of p equal to or less than 0.2 were used to determine covariate inclusion, and p values equal to or less than 0.05 were used for covariate retention. Model fit was determined using the c statistic and the Hosmer-Lemeshow Test. Using logistic regression analysis in this study may have some limitation. Because the continuous variable is analyzed as if it were dichotomous, there is a possibility that some information that could have yielded different results may have been discarded. These analyses were conducted using a commercial statistical software package (SAS Version 6.09 for Microsoft Windows NT, Redmond, WA).
   

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Fourteen preoperative (see Table 1), seven operative (see Table 2), and four postoperative (see Table 3) variables were analyzed. Univariate analyses were used to determine the preoperative differences between group A (<12 hours) and group B (12 to 24 hours). The analyses revealed small differences between the two groups: Only 6 of 25 variables were found to reach statistical significance as listed in Table 4. More of the patients in group B were taking diuretics (p = 0.003) and maintained on nitroglycerin drips (p = 0.05) up to the time of operation. Intraoperatively, however, only one observed variable, the pump time, was longer in group B (97 versus 89 minutes; p = 0.007). The patients intubated overnight returned to the operating room more often for continued postoperative bleeding (3% versus 0.3%; p = 0.05) and had higher creatine kinase-MB level (57.4 ± 99 versus 40.5 ± 47 ng/mL; p = 0.01). However, there was no difference in the incidence of perioperative myocardial infarction. The overnight intubation group (group B) had almost double the incidence of atrial fibrillation seen in the early extubation group (37% versus 21%; p = 0.05).

The Society of Thoracic Surgeons' statistical model for the prediction of operative mortality [6] was used to assist in determining the overall risk profile of these patients before operation. This revealed a small (27%) but statistically significant difference in preoperative risk for death (group A = 1.66%, group B = 2.28%; p = 0.0036).

To determine whether there was a stronger relationship between late extubation and the predictor variables, stepwise logistic regression analyses were carried out in 269 patients from group A and 376 patients from group C (12 hours). Older patients (log of age, p = 0.0001), female sex (p = 0.0129; odds ratio = 1.634), use of preoperative diuretics (p = 0.0010; odds ratio = 1.965), and unstable angina (p = 0.0301; odds ratio = 1.544) were noted to be clinical factors associated with late extubation of longer than 12 hours (Table 5). The model fit statistics for these two groups indicated better predictive power (c = 0.694; Hosmer-Lemeshow p = 0.9226) for the model relative to the prior comparison between group A (<12 hours) and B (12 to 24 hours). However, this better predictive power (increase in the number of significant predictors) may be representative of more patients in the latter analysis.

The length of hospital stay after operation was significantly shorter in group A (6.4 versus 8.0 days; p = 0.0001). The details of the hospitalization days are listed in Table 6.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

Because of the rapid changes in health care in the state of Minnesota, cost-effectiveness becomes a prime concern of everyone involved in the daily practice of cardiac surgery. The continuous quality improvement team was developed in early 1990 to maintain excellent care and improve cost-effectiveness in cardiac surgery. The details of these accomplishments have been reported elsewhere [7]. The team headed by the cardiac surgeons has developed clinical pathways for shortening the length of the hospital stay and minimizing resource utilization for surgical DRGs. Early extubation is one of the many areas that has been looked at in detail, and it is expected that early extubation will lead to shorter hospital stays. The results of this study show that early extubation can be accomplished in more than 40% of the entire group of nonselected patients regardless of preoperative condition, the complexity of the operation, or postoperative difficulty. The incidence of reintubation is negligible, and the incidence of myocardial ischemia secondary to stress response in the immediate postbypass has never materialized.

Two statistical analysis models were created to accomplish two different goals: first, to identify the difference between early extubation and overnight ventilation group and to learn how to improve the percentage of early extubation, and second, to identify the preoperative risk factors that could predict late extubation.

Eighteen percent of the patients in group A and 25% of the patients in group B were unstable and were maintained on intravenous nitroglycerin up to the time of operation. Also, 17% of patients in group A and 28% of patients in group B had a history of congestive heart failure and received diuretics up to the time of operation. These two subsets of patients who were not extubated early accounted for less than 50% of the entire group. The rest of the patients appeared to be stable and probably were candidates for early extubation.

Intraoperatively, an 8-minute difference in pump time was the only factor that appeared to play a role in delaying extubation. After operation, more patients in the overnight ventilation (12 to 24 hours) group had to return to the operating room for bleeding, more had a higher creatine kinase-MB level, and more had atrial fibrillation. These variables, except for continued mediastinal bleeding, were not in the clinical pathway as contraindications to early extubation. The univariate analysis suggested that there is little difference between the patients in the early extubation and the overnight ventilation groups. Therefore, many of the patients who were ventilated overnight could be safely extubated early as well. It is interesting to observe that there was no significant difference in length of stay in the ICU between the two groups (1.7 versus 1.3 days; p = 0.06). This reflects the clinical pathway protocol that did not allow transfer of patients out of the ICU until early the next morning. Work is now underway for the stepdown unit to accept transferring patients on the day of operation.

The logistic regression analysis between early extubation (<12 hours) and late extubation (12 hours) groups also indicated that older patients (log of age) as a continuous variable, female sex, preoperative diuretic therapy, and unstable angina are independent predictors of prolonged intubation. These findings agree with previous observations that the increment of age could play a significant role in prolonged intubation [8]. Only 34% of female patients were extubated early, compared with 53% of male patients. From previous observations, female sex alone has not been a predictor of delayed extubation; however, patients with congestive heart failure have been observed to require prolonged intubation [8]. Our experience revealed that patients who were taking diuretics retained more fluid and gained more weight postoperatively. Earlier and more aggressive use of diuretics during and immediately after operation may help expedite extubation. Finally, unstable angina patients requiring intravenous nitroglycerin up to the time of operation are sicker, have a higher risk, and may have other systemic problems that cannot be resolved until emergency myocardial revascularization is completed. The data analyzed using The Society of Thoracic Surgeons' statistical model for the prediction of operative mortality confirmed higher risk for the patients in group C, with a predicted operative mortality of 3.3%, compared with only 1.6% in group A and 2.3% in group B.

The fact that patients with fewer preoperative risk factors tend to do well and high-risk patients do poorly influences decision-making on extubation. In healthy patients, even the minimal risks of prolonged ventilation are outweighed by advantages of early extubation. Conversely, in higher-risk patients, the chance of infrequent but major events, such as reoperation for continued mediastinal bleeding, relegates the risks of continued ventilation to a secondary status. Thus, it is necessary to distinguish between patients likely to succeed after early extubation and those requiring further support. Patients with inadequate postoperative cardiovascular performance are best managed by controlling ventilation to reduce the work of breathing and to allow adequate sedation and, if necessary, neuromuscular blockade. Commonly, ICU discharge in these patients will be governed by issues other than time of extubation. Postoperative morbidity and mortality are, to a large extent, predictable based on preoperative status. Patients likely to have respiratory complications after a cardiac operation can be identified by the presence of congestive heart failure, emergency procedures, reoperation, impaired renal function, chronic obstructive pulmonary disease, prior vascular operation, and older age [8]. Unexpected events in the operating room such as incomplete revascularization or poor myocardial preservation may dictate prolonged postoperative ventilation.

There are many benefits from early extubation [9], especially respiratory and cardiovascular benefits that are well documented after extubation [10–19]. The economic benefit has now become one of the very important issues of health care reform. Early discharge from the hospital decreases resource utilization, which could translate into significant cost savings. Earlier extubation permits earlier discharge from the ICU, avoiding oversedation and resultant depression of the brain stem respiratory center. Although Prakash and associates [18] documented fewer ICU days in their study, Quasha and colleagues [12] failed to find a difference in ICU time, although they did document cost savings from earlier extubation.

Indirect economic benefits also accrue: earlier mobilization of the patient, less need for sedation, less cardiopulmonary morbidity, and presumably reduced nursing demands and resource utilization. In this study, early extubation accomplished the above economic benefit and decreased the average hospital charge by $6,000 per patient. When the clinical pathway criteria is changed to allow early transfer from the ICU, the resource utilization will decrease even further, and more cost savings will accrue.

In summary, early extubation requires education, cooperation, and leadership. It was accomplished in 42% of the patients in this study. However, analysis of the data revealed that many of the patients who were intubated overnight could have been extubated sooner. The log of age, female sex, congestive heart failure with administration of diuretics up to the time of operation, and unstable angina are independent predictors of prolonged intubation. Work is being done by a continuous quality improvement team to improve extubation in these groups of patients. Our preliminary observation suggested more aggressive and early administration of diuretics could expedite the extubation. Postoperative patients with stable cardiopulmonary physiology respond to endotracheal extubation with improved cardiac performances as a result of enhanced ventricular filling. These benefits may be derived earlier in the postoperative period if mechanical ventilation is discontinued as soon as extubation criteria are met. Early extubation is a reliable and safe postoperative technique in an easily definable subset of patients. Our data together with those of other studies suggest that early extubation should be the current standard of care after uncomplicated elective cardiac operations. Early extubation and rapid stepdown from the ICU has both clinical and economic benefits. Early mobilization and return to normal nutrition have led to shorter stays in the hospital. Conventional prolonged intubation and unnecessary sedation led to delays in returning patients to a normal ward and a protracted recovery. Reductions in the period of intubation, sedation, ventilation, and thus recovery time led to a rapid reduction in nursing dependency. Early extubation shortened the postoperative length of stay, resulting in reduction of cost and resource utilization. The average hospital charge per patient was approximately $6,000 less in the early extubation group.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The invaluable help of Mary Jane Tocko, RN, Karen Dubois, RN, and Lisa McCallum, MS, in the preparation of the data is gratefully appreciated.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov –12, 1994.

Address reprint requests to Dr Arom, 920 E 28th St, Suite 420, Minneapolis, MN 55407.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kit V. Arom Robert W. Emery Rebecca J. Petersen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Arom, K. V. Articles by Schwartz, M. Search for Related Content PubMed PubMed Citation Articles by Arom, K. V. Articles by Schwartz, M. Related Collections Related Article