Opening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery

doi:10.1016/S0952-8180(02)00403-8

Journal of Clinical Anesthesia

Volume 14, Issue 7, November 2002, Pages 486-493

https://doi.org/10.1016/S0952-8180(02)00403-8 Get rights and content

Abstract

Study objectives

To assess the impact of a new postanesthesia care unit (PACU) on intensive care unit (ICU) utilization, hospital length of stay, and complications following major noncardiac surgery.

Design

Observational study.

Setting

University hospital.

Patients and measurements

From 1992 to 1999, 915 patients underwent either abdominal aortic reconstruction (n = 448) or lung resection for cancer (n = 467). Demographic, clinical, surgical, and anesthetic data, as well as perioperative complications, were abstracted from two institutional databases.

Interventions

Patients were divided in two study periods, before and after the opening of a new PACU (period 1992–1995 and period 1996–1999).

Main results

Utilization of ICU decreased from 35% to 16% for vascular patients and from 57% to less than 4% for thoracic patients during the second period. Readmission to the ICU, perioperative mortality, and respiratory complications were comparable between the two periods. Patients with congestive heart failure, chronic obstructive pulmonary disease, or renal insufficiency were more likely to be admitted to the ICU than the PACU. Following vascular surgery the frequency of cardiac complications decreased from 10.6% in 1992–1995 to 5.2% in 1996–1999 (p < 0.005), as well as the need for postoperative mechanical ventilation (25% vs. 12%; P < 0.05).

Conclusions

Increased availability of PACU beds resulted in reduced utilization of ICU resources without compromising patient care after major noncardiac surgery.

Introduction

Utilization of the intensive care unit (ICU) for routine postoperative care is commonplace, and it is often necessitated by the complex physiological interactions between patients’ underlying pathologic conditions and anesthetic and operative interventions. Progress in intensive care medicine has contributed largely to a better understanding of the pathophysiology of many acute disease processes and has allowed invasive therapeutics to be available to increasingly sick patients.1, 2 However, because of the sophisticated technological support and the high density of staffing, ICUs account for an ever increasing proportion of a hospital’s budget.3 After costs associated with the operating room (OR), ICU care is the most expensive component of the hospital stay for patients undergoing cardiothoracic surgery.4

In an effort to limit ICU costs and to improve the efficiency of hospital resources, two complementary strategies have been proposed: 1) implementation of strict admission and discharge criteria to ICUs, by selecting patients who will most benefit from high-quality intensive care;5 and 2) opening of intermediate care units to enable earlier discharge from ICUs and to free ICU beds for the most seriously ill patients.6, 7, 8, 9 Alternatively, the postanesthesia care unit (PACU) can be used as an intermediate care unit to monitor and support selected patients after uncomplicated major surgery.10

Presently, no randomized controlled trial has compared the costs, benefits, or safety of surgical patients allocated either to ICU, PACU, or intermediate care unit. Such a study would be difficult to conduct for ethical considerations, clinical judgement of the investigators, and unwillingness of the patients to be randomized. An observational study analyzing a cohort of surgical patients then is a suitable alternative to evaluate new health care interventions and identify risk factors for mortality and morbidity.11

In this study, we set out to analyze the impact of a new PACU on mortality, hospital duration of stay, (re-)admission to ICU, and postoperative complications in patients undergoing abdominal aortic reconstruction or resection for lung cancer.

Section snippets

Study setting and patient management

The University Hospital of Geneva is a tertiary-care public facility offering residency programs in all surgical and medical specialties. Up to 18,000 adult patients undergoing elective and emergency surgical procedures are admitted annually to the main PACU. In April 1995, the PACU was moved to an area, located closer to the OR and the ICU, and, has been expanded with additional beds to provide overnight care following major noncardiac surgery. This new PACU—equipped with 10 monitors and one

Results

From 1992 to 1999, completed data were obtained on 448 consecutive cases of aortic abdominal reconstruction and 467 consecutive resection for lung cancer at our institution. Eleven patients were excluded from the study for incomplete data. As shown in Figure 1, the annual elective case load varied between 48 and 72 cases of vascular surgery and between 48 and 83 cases of thoracic surgery.

During the first study period (Jan. 1992 to Dec. 1995), 152 of 235 patients undergoing major vascular

Discussion

In the present 8-year observational study, we found that the opening of a new PACU (with 24-hr coverage) led to a marked reduction in ICU utilization after elective major noncardiac surgery. Admission rates in the ICU decreased from 35% to 16% following vascular surgery, and from 57% to less than 2% following thoracic surgery. No negative impact on the quality of care was associated with this shift from ICU to PACU utilization: re-admission in ICU, perioperative mortality, and respiratory

Conclusion

In the present study, we found that PACU provided a safe and effective alternative to ICU for most patients undergoing abdominal aortic reconstruction and open lung resection. Patients with unstable condition or multiple organ dysfunction still will require management in the ICU environment. Along with their specific clinical expertise, surgeons, anesthesiologists, and intensivists should collaborate closely within the hospital network in selecting surgical candidates, stratifying operative

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^*: Staff Anesthesiologist

^†: Staff Cardiovascular Surgeon

^‡: Associate Professor, Chief-Surgeon, Thoracic Surgical Unit

^§: Staff Intensivist

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Original contributionOpening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery

Abstract

Study objectives

Design

Setting

Patients and measurements

Interventions

Main results

Conclusions

Introduction

Section snippets

Study setting and patient management

Results

Discussion

Conclusion

J Vasc Surg

Cardiovasc Surg

Chest

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Vasc Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

Improving the outcome and efficiency of intensive carethe impact of an intensivist

Crit Care Med

Effects of an organized critical care service on outcomes and resource utilizationa cohort study

Crit Care Med

The cost of intensive carea comparison on one unit between 1988 and 1991

Intensive Care Med

Coronary bypass graftinghow much does it cost?

CMAJ

Guidelines for intensive care unit admission, discharge and triage

Crit Care Med

Original contribution
Opening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery