Dataset Information

Cerebral oximetry in adult cardiac surgery to reduce the incidence of neurological impairment and hospital length-of-stay: A prospective, randomized, controlled trial.

ABSTRACT:

Background

Cerebral oximetry using near-infrared spectroscopy (NIRS) has been shown to reduce neurological dysfunction and hospital length-of-stay after adult cardiac surgery in some but not all studies. We audited maintaining cerebral saturations at or above baseline and showed improved neurological and length-of-stay outcomes. Our hypothesis for this study was that our NIRS protocol would improve neurological and length-of-stay outcomes.

Methods

This prospective, single centre, double-blinded controlled study randomized 182 consecutive patients, scheduled for cardiac surgery using cardiopulmonary bypass. Participants were randomized by concealed envelope prior to anaesthesia. NIRS study group were managed perioperatively using our NIRS protocol of 8 interventions, increase cardiac output, normocapnia, increase mean arterial pressure, increase inspired oxygen, depth of anaesthesia, blood transfusion, correction of bypass cannula, change of surgical plan to restore levels equal to or above baseline. The control group had standard management without NIRS. Primary outcomes were neurological impairment (early and late) and hospital length-of-stay. Secondary outcomes were ventilation times, intensive care length-of-stay, major organ dysfunction and mortality.

Results

91 patients entered each group. There was a significant improvement in self-reported six-month general functionality in the NIRS group (p = 0.016). Early neurological dysfunction and hospital length-of-stay was the same in both groups. Of the secondary outcomes only Intensive Care length-of-stay was statistically significant, being shorter in the NIRS group (p = 0.026).

Conclusion

Maintaining cerebral saturations above baseline reduces time spent in Intensive Care and may improve long term functional recovery but not stroke, major organ dysfunction and mortality.

SUBMITTER: Bennett SR

PROVIDER: S-EPMC9125448 | biostudies-literature | 2022 May

REPOSITORIES: biostudies-literature

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Publications

Cerebral oximetry in adult cardiac surgery to reduce the incidence of neurological impairment and hospital length-of-stay: A prospective, randomized, controlled trial.

Bennett Sean R SR Smith Neil N Bennett Miriam R MR

Journal of the Intensive Care Society 20201206 2

<h4>Background</h4>Cerebral oximetry using near-infrared spectroscopy (NIRS) has been shown to reduce neurological dysfunction and hospital length-of-stay after adult cardiac surgery in some but not all studies. We audited maintaining cerebral saturations at or above baseline and showed improved neurological and length-of-stay outcomes. Our hypothesis for this study was that our NIRS protocol would improve neurological and length-of-stay outcomes.<h4>Methods</h4>This prospective, single centre, ...[more]

PMID: 35615236

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Project description:BackgroundEven though the importance of preparing patients for a surgical event is recognized, there are still gaps about the benefit of improving functional capacity by walking during the waiting time among patients scheduled for non-cardiac surgery. The aim of this study was to evaluate the impact of pre-surgical walking in-hospital length of stay, early ambulation, and the appearance of complications after surgery among patients scheduled for non-cardiac surgery.MethodsA two-arm, single- blinded randomized controlled trial was developed from May 2016 to August 2017. Eligible outpatients scheduled for non-cardiac surgery, capable of walking, were randomized (2:1 ratio) to receive a prescription of walking 150 min/week during the whole pre-surgical waiting time (n = 249) or conventional care (n = 119). The primary outcome was the difference in hospital length of stay, and secondary results were time to first ambulation during hospitalization, description of ischemic events during hospitalization and after six months of hospital discharge, and the walking continuation. We performed an intention to treat analysis and compared length of stay between both groups by Kaplan-Meier estimator (log-rank test).ResultsThere were no significant differences in the length of hospital stay between both groups (log-rank test p = 0.367) and no differences in the first ambulation time during hospitalization (log-rank test p = 0.299). Similar rates of postoperative complications were observed in both groups, but patients in the intervention group continued to practice walking six months after discharge (p < 0.001).ConclusionOur study is the first clinical trial evaluating the impact of walking before non-cardiac surgery in the length of stay, early ambulation, and complications after surgery. Prescription of walking for patients before non-cardiac surgery had no significant effect in reducing the length of stay, and early ambulation. The results become a crucial element for further investigation.Trial registrationPAMP-Phase2 was registered in ClinicalTrials.gov NCT03213496 on July 11, 2017.

Project description:ImportanceMany strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction.ObjectiveTo identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS.Evidence reviewMultiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide.FindingsOur searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days).Conclusions and relevanceThis systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Project description:ObjectiveWe examined the consequences of perioperative respiratory event (PRE) in terms of hospitalization and hospital cost in children who underwent ambulatory surgery.MethodsThis subgroup analysis of a prospective cohort study (ClinicalTrials.gov: NCT02036021) was conducted in children aged between 1 month and 14 years who underwent ambulatory surgery between November 2012 and December 2013. Exposure was the presence of PRE either intraoperatively or in the postanesthetic care unit or both. The primary outcome was length of stay after surgery. The secondary outcome was excess hospital cost excluding surgical cost. Financial information was also compared between PRE and non-PRE. Directed acyclic graphs were used to select the covariates to be included in the multivariate regression models. The predictors of length of stay and excess hospital cost between PRE and non-PRE children are presented as adjusted odds ratio (OR) and cost ratio (CR), respectively with 95% confidence interval (CI).ResultsSixty-three PRE and 249 non-PRE patients were recruited. In the univariate analysis, PRE was associated with length of stay (p = 0.004), postoperative oxygen requirement (p <0.001), and increased hospital charge (p = 0.006). After adjustments for age, history of snoring, American Society of Anesthesiologists physical status, type of surgery and type of payment, preoperative planned admission had an effect modification with PRE (p <0.001). The occurrence of PRE in the preoperative unplanned admission was associated with 24-fold increased odds of prolonged hospital stay (p <0.001). PRE was associated with higher excess hospital cost (CR = 1.35, p = 0.001). The mean differences in contribution margin for total procedure (per patient) (PRE vs non-PRE) differed significantly (mean = 1,523; 95% CI: 387, 2,658 baht).ConclusionPRE with unplanned admission was significantly associated with prolonged length of stay whereas PRE regardless of unplanned admission increased hospital cost by 35% in pediatric ambulatory surgery.Trial registrationClinicalTrials.gov registration number NCT02036021.

Project description:BackgroundGiven growing demand for hip and knee arthroplasty and unsustainable resource requirements, safe and efficient models of care are critical. This study aims to determine the impact on healthcare costs of implementing an enhanced short-stay model of care (ESS-MOC) for arthroplasty at a national level.MethodsA budget impact analysis was conducted for the years 2023-2030 in the setting of Australian publicly and privately funded hospitals performing hip or knee arthroplasty. The model considered population-based future arthroplasty projections, published data on healthcare costs and resource utilisation, and aggregate health insurer claims data related to minor complexity elective hip or knee arthroplasty for osteoarthritis. The ESS-MOC assigned a conservative hypothesized 30% of eligible patients to an enhanced recovery from surgery (ERAS) pathway which comprised a shortened acute ward stay (average 2 days versus 4 days with current care) and outpatient rehabilitation. The primary outcome was total healthcare cost savings post-ESS-MOC implementation, stratified by joint (knee/hip) and healthcare sector (public/private). Return on investment (ROI) ratio, measuring the return for each dollar invested in implementation, and hospital bed days utilized, were also estimated. Costs are presented in Australian dollars (AUD), at 2023 prices.ResultsEstimated cost savings for 2023-2030 from implementing the ESS-MOC pathway were AUD641 million (95% CI: AUD99 million to AUD1250 million), corresponding to a ROI ratio of AUD8.88 (AUD1.3 to AUD17.9). Total implementation costs for the ESS-MOC were estimated at AUD38 million and AUD34 million for the private and public sectors, respectively. Savings would be 8-fold higher in the private sector (AUD571 million vs. AUD70 million in the public sector), primarily attributable to the > 80,000 rehabilitation bed days saved annually in this sector. For the period 2023-2030, an estimated 337,000 (261,000 to 412,000) acute bed days could be saved (private sector 262,000 [200,000 to 324,000]; public sector 74,000 [57,000 to 92,000]). Less than 10% of eligible patients would need to move into the ERAS pathway to realise cost savings.ConclusionsImplementation of an enhanced short-stay model of care for eligible arthroplasty patients in Australia would generate significant cost and resource savings, particularly for the private hospital sector.

Project description:Background contextLength-of-hospital stay (LOS) after lumbar spine surgery (LSS) can be affected by many factors. However, few studies have evaluated predictors of LOS, and all have used limited number of variables as predictors.PurposeThe purpose of the study was to identify presurgical, surgical, and postsurgical predictors of LOS after LSS.Study design/settingRetrospective review of consecutive patients who had LSS at the University of Kansas Hospital from October 2008 to April, 2012.Patient sampleFive hundred ninety-three patients underwent LSS consisting of laminotomy, laminectomy, or arthrodesis.Outcome measuresDependent variableLOS. Multiple presurgical, surgical, and postsurgical variables were extracted from the patients' medical records and considered as possible predictors (independent variables) of LOS.MethodsPotential predictors that were significantly correlated with LOS were used as indicators to construct three latent factors presurgical, surgical, and postsurgical, which were in turn used to predict LOS in a structural equation model.ResultsThe average LOS was 4.01±2.73 days. The presurgical factor was indicated by age (61.97±14.49 years), previous level of function (60.5% were totally independent), previous hemoglobin level (13.70±1.36 mg/dL), and use of assistive devices (60% were assistive device users). The surgical factor was indicated by severity of illness (50.2% had minor disease severity), presence of complications (1.9%), and stay in an intensive care unit (4.0%). The postsurgical factor was indicated by postsurgical walking distance (166.43±175.75 ft), level of assistance during walking (5.18±0.81 out of 7 points), balance scores (6.18±1.82 out of 10 points), and bed mobility and transfer dependency scores (9.81±1.99 out of 14 points). These three latent factors explained 47% of variation in LOS.ConclusionsPostsurgical factors predicted the highest variation in LOS in comparison with presurgical and surgical factors and should be taken into consideration for discharge planning. Postsurgical factors are related to the patient's function, modifiable with rehabilitation, and can be improved to shorten LOS. Inclusion of more reliable and standardized presurgical variables could improve the predictability of the model.

Dataset Information

Cerebral oximetry in adult cardiac surgery to reduce the incidence of neurological impairment and hospital length-of-stay: A prospective, randomized, controlled trial.

Background

Methods

Results

Conclusion

Publications

Cerebral oximetry in adult cardiac surgery to reduce the incidence of neurological impairment and hospital length-of-stay: A prospective, randomized, controlled trial.

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