Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score.

PURPOSE: The APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated. MATERIAL AND METHODS: In a prospective consecutive cohort of 805 patients ≥18 years admitted to the CVICU after coronary artery bypass and/or valvular surgery, the APPROACH CVICU readmission score was calculated at the time of discharge to a surgical ward. The study compared observed versus predicted CVICU readmission and the model discrimination was evaluated using AUC c-index. The incremental prognostic utility of 6 pre-specified prospectively collected respiratory (re-intubation, tracheostomy, oxygen at discharge) and hemodynamic variables (heart rate, systolic blood pressure, inotropes at discharge) were tested using net reclassification index (NRI) and integrated discrimination improvement (IDI). RESULTS: A total of 37 (4.6%) patients were readmitted to the CVICU. The median CVICU length of stay (9.0 vs 2.0 days, p < .001) and all-cause in-hospital mortality (8.1% vs 0.4%, p < .001) was higher among readmitted patients. The model had good discrimination (c-index = 0.748). Systolic blood pressure at discharge yielded the largest improvement in model discrimination (c-index = 0.782; Hosmer-Lemshow p = .749). CONCLUSIONS: In a prospective validation cohort, the APPROACH CVICU readmission risk score had good discrimination and could be operationalized in future research and clinical practice.

Postoperative Complications and Outcomes Associated With a Transition to 24/7 Intensivist Management of Cardiac Surgery Patients.

OBJECTIVES: Nighttime intensivist staffing does not improve patient outcomes in general ICUs. Few studies have examined the association between dedicated in-house 24/7 intensivist coverage on outcomes in specialized cardiac surgical ICUs. We sought to evaluate the association between 24/7 in-house intensivist-only management of cardiac surgical patients on postoperative complications and health resource utilization. DESIGN: Before-and-after propensity matched cohort study. SETTING: Tertiary care cardiac surgical ICU. PATIENTS: Patients greater than 18 years old who underwent cardiac surgery between January 1, 2006, and April 30, 2013 (nighttime resident model), were propensity-matched (1:1) to patients from August 1, 2013, to December 31, 2014 (24/7 in-house intensivist model). INTERVENTIONS: Cardiac surgical ICU coverage change from a nighttime resident physician coverage model to a 24/7 in-house intensivist staffing model. MEASUREMENTS AND MAIN RESULTS: The primary outcome of interest was a composite of postoperative major complications. Secondary outcomes included duration of mechanical ventilation, all-cause cardiac surgical ICU readmissions, and surgical postponements attributed to lack of cardiac surgical ICU bed availability. A total of 1,509 patients during the nighttime resident model were matched to 1,509 patients during the intensivist model. The adjusted risk of major complications (26.3% vs 19.3%; odds ratio, 0.73; 95% CI, 0.36-0.85; p < 0.01), mean mechanical ventilation time (25.2 vs 19.4 hr; p < 0.01), cardiac surgical ICU readmissions (5.3% vs 1.6%; odds ratio, 0.31; 95% CI, 0.19-0.48; p < 0.01), and surgical postponements (3.4 vs 0.3 per mo; p < 0.01) were lower with the intensivist model. CONCLUSIONS: A transition to a 24/7 in-house intensivist care model was associated with a reduction in postoperative major complications, duration of mechanical ventilation, cardiac surgical ICU readmissions, and surgical postponements. These findings suggest that 24/7 intensivist physician care models may improve patient outcomes and health resource utilization in specialized cardiac surgical ICUs.