Cardiothoracic surgeon management of postoperative cardiac critical care.

OBJECTIVE: To determine whether postoperative cardiac care by cardiothoracic surgeons in a semiclosed intensive care unit model could be distinguished from that given by intensivists who are not board certified in cardiothoracic surgery. DESIGN: From January 2007 to February 2009, we retrospectively examined data on patients after cardiac operations from 2 consecutive periods during which full-time management of intensive care was changed from noncardiothoracic intensivists (period 1, 168 patients) to cardiothoracic surgeons (period 2, 272 patients). MAIN OUTCOME MEASURES: Variables measured included Society of Thoracic Surgeons observed and expected mortality, central venous line infections, ventilator-acquired pneumonia, red blood cell exposure, adherence to blood glucose level target at 6 am on the first and second postoperative days, length of stay, and intensive care unit pharmacy costs. Results were compared using a 2-sample t test or 2-tailed Fisher exact test. RESULTS: In similar populations, as witnessed by equivalent Society of Thoracic Surgeons operative risk, cardiothoracic surgeons providing postoperative critical care led to a mean (SD) decrease in hospital length of stay from 13.4 (0.9) to 11.2 (0.4) days (P = .01) and decreased drug costs from $4300 (1000) to $1800  (200) (P < .001). These improvements occurred without losing benefits in other quality measures. CONCLUSIONS: By virtue of their cardiac-specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. In a semiclosed unit where care of the patient is codirected, the improvements noted may have been facilitated by the commonalities between surgeons and intensivists associated with similar training and experiences.

Intense implementation of a strict insulin infusion protocol does not guarantee postoperative glycemic control.

BACKGROUND: The Surgical Care Improvement Project (SCIP) has benchmarked 6:00 AM blood sugars on postoperative days (PODs) 1 and 2 at <200 mg/dL as an indicator of overall glycemic control (GC) in postoperative cardiac surgery patients. However, even in demonstration hospitals that publicly report for incentive payments, only 10% are compliant with this benchmark. The objectives of this study were to validate that the SCIP indicator correlates with overall GC, and relate the intensity of implementation of an insulin infusion protocol (IIP) (goal, blood sugar 100 to 140 mg/dL) to effective GC. STUDY DESIGN: All postoperative cardiac surgery patients for 12 consecutive months on the IIP were divided into 2 groups: group 1 included patients who were SCIP compliant (n = 98), and group 2 were patients who were not SCIP compliant (n = 10). For each patient, we determined average blood sugar, duration of hyperglycemia (percent of time with blood sugar >200mg/dL), and intensity of implementation of the IIP, defined as (number of blood sugar checks/hours on IIP), with 0.5 = minimum intensity of implementation dictated by the IIP, ie, an insulin adjustment every 2 hours. RESULTS: The average blood sugar for each of the 110 patients was no different than the SCIP 6:00 AM blood sugar: 146 versus 154 mg/dL, p = 0.18. SCIP noncompliance correlated with more intense implementation of the IIP, 0.72 ± 0.03 versus 0.83 ± 0.06 blood sugar checks/hour. CONCLUSIONS: The SCIP 6:00 AM blood sugar metric does correlate with average blood sugar on POD 1. Compliance with SCIP 6:00 AM blood sugar measurement is a valid surrogate for GC, though duration of hyperglycemia was still 14% in the compliant group. Use of an IIP does not guarantee GC, despite increased intensity of its application. Even intense use of an IIP may be ineffective when it fails to account for patient risk factors for hyperglycemia.