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Selection of patients for same-day coronary bypass operations
R P Anderson1, S W Guyton, D L Paull
1Department of Surgery, Virginia Mason Clinic, Seattle, WA 98101.
Insights
Same-day admission for coronary bypass surgery is safe, with no increased complications. While it reduces hospital stays, the cost savings are minimal, justifying preoperative admission for high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
Background:
- Chronic stable angina pectoris patients undergoing coronary bypass grafting (CABG) have varying admission protocols.
- Preoperative admission is often used for higher-risk patients, but its necessity for all is debated.
Purpose of the Study:
- To compare outcomes and resource utilization between same-day admission and preoperative admission for isolated CABG.
- To determine if selective same-day admission increases patient risk.
Main Methods:
- Retrospective analysis of 175 consecutive CABG patients (March 1990-December 1991).
- Patients were divided into same-day admission (n=100) and preoperative admission (n=75) groups.
- Postoperative progress monitored using a clinical pathway with physiologic and activity measures.
Main Results:
- No significant differences in age, sex, or overall comorbidity burden between groups.
- Higher prevalence of diabetes and low ejection fraction in the preoperative admission group.
- No significant difference in major/minor complications, but two deaths occurred in the preoperative group.
- Same-day admission patients had a 1.5-day shorter hospital stay (p<0.001).
- Total hospital charges were minimally higher for the preoperative group ($286 difference, not statistically significant).
Conclusions:
- Selective same-day admission for coronary bypass surgery is safe and does not increase complication rates.
- While same-day admission reduces hospital length of stay, the financial savings are marginal.
- Preoperative admission remains justified for patients with significant comorbidities or physical limitations.
- Surgeons should retain discretion over patient admission decisions.
Abstract:
Between March 15, 1990, and December 31, 1991, we admitted to the Virginia Mason Hospital for isolated coronary bypass operations 175 consecutive patients with chronic, stable angina pectoris who had prior coronary arteriography. One hundred patients were admitted on the same day as their operations, and 75 patients, deemed to be at higher risk, were admitted 1 day before the operation. Postoperative progress of all patients was monitored by means of a clinical pathway form with physiologic and activity measures plotted against postoperative days. We found no difference in age, sex, or total number of comorbidity factors. Diabetes and ejection fraction less than 0.50 were significantly more common in preoperatively admitted patients and were independently predictive of admitting group. Significant differences between surgeons in the proportion of same-day patients admitted could not be explained by differences in common risk factors. There was no significant difference in postoperative major or minor complications or number of clinical pathway deviations, but two deaths occurred in patients admitted preoperatively. Average total hospital stay was 1 1/2 days less for same-day patients, a highly significant difference. Total hospital charges averaged $19,000 for the series and were $286 more for preoperatively admitted patients, a difference that was not statistically significant. Patients admitted selectively for same-day coronary bypass are not at risk for an increased number of complications. Although their hospital stay is reduced, the reduction of their hospital charges is minimal. Preoperative admission of patients with comorbidity requiring medical management or with physical incapacity remains justified, and admitting decisions should remain with the operating surgeon, not third parties.