Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis

doi:10.1016/S0090-3019(03)00517-2

Surgical Neurology

Volume 60, Issue 6, December 2003, Pages 483-489

https://doi.org/10.1016/S0090-3019(03)00517-2 Get rights and content

Abstract

Objective

Postoperative monitoring in an intensive care unit (ICU) setting following elective craniotomy is routine at many institutions, as it is believed that this reduces the incidence and potential seriousness of early postoperative complications. This is unproven, however, and ICU resources are scarce and costly. At our institution, one surgeon began to routinely transfer elective craniotomy patients directly to the floor following an uneventful postanesthesia care unit (PACU) recovery. This study was undertaken to see whether that practice was safe and cost-effective.

Methods

A retrospective cohort of 430 consecutive, elective adult craniotomies, from February, 2000 to September, 2001 were analyzed. Variables were divided into 12 major groups: attending surgeon, age, sex, diagnosis, Current Procedural Terminology (CPT) code, length of stay, preoperative deficit, medical co-morbidities, postop floor, medical complications, neurological complications, and total hospitalization cost.

Results

Patients admitted to the surgical intensive care unit (SICU) did not have fewer complications than patients transferred directly to the floor. Patients admitted to the SICU did not have more preoperative neurological deficits or medical co-morbidities. Age was not a significant predictor of either medical or neurological complications. In patients without initial postop complications, only length of stay and postop floor assignment correlated with cost (p < 0.001). Immediate transfer to the floor decreased average hospitalization length by 3 days, and provided cost savings of $4,026 per patient.

Conclusions

Selective, rather than routine use of postoperative ICU care in elective craniotomy patients is safe, resulting in no greater incidence of medical or neurological complications, and may provide significant reductions in average hospitalization length and cost.

Section snippets

Methods

A retrospective cohort of all consecutive, elective adult craniotomies for brain tumor, pituitary adenoma, trigeminal neuralgia, hemifacial spasm, and Chiari malformation performed at our institution from February 2000 to September 2001 was analyzed. Craniotomies for aneurysm, AVM, or epilepsy were excluded, as specific faculty members (other than WAF) perform the majority of these procedures, and these faculty consistently sent their patients only to the SICU postoperatively. A total of 430

Results

A total of 429 patients were analyzed; 1 patient was dropped from the analysis because of a lack of clinical information. Demographics are summarized in Table 2 . Statistical analysis did not disclose a difference in preoperative medical (p < 0.77) or neurological (p < 0.43) morbidities between those groups of patients admitted to the floor or to the ICU postop. Using very rigorous definitions of complications, there were 69 (16%) medical and 94 (22%) neurological complications (see Table 3).

Discussion

Since the 1970s, medical economists have analyzed the “cost-effectiveness” of common medical practices 7, 24. With increasing limits on medical resources, it is increasingly important to identify not only the practice which produces the best “evidence-based” result, but to choose amongst a variety of equally effective interventions those that are the least expensive [18]. As discussed below, surgeons and neurosurgeons have more recently become involved in this type of analysis [21].

Over the

Conclusions

1.
In this analysis of 430 consecutive elective craniotomies, immediate transfer of uncomplicated patients to the hospital floor did not result in an increased complication rate. Only 2 patients required return to the ICU and their ultimate outcomes were good.
2.
Immediate transfer to the hospital floor resulted in a decreased length of hospitalization and a substantial cost savings.
3.
Selective, rather than routine use of the ICU for uncomplicated postoperative elective craniotomies may be a

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The mean hospital stay duration and the operation time were significantly longer in the ICU requirement group than in the no ICU requirement group (9.9 ± 10.7 vs. 6.3 ± 3.7 days, p = 0.041), (259.9 ± 128.4 vs. 210.5 ± 46.1 min, p = 0.019). The transfusion rate was significantly higher (p = 0.024) in the ICU requirement group. Multivariable logistic regression analysis identified male sex (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.15–4.76; p = 0.0195), operation time (OR, 1.01; 95% CI, 1.00–1.01; p = 0.0022), and transfusion (OR, 2.35; 95% CI, 1.00–5.51; p = 0.0500) as independent risk factors for requiring ICU care after clipping.
Postoperative ICU management may not be mandatory after clipping surgery for UIAs. Our results suggest that postoperative ICU management may be more required in the male sex, patients with longer operation times, and those who received a transfusion.
Perioperative Risk Factors Associated with Unplanned Neurological Intensive Care Unit Events Following Elective Infratentorial Brain Tumor Resection
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Citation Excerpt :
However, it is unclear whether routine postoperative NICU admission improves outcomes following craniotomies for tumor resection; only a small proportion of postoperative elective craniotomy patients require medical interventions in the NICU. A study on elective craniotomies suggested that eschewing NICU postsurgical observation was associated with no additional complications and a shorter hospital stay and was more cost-effective.3 Therefore, it is arguable whether such patients should necessarily be sent to the NICU.
Our aim of this study was to identify risk factors and develop a prediction model for unplanned neurological intensive care unit (NICU) events after elective infratentorial brain tumor resection in order to propose an individualized admission to the NICU tailored to patient needs.
Patients admitted to our NICU between September 2018 and May 2021 after elective infratentorial brain tumor resection were reviewed. Prolonged NICU stays and unplanned NICU admissions were defined as unplanned NICU events. The prognostic model of unplanned NICU events was developed using a forward stepwise logistic regression analysis, and external validation was evaluated. The C-statistic was used to assess discrimination, and a smooth, nonparametric calibration line was used to assess calibration graphically in the model.
Of the 1,710 patients in the development cohort, unplanned NICU events occurred in 162 (9.5%). Based on the lesion type, a Karnofsky Performance Status score <70 at admission, longer duration of surgery, bleeding in the operative area evident on postoperative computed tomography, higher fibrinogen and blood glucose levels at admission, and more intraoperative blood loss were independently associated with unplanned NICU events. The external validation test showed good discrimination (C-statistic = 0.811) and calibration (Hosmer-Lemeshow P = 0.141) for unplanned NICU events.
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Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series
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No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost.
In 2018–2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated.
Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of –8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016.
These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.
Perioperative risk factors associated with ICU intervention following select neurosurgical procedures
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What warrants ICU level of care is often a fluid process. Several articles have evaluated guidelines for admission criteria to help optimize patient care in both general and neurological ICUs [2–14]. Retrospective studies have revealed circumstances in which the length of hospital stay and clinical outcomes can be predicted following select neurosurgical interventions [15].
Following cranial neurosurgical procedures, intensive care unit (ICU) admission is routine; however, our institution’s growing referral network has led to more frequent bed shortages. Consequently, there are increased requests to transfer our postoperative patients out of the ICU early in the monitoring window. We aimed to find risk factors to prioritize which postoperative neurosurgical patients that should remain in the unit.
An unmatched case-control study was conducted following retrospective chart review of patients who underwent common cranial procedures between August 2015 and June 2016 at our institution. Patients receiving postoperative ICU intervention were defined as cases. Several perioperative events were investigated for association with postoperative ICU level care. Individual risk factors were analyzed using Chi-squared tests for categorical variables (reported as odds ratio) and independent sample two tailed t-tests for continuous variables. Regression models were used for multivariate analysis.
We identified 282 patients who met inclusion criteria, with 148 cases and 134 controls and no statistically significant differences between group demographics. Elective cases carried an odds ratio (OR 0.12, 95 % CI 0.05-0.26, p < 0.001), suggesting decreased likelihood of postoperative intensivist intervention. Single variable analysis showed ICU level of care was more more likely with general anesthesia (OR 3.72, 95 % CI 1.90–7.25, p < 0.001) and American Society of Anesthesiologists (ASA) class IV patients (OR 3.28, 95 % CI 1.59–6.78, p < 0.001). Continuous variables (blood loss and operative time) both demonstrated statistically significant differences (p < 0.001) between case and control groups with higher blood loss (100 ± 167 mL) and operative times (245 ± 119 min) seen in the ICU intervention group. Our regression model identified non-elective cases, operative time, and blood loss having associations with postoperative intensivist intervention.
Growing demand for ICU beds at our institution has us looking for more objective data guiding decisions on lower-risk patients who could transfer early out of the ICU in times of overcapacity. Elective endovascular aneurysm treatment and DBS are cranial procedures least likely to receive postoperative ICU level intervention. Consideration to procedural blood loss of 100 cc or more and operative time greater than 4 h should also be given as these risk factors were associated with more likely needing postoperative ICU intervention. These results should not spur drastic changes in ICU protocols, but continued quality improvement projects should investigate these correlations to add more objective data for ICU utilization.
Postoperative circuits in patients undergoing elective craniotomy. A narrative review
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En 2017 la sección de Neurociencias de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor publicó una encuesta nacional sobre los circuitos de atención y tratamiento postoperatorio en neurocirugía. La encuesta evidenció una gran heterogeneidad de respuestas en función del centro, el anestesiólogo y la afección del paciente. En la actualidad, no disponemos de un estándar de circuito postoperatorio y existe evidencia suficiente para no indicar de forma rutinaria el ingreso en Unidades de Cuidados Críticos Postquirúrgicos a todos los pacientes intervenidos de craneotomía programada. El objetivo de este estudio es hacer una revisión narrativa de los circuitos postoperatorios en la craneotomía programada, para intentar homogeneizar nuestra práctica clínica a la luz de los estudios publicados. Se ha hecho una revisión bibliográfica de los últimos diez años, fecha de actualización noviembre 2019, utilizando las palabras clave neurosurgery and postoperative care y craniotomy and postoperative care en MEDLINE (PubMed).
In 2017, the Neurosciences section of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy published a national survey on postoperative care and treatment circuits in neurosurgery. The survey showed that practices vary widely, depending on the centre, the anaesthesiologist and the pathology of the patient. There is currently no standard postoperative circuit for cranial neurosurgical procedures in Spanish hospitals, and there is sufficient evidence to show that not all patients undergoing elective craniotomy should be routinely admitted to a postsurgical critical care unit. The aim of this study is to perform a narrative review of postoperative circuits in elective craniotomy in order to standardise clinical practice in the light of published studies. For this purpose, we searched MEDLINE (PubMed) to retrieve studies published in the last ten years, up to November 2019, using the keywords neurosurgery and postoperative care, craniotomy and postoperative care.
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SocioeconomicRoutine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Am J Surg

J Chronic Dis

J Chron Dis

Surgery

Neurosurgical Clinics of North America

Surg Neurol

Chest

New classification of physical status

Anesthesiology

The role of anaesthesia in surgical mortality

JAMA

Multifactorial index of cardiac risk in noncardiac surgical procedures

N Engl J Med

A computer protocol to predict myocardial infarction in emergency department patients with chest pain

N Engl J Med

Socioeconomic
Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis