hfmsiw and CtiUcal Care Nursing ( 1994) 10,7 l-74 0 Longman Group UK Ltd 1994

Recovery units: the future of postoperative cardiac care

Debbie Massey and Glen Meggit

In the current climate of scarce financial resources health care managers have had to question the financial viability of a 36-hour stay in an ICU for patients undergoing cardiac surgery. The management of this group of patients has had to be reexamined. The solution to this problem appears to lie in the utilisation of a designated recovery area for the management of this group of patients.

This paper is an audit of the first 100 cardiac patients who recovered in such a designated recovery unit. The audit examines types of operations performed, average length of time patients required artificial ventilation, blood loss in the first 4 h, average length of stay in hospital, and postoperative complications.

Possible methods of improving the utilisation of a recovery area in the management of postoperative cardiac patients are discussed.

The conclusion is that utilisation of a designated recovery area for the immediate postoperative management of cardiac surgical patients is a financially viable alternative to an intensive care environment. More importantly, high quality service and care is maintained without increasing the utilisation of resources.

INTRODUCTION

In April 1992 Papworth Hospital opened a purpose built three-bedded recovery unit. Its purpose was two-fold. Primarily it was to be utilised as a designated recovery area for the majority of postoperative thoracic patients (with the obvious exception of those patients who would require overnight ventilation) for

Debbie Massey, ‘G’ Grade Sister, Cardiac Recovery Unit, John Radcliffe Hospital, Oxford, Glenn Meggit, Nursing Director, Critical Care, Papworth Hospital, Papworth, UK (Requests for offprints to DM) Manuscript accepted 24 November 1993 This paper was written while DM held the position of ‘F’ Grade Staff Nurse, Recovery Unit, Papworth Hospital.

example postoperative oesophagectomies or any thoracic case who had suffered a peri-operative insult. These patients were transferred directly to either the high dependency unit or, if neces- sary, to the intensive care unit (ICU). The recovery area staff were also responsible for care of a designated number of cardiac patients. These patients had to fulfil both pre- and peri- operative criteria (see Appendix 1).

In the past decade there has been a significant increase in the demands for cardiac surgery and the obvious benefits of successful myocardial revascularisation are well documented (Williams 1985). Cardiac surgery is an expensive specialty. The single factor that differentiates open-heart surgery from all other types of major surgery is the physiological effect of cardio-pulmonary bypass.

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Traditionally postoperative cardiac patients have occupied expensive intensive care beds for up to 36 h as a precaution, to help prevent the complications of cardio-pulmonary bypass and to counteract the effect of prolonged anaesthe- sia. The possible physical and psychological effects of the impact of ICUs on patients are well documented (Hudak, Gallo & Benz 1990). In the past the patient’s sex/age, underlying degree of cardiac disease, left ventricle function, length of time on bypass and peri-operative complications have not been considered in deciding the need for intensive care after cardiac surgery.

The average cost of an intensive care bed day at Papworth Hospital is approximately f480, excluding the cost of medical staff and blood/ blood products. Improvements in membrane technology utilised in cardio-pulmonary bypass and improvements in anaesthetic and surgical techniques have both dramatically reduced the length of time patients spend on cardiopulmo- nary bypass. The utilisation of the recovery unit in the management of postoperative cardiac patients appeared to be the ideal solution to meeting the ever-increasing demands on cardiac intensive care to provide more critical care beds.

Results The recovery unit was given a target of admit- ting for recovery 200 cardiac patients from April 1992 to April 1993. Analysis of data from the first 100 patients produced the following results. Between April 1992 and October 1992 84 men and 16 women had cardiac surgery and recov- ered in the recovery unit. the mean age was 54 years old. A summary of the operations per- formed can be seen in Table 1.

Table 1

Patients’ mean length of time artificially ventilated was 5.57 h, mean length of stay in the recovery unit 6.00 h, and mean length of stay in hospital 7.15 days.

Postoperative management After admission to the recovery unit all patients were weaned from ventilatory support as soon as possible once haemodynamic stability had been established and postoperative bleeding had ceased. When patients had regained conscious- ness and moved all limbs intermittent positive pressure ventilation was discontinued. Patients were connected to an O2 reservoir circuit, assess- ment of their respiratory status was determined by regular blood gas analysis. When satisfactory arterial blood gas results were obtained patients were extubated.

Postoperative bleeding The amount of postoperative bleeding was ass- essed and analysed, excessive bleeding is the most influential factor in patients returning to theatre. All patients who were returned to theatre were automatically transferred to the intensive care unit postoperatively. The amount of bleeding was determined by measuring the blood loss per hour in the first 4h postopera- tively (see Table 2).

Two patients were returned to theatre because of excessive bleeding. No obvious bleeding point was found in one patient, the other was bleeding from the left internal mammary artery.

Postoperative complications Any life-threatening complications were recorded and data were analysed. One patient

CABG CABG Type of operation CABG IAVR /AS0 AVR ASD Other

No. of patients 76 2 1 16 3 2

CABG = Coronary artery bypass grafts; AVR = Aottic valve replacement; ASD = Atrial septal defect.

INTENSIVE AND CRITICAL CARE NURSING 73

Table 2

Mean blood loss per h in first 4h

No. of patients

c5Omllh 50-15Omllh

26 53

>150ml/h

21

Table 3

Complications Atrial fibrillation Pyrexia

Wound infection

Nausea/ vomiting

Heart block

No. of patients 4 7 2 6 2

suffered cardiac arrest, was successfully resus- citated and transferred to the ICU. The patient made a complete recovery and was discharged 6 days after operation. One patient developed anaphylactic shock and was transferred to the ICU. The patient made a slow postoperative recovery and was still an inpatient 10 days after operation.

Information on less acute complications was obtained by visiting the patients 3 and 6 days postoperatively (see Table 3).

One patient suffered severe sternal wound infection. The organism isolated was Klebsielh, the patient was treated with intravenous anti- biotics, but was still an inpatient 10 days after operation.

DISCUSSION

Advances in anaesthetic, surgical, perfusion, and nursing techniques have resulted in improved postoperative outcomes. However, sadly attitudes towards postoperative care have not kept pace with these improvements.

The results of analysing data from Papworth recovery unit clearly beg the questions ‘Does modern cardiac surgery justify the expense of 2450 per day for an intensive care bed? Or can cost be substantially reduced without com- promising patient safety?’ The average cost of a recovery bed at Papworth is S 150 per day (10 h day). Previous studies have demonstrated that less than 7% of cardiac patients require intensive care following cardiac surgery (Chong 1992). It is my opinion that within the recovery unit at

Papworth many improvements could be intro- duced to maximise the obvious economic bene- fits of this system of caring for patients.

Primarily the selection criteria should be less selective (see Appendix). At present in accord- ance with this policy, age is a major determinant in selecting which patients are admitted to the recovery unit. However, age need not be an adverse factor as previous studies (Chong 1992) have demonstrated; 40% of the patients who recovered in the recovery unit were aged over 65 years.

Modification in the anaesthetic protocol would ensure early extubation and thus a rapid reduc- tion in dependency; this in itself has major clinical and economic effects. Early mobilisation and return to normal dietary intake have lead to shorter stay in hospital. Conventional intensive care after open-heart surgery at Papworth has always included elective postoperative venti- lation for long periods. This, along with occas- ional unnecessary use of sedatives, has led to delayed recovery time resulting in prolonged hospital stay.

It can be argued that in the light of these results greater economic rewards could be obtained by increasing utilisation of the recovery unit. This could be achieved by opening the recovery unit 24 h a day for 6 days a week, instead of 5 days a week for 10h a day. Admit- tedly, this would mean the cost of a recovery bed rising from f150.00 to S380.00 per day but this rise in cost could be offset by rapid turnover, thus allowing a single recovery bed to be used more than once in a 24 h period.

It also seems probable that in view of the

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United Kingdom Central Council (UKCC) Scope of Professional Practice document (1992) nurses within the ward area would be prepared to take on new skills and more expanded roles thus facilitating swifter transfer of patients from the critical care area to the ward environment.

Perhaps this is the future of postoperative cardiac care, ensuring provision of a safe environment for patients’ recovery but at the same time preventing the waste of expensive resources.

References Williams A 1985 Economics of coronary artery bypass

grafting. British Medical Journal 29 I : 326329 Hudak C M, Gallo B M, Benz J J 1990 Critical care

nursing. Lippincott, Philadelphia, pp 26-50 Chong J L 1992 Cardiac surgery moving away from

intensive care. British Heart Journal 68: 430-433 UKCC 1992 The scope of professional practice. United

Kingdom Central Council for Nursing, Midwifery and Health Visiting, London.

APPENDIX

Protocol for cardiac recovery patients Pre-operative criteria:

* Aged less than 70 years. * Normal left ventricular function. * No serious pre-existing lung disease. * Normal renal function. * Normal liver function. * No past history of cerebra-vascular accident. * No recent myocardial infarction within past 6

months. * No drug, alcohol abuse or psychiatric history. * No current infection.

* No gross obesity (not over 20% of ideal body weight: see normogram).

* No insulin controlled diabetes. * No pulmonary hypertension (PA mean less

than 40mmHg).

Peri-operative criteria:

Patient should be 1st on the operating list and arrive in the Recovery Unit no later than 13.00h. Bypass time less than IOOmin. No peri-operative critical event. Apparently adequate haemostasis. Pa02 > 12Kpa, PaC02 < 7 Kpa, MAP > 55mmHg.

On any day where there is a thoracic surgical list only, one recovery bed will be available for cardiac recovery. On days when there is no thoracicsurgical listtwo bedswill beavailablefor suitable patients.

Patients for the cardiac recovery route for the following week will be identified at the Thursday 09.30 Anaesthetic Meeting in the anaesthetic library attended by the senior surgical registrar or deputy, senior anaesthetic registrar or deputy, recovery nurse, service manager, senior prin- cipal operating department assistant (ODA) and perfusion representative.

Patients will be identified for the following week and the respective consultant surgeon and consultant anaesthetist informed on the evening before operation by the junior doctor.

The cardiac recovery route must not go ahead without the agreement of the consultant surgeon and consultant anaesthetist.

Patients not selected pre-operatively can be included in the cardiac recovery programme providing they meet the peri-operative criteria and both consultant surgeon and consultant anaesthetist are in agreement.