title: Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.
abstract: BACKGROUND
  Economics has caused the trend of early tracheal extubation after cardiac surgery, yet no prospective randomized study has directly validated that early tracheal extubation anesthetic management decreases costs when compared with late extubation after cardiac surgery.
  
  
  METHODS
  This prospective, randomized, controlled clinical trial was designed to evaluate the cost savings of early (1-6 h) versus late tracheal extubation (12-22 h) in patients after coronary artery bypass graft (CABG) surgery. The total cost for the services provided for each patient was determined for both the early and late groups from hospital admission to discharge home. All costs applicable to each of the services were classified into direct variables, direct fixed costs, and overhead (an indirect cost). Physician fees and heart catheterization costs were included. The total service cost was the sum of unit workload and overhead costs.
  
  
  RESULTS
  One hundred patients having elective CABG who were younger than 75 yr were studied. Including all complications, early extubation (n = 50) significantly reduced cardiovascular intensive care unit (CVICU) costs by 53% (P < 0.026) and the total CABG surgery cost by 25% (P < 0.019) when compared with late extubation (n = 50). Forty-one patients (82%) in each group were tracheally extubated within the defined period. In the early extubation group, the actual departmental cost savings in CVICU nursing and supplies was 23% (P < 0.005), in ward nursing and supplies was 11% (P < 0.05), and in respiratory therapy was 12% (P < 0.05). The total cost savings per patient having CABG was 9% (P < 0.001). Further cost savings using discharge criteria were 51% for CVICU nursing and supplies (P < 0.001), 9% for ward nursing and supplies (P < 0.05), and 29% for respiratory therapy (P < 0.001), for a total cost savings per patient of 13% (P < 0.001). Early extubation also reduced elective case cancellations (P < 0.002) without any increase in the number of postoperative complications and readmissions.
  
  
  CONCLUSIONS
  Early tracheal extubation anesthetic management reduces total costs per CABG surgery by 25%, predominantly in nursing and in CVICU costs. Early extubation reduces CVICU and hospital length of stay but does not increase the rate or costs of complications when compared with patients in the late extubation group. It shifts the high CVICU costs to the lower ward costs. Early extubation also improves resource use after cardiac surgery when compared with late extubation.
authors.affiliation: Department of Anesthesia, Toronto Hospital, University of Toronto, Ontario, Canada. 75147.1500@compuserve.com
authors.forename: D C
authors.initials: DC
authors.lastname: Cheng
authors.forename: J
authors.initials: J
authors.lastname: Karski
authors.forename: C
authors.initials: C
authors.lastname: Peniston
authors.forename: G
authors.initials: G
authors.lastname: Raveendran
authors.forename: B
authors.initials: B
authors.lastname: Asokumar
authors.forename: J
authors.initials: J
authors.lastname: Carroll
authors.forename: T
authors.initials: T
authors.lastname: David
authors.forename: A
authors.initials: A
authors.lastname: Sandler
mesh_terms: D000368:Aged; D000758:Anesthesia / Q000379:methods*; D001026:Coronary Artery Bypass / Q000191:economics*; D004180:Direct Service Costs; D005260:Female; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D007442:Intubation, Intratracheal / Q000191:economics*; D008297:Male; D011184:Postoperative Period; D011446:Prospective Studies; D013997:Time Factors