title: Fast-tracking revisited: routine cardiac surgical patients need minimal intensive care.
abstract: OBJECTIVE
  Following cardiac surgery, patients are transferred from the operating theatre to intensive care. This clinical environment has one nurse per patient and facilities for mechanical ventilation. Patients are kept in this setting until the following day. This practice has been challenged with early extubation of patients. At our institution we have established a fast-track policy including the following features: (1) patient selection; (2) operating list scheduling with fast-track patients first; (3) anaesthetic tailored to early extubation; (4) methodical procedure with warm cardiopulmonary bypass; (5) removal of the arterial line; (6) transfer from intensive care to a separate high dependency unit ('step-down') on the day of operation, where the ratio of nurse to patient is one to three and there are no ventilatory facilities and no invasive monitoring; or (7) to keep these patients on ICU but decrease the nurse to patient ratio.
  
  
  METHODS
  The case notes of 572 patients who predominantly had myocardial revascularisation, undergoing this process from July 1996 to July 2000 at our institution were reviewed.
  
  
  RESULTS
  Mean EUROSCORE for the study group was 1.42. The 30-day mortality rate for the study group was 0.34%, mean intensive care time was 5 h 52 min, mean time to extubation was 3 h 10 min, mean readmission rate to intensive care was 0.34% and mean hospital stay from day of operation (inclusive) was 5.65 days. This process increased our throughput by 14.6% (compared to standard practices).
  
  
  CONCLUSIONS
  This study demonstrates that transfer of appropriate patients to a high dependency area from intensive care following cardiac surgery is safe. It allows intensive care beds to be used by more than one patient each day and allows significant cost savings by reducing the nursing ratio per patient.
authors.affiliation: Department of Cardiothoracic Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK. barradrum@hotmail.com
authors.forename: M
authors.initials: M
authors.lastname: Flynn
authors.forename: S
authors.initials: S
authors.lastname: Reddy
authors.forename: W
authors.initials: W
authors.lastname: Shepherd
authors.forename: C
authors.initials: C
authors.lastname: Holmes
authors.forename: D
authors.initials: D
authors.lastname: Armstrong
authors.forename: C
authors.initials: C
authors.lastname: Lunn
authors.forename: K
authors.initials: K
authors.lastname: Khan
authors.forename: S
authors.initials: S
authors.lastname: Kendall
mesh_terms: D000328:Adult; D000368:Aged; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality; D003422:Critical Care / Q000458:organization & administration*; D005260:Female; D006305:Health Status Indicators; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009204:Myocardial Revascularization; D011182:Postoperative Care; D011379:Prognosis; D018570:Risk Assessment