title: Fast-track failure after cardiac surgery: external model validation and implications to ICU bed utilization.
abstract: OBJECTIVE
  To facilitate the planning of perioperative care pathways, a fast-track failure prediction model has been developed in patients undergoing cardiac surgery. This study externally validated such a fast-track failure risk prediction model and determined the potential clinical consequences to ICU bed utilization.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Cardiothoracic Surgery Department and Intensive Care Unit of Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
  
  
  METHODS
  The St. Mary's Hospital fast-track failure risk prediction model was applied to patients included in an adult cardiac surgery database (January 2006 to June 2011).
  
  
  METHODS
  The performance of the fast-track failure risk model was assessed by discrimination and calibration methods. The potential clinical consequences of applying the model on ICU bed utilization was assessed using a decision curve analysis.
  
  
  RESULTS
  Of the 1,597 patients, 175 (11%) failed fast-track management. The final updated model showed very good discrimination (area under the receiver operating characteristic curve = 0.82, 95% confidence interval 0.78-0.86) and adequate calibration (Hosmer-Lemeshow goodness-of-fit statistic, p = 0.80). A decision curve analysis showed that if a threshold probability range of fast-track failure of 5% to 20% is used to determine who should be electively admitted to the ICU and who should be admitted to a fast-track recovery unit, it would lead to a substantial benefit (23%-67%) in terms of effective bed utilization, even after taking into account the negative consequences of unplanned admissions.
  
  
  CONCLUSIONS
  As the performance of the final updated fast-track failure model was very good, it can be used to estimate the predicted probability of fast-track failure on individual patients. The clinical consequence of applying the final model appears substantial with regard to the potential increase in effective ICU bed utilization.
authors: Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong. annalee@cuhk.edu.hk
authors: Anna
authors: A
authors: Lee
authors: Fang
authors: F
authors: Zhu
authors: Malcolm John
authors: MJ
authors: Underwood
authors: Charles David
authors: CD
authors: Gomersall
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods / Q000706:statistics & numerical data*; D015331:Cohort Studies; D019091:Critical Pathways; D005260:Female; D006723:Hong Kong; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012308:Risk Management; D017211:Treatment Failure