title: Risk factor analysis for fast track protocol failure.
abstract: BACKGROUND
  The introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program.
  
  
  METHODS
  229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU.
  
  
  RESULTS
  Over the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36).
  
  
  CONCLUSIONS
  Re-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany. cardiac.surgeon@dr-kiessling.com
authors.forename: Arndt H
authors.initials: AH
authors.lastname: Kiessling
authors.forename: Patrick
authors.initials: P
authors.lastname: Huneke
authors.forename: Christian
authors.initials: C
authors.lastname: Reyher
authors.forename: Tobias
authors.initials: T
authors.lastname: Bingold
authors.forename: Andreas
authors.initials: A
authors.lastname: Zierer
authors.forename: Anton
authors.initials: A
authors.lastname: Moritz
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D005858:Germany; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009026:Mortality; D010359:Patient Readmission / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome