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Critical Care Medicine:
doi: 10.1097/CCM.0b013e31827711ad
Clinical Investigations

Fast-Track Failure After Cardiac Surgery: External Model Validation and Implications to ICU Bed Utilization

Lee, Anna PhD, MPH1; Zhu, Fang MMed1; Underwood, Malcolm John MD, FRCS(CTh)2; Gomersall, Charles David FCICM, MBBS1

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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.

Design: Prospective cohort study.

Setting: Cardiothoracic Surgery Department and Intensive Care Unit of Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.

Patients: 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).

Interventions: 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.

Measurements and Main 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.

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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