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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

doi: 10.1097/CCM.0b013e31827711ad
Clinical Investigations

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.

1Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.

2Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong.

Drs. Lee and Gomersall conceived the study. Dr. Lee designed the study, analyzed and interpreted the data, and drafted the manuscript. All authors participated in the study design and interpretation of the data. Dr. Zhu collected the data extracted from the electronic databases, checked and helped analyze the data. Drs. Zhu, Underwood, and Gomersall helped revised the manuscript. All authors read and approved the final manuscript.

This work was performed at the Department of Anaesthesia and Intensive Care and Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong.

Supported, in part, by institutional and departmental funding.

Part of this work was presented at the 11th Congress in Evidence-based Perioperative Medicine, London, United Kingdom, July 6-7, 2012.

The authors have not disclosed any potential conflicts of interest.

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