Arch Gynecol Obstet DOI 10.1007/s00404-014-3180-1
Gynecologic Oncology
Gynecologic oncology patients in the surgical high dependency unit: an analysis of indications Nikolaos Thomakos · Dimitrios Zacharakis · Alexandros Rodolakis · Flora Zagouri · Christos A. Papadimitriou · Aristotle Bamias · Meletios‑Athanassios Dimopoulos · Dimitrios Haidopoulos · Georgios Vlahos · Aris Antsaklis
Received: 16 April 2013 / Accepted: 6 February 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The establishment of high dependency units (HDUs) has been an undoubted advance in the management of patients undergoing major oncological procedures. The aim of this study was to examine the impact of various preoperative and perioperative patients’ characteristics on the prolonged HDU stay. Methods We conducted a retrospective study including all gynecologic oncology patients who underwent surgical management and were admitted postoperatively to our hospitals’ HDU from 2006 to 2010. Results A total of 1,014 patients were transferred to the HDU and divided into two groups according to the length of HDU stay. Group A consisted of 840 (82.8 %) patients who stayed in the HDU for ≤24 h and Group B included 174 (17.2 %) patients who remained in the HDU under close observation for >24 h. Older age was the only preoperative characteristic that remained significantly associated with HDU prolonged stay. In addition, three intraoperative factors such as use of invasive hemodynamic monitoring, bowel resection and estimated blood loss were proved to be independently associated with prolonged HDU stay.
N. Thomakos · D. Zacharakis · A. Rodolakis · D. Haidopoulos · G. Vlahos · A. Antsaklis Department of Obstetrics and Gynaecology, Alexandra Hospital, Medical School, University of Athens, Athens, Greece F. Zagouri (*) · C. A. Papadimitriou · A. Bamias · M.-A. Dimopoulos Department of Clinical Therapeutics, Alexandra Hospital, Medical School, University of Athens, Vas Sofias Ave and Lourou Str, 11521 Athens, Greece e-mail: [email protected]
Conclusion Certain characteristics could identify those patients who are more likely to benefit most from HDU admission. Keywords Gynecology oncology · High dependency units · Indications
Introduction Complex gynecologic oncology surgical procedures for diagnostic and therapeutic indications such as surgical staging or cytoreductive procedures may lead to significant morbidity [1]. In particular, patients with ovarian cancer undergo extensive surgery in order to achieve minimal residual disease. Furthermore, women undergoing radical hysterectomy for cervical cancer or patients with endometrial cancer or sarcomas frequently experience significant morbidity due to long operating time and significant blood loss. It is well recognized nowadays that for successful running of a surgical unit, it is imperative that postoperative care be optimized [2]. During the past two decades we have witnessed a significant change in the management of patients undergoing major oncological procedures. The establishment of high dependency units (HDUs) has been an undoubted advance, but not all surgical patients can be cared for there and in any event patient care in HDU often remains a responsibility of the surgical team [2]. The HDU has been variously defined in the literature. The association of Anesthetists of Great Britain and Ireland define HDU as ‘an area for patients who require more intensive observation, treatment and nursing care than can be provided on a general ward. It would not normally accept patients requiring mechanical ventilation,
13
but could manage those receiving invasive monitoring’ [3]. The challenge for all gynecologists (junior and senior staff) who deal with patients that may become critically ill is to identify and correct complications at the earliest stage and patients’ assessment in the HDU often gives this opportunity. Given the increase in health care spending in recent decades, numerous researchers have focused their attention on reducing the costs of treating cancer in general and the proper use of postsurgical critical care units specifically [1, 4–6]. HDU involves expensive technology and high-level nursing, so the actual savings from avoiding unnecessary admissions would be significantly greater than the amount calculated solely on the cost of a room. Aim of this study is to examine the impact of various preoperative and perioperative patients’ characteristics on the prolonged HDU stay. The question is whether patients admitted in the HDU for >24 h have different preoperative clinical conditions or intraoperative management compared with patients admitted for ≤24 h and if patients discharged to the gynecologic oncology ward on the first postoperative day need an HDU admission for receiving an adequate postsurgical care. In order to meet our goal we tried to develop a profile of preoperative and perioperative patients’ characteristics that would enable gynecologic oncologists to timely identify those patients who are more likely to benefit most from HDU admission.
Materials and methods Our institution is a tertiary care teaching hospital dealing with all kinds of gynecological and obstetrical care including major gynecological oncology surgery. About 30 % of the gynecologic procedures performed in our hospital are transfers from the rest of the country, mainly because our center is an ESGO approved Gynecologic Oncology referral institution. Our hospital has 24-hour on-site consultants in gynecology, anesthesia and intensive care. Laboratory, blood bank, hematology and radiology facilities are also available in the hospital. Ethical approval for this study was obtained from the Hospitals Health Ethics Committee. We retrospectively reviewed all gynecologic oncology patients that underwent surgical evaluation and management and were admitted postoperatively to our hospitals’ HDU from January 2006 to December 2010. All data were collected from HDU charts and the patient data system of the hospital. Patient evaluation for admission in the HDU was determined by the severity of illness, concomitant disease processes, need for pain control and the complexity of the surgical procedure. Selected patients undergoing cancer surgery were monitored in the HDU for the first or as needed postoperative
13
Arch Gynecol Obstet
days, and if stable were transferred to the ward for further postoperative care. Patients’ characteristics such as age, body mass index (BMI), medical history-prior medical condition, oncologic underlying disease process, type of surgery, estimated blood loss (EBL), duration of surgery, need for invasive hemodynamic monitoring (central venous line–arterial line), indications for HDU admission, length of HDU stay and need for ICU support were recorded. Patients were mainly classified into two groups according to the length of HDU stay. Length of stay in HDU is a very important index for hospitals as it is a major contributor to the overall cost of care. It seemed prudent to audit the postsurgical management of gynecologic oncology patients in order to avoid unnecessary admissions in the HDU, enabling resources to be used effectively. Identification of preoperative and perioperative patients’ characteristics with prolonged HDU stay may be the key issue for HDU admissions reduction, without increasing the complications and mortality rate. Statistical analysis Continuous variables are presented with mean and standard deviation (SD) or median and interquartile range (IQR), while quantitative variables are presented with absolute and relative frequencies. For the comparisons of proportions, Chi-square and Fisher’s exact tests were used. Student’s t tests were computed for the comparison of mean values. In order to find independent factors associated with prolonged HDU stay a stepwise multiple logistic regression analysis (p for removal was set at 0.1 and p for entry was set at 0.5) was conducted with dependent the variables presented HDU length of stay. Adjusted odds ratios with 95 % confidence intervals were computed from the results of the logistic regression analyses. Model diagnostics were evaluated using the Hosmer and Lemeshow statistic. All p values reported are two tailed. Statistical significance was set at 0.05 and analyses were conducted using SPSS statistical software (version 17.0).
Results A chart review yielded 1,823 gynecological oncology patients who had undergone surgical management during the study period. A total of 1,014 (55.62 %) patients were admitted to the HDU and were divided into two groups according to the length of HDU stay. Group A consisted of 840 (82.8 %) patients admitted to the HDU for ≤24 h and discharged to the gynecologic oncology ward on the first postoperative day. Group B consisted of 174 (17.2 %) patients, who remained in the HDU under close observation
Arch Gynecol Obstet
for >24 h. The HDU length of stay had mean equal to 1.3 days (SD = 1.0 day) and median equal to 1 day (IQR 1–1) with range 1 to 21 days. Comparison of preoperative and perioperative factors between the two study groups (Table 1) demonstrated that patients who had a prolonged HDU stay were older, required more often use of invasive hemodynamic monitoring (central venous line–arterial line), while surgical Table 1 Patients’ preoperative and perioperative characteristics
‡
Chi-square test
* Fisher’s exact test ** Student’s t test
procedures included frequently bowel resection or systematic lymph node dissection. In addition, the operation room time (p = 0.003) and the estimated blood loss (EBL) (p 24 h (Group B)
N (%)
N (%)
Age (years) 60.8 (15.4) 64.5 (14.6) 24.9 (4.8) 25.2 (5.1) BMI (kg/m2) Menopausal status Pre 198 (23.6) 30 (17.2) Post 642 (76.4) 144 (82.8) Diagnosis Uterine sarcomas 9 (1.1) 0 (0) Vulvar cancer 96 (11.4) 17 (9.8) Endometrial cancer 287 (34.2) 51 (29.3) Surgical complication 10 (1.2) 8 (4.6) Vaginal cancer 4 (0.5) 0 (0) Fallopian tubes cancer 2 (0.2) 0 (0) Cervical cancer 158 (18.8) 15 (8.6) Ovarian cancer 274 (32.6) 83 (47.7) Indications for HDU admission Hemodynamic monitoring 380 (45.2) 57 (32.8) Respiratory disease 30 (3.6) 10 (5.7) Cardiovascular disease 366 (43.6) 97 (55.7) Metabolic disorder 40 (4.8) 3 (1.7) Neurological disorder 13 (1.5) 2 (1.1) Renal insufficiency 11 (1.3) 5 (2.9) Invasive hemodynamic monitoring (central venous line–arterial line) No 765 (91.1) 115 (66.1) Yes 75 (8.9) 59 (33.9) Splenectomy No 835 (99.4) 171 (98.3) Yes 5 (0.6) 3 (1.7) Bowel resection No 801 (95.4) 146 (83.9) Yes 39 (4.6) 28 (16.1) Lymph node dissection No 397 (47.3) 121 (69.5) Yes 443 (52.7) 53 (30.5) ICU support No 833 (99.2) 160 (92) Yes 7 (0.8) 14 (8) Operating room time (min) 158.2 (42.4) 168.8 (46.6) Estimated blood loss (ml)
1,090.4 (678.1)
1,763.8 (862.1)
p χ2 test
0.003** 0.458** 0.069‡
0.372* 0.527‡ 0.216‡ 0.006* >0.999* >0.999* 0.001‡ 0.999* 0.171*
Gynecologic Oncology
Gynecologic oncology patients in the surgical high dependency unit: an analysis of indications Nikolaos Thomakos · Dimitrios Zacharakis · Alexandros Rodolakis · Flora Zagouri · Christos A. Papadimitriou · Aristotle Bamias · Meletios‑Athanassios Dimopoulos · Dimitrios Haidopoulos · Georgios Vlahos · Aris Antsaklis
Received: 16 April 2013 / Accepted: 6 February 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The establishment of high dependency units (HDUs) has been an undoubted advance in the management of patients undergoing major oncological procedures. The aim of this study was to examine the impact of various preoperative and perioperative patients’ characteristics on the prolonged HDU stay. Methods We conducted a retrospective study including all gynecologic oncology patients who underwent surgical management and were admitted postoperatively to our hospitals’ HDU from 2006 to 2010. Results A total of 1,014 patients were transferred to the HDU and divided into two groups according to the length of HDU stay. Group A consisted of 840 (82.8 %) patients who stayed in the HDU for ≤24 h and Group B included 174 (17.2 %) patients who remained in the HDU under close observation for >24 h. Older age was the only preoperative characteristic that remained significantly associated with HDU prolonged stay. In addition, three intraoperative factors such as use of invasive hemodynamic monitoring, bowel resection and estimated blood loss were proved to be independently associated with prolonged HDU stay.
N. Thomakos · D. Zacharakis · A. Rodolakis · D. Haidopoulos · G. Vlahos · A. Antsaklis Department of Obstetrics and Gynaecology, Alexandra Hospital, Medical School, University of Athens, Athens, Greece F. Zagouri (*) · C. A. Papadimitriou · A. Bamias · M.-A. Dimopoulos Department of Clinical Therapeutics, Alexandra Hospital, Medical School, University of Athens, Vas Sofias Ave and Lourou Str, 11521 Athens, Greece e-mail: [email protected]
Conclusion Certain characteristics could identify those patients who are more likely to benefit most from HDU admission. Keywords Gynecology oncology · High dependency units · Indications
Introduction Complex gynecologic oncology surgical procedures for diagnostic and therapeutic indications such as surgical staging or cytoreductive procedures may lead to significant morbidity [1]. In particular, patients with ovarian cancer undergo extensive surgery in order to achieve minimal residual disease. Furthermore, women undergoing radical hysterectomy for cervical cancer or patients with endometrial cancer or sarcomas frequently experience significant morbidity due to long operating time and significant blood loss. It is well recognized nowadays that for successful running of a surgical unit, it is imperative that postoperative care be optimized [2]. During the past two decades we have witnessed a significant change in the management of patients undergoing major oncological procedures. The establishment of high dependency units (HDUs) has been an undoubted advance, but not all surgical patients can be cared for there and in any event patient care in HDU often remains a responsibility of the surgical team [2]. The HDU has been variously defined in the literature. The association of Anesthetists of Great Britain and Ireland define HDU as ‘an area for patients who require more intensive observation, treatment and nursing care than can be provided on a general ward. It would not normally accept patients requiring mechanical ventilation,
13
but could manage those receiving invasive monitoring’ [3]. The challenge for all gynecologists (junior and senior staff) who deal with patients that may become critically ill is to identify and correct complications at the earliest stage and patients’ assessment in the HDU often gives this opportunity. Given the increase in health care spending in recent decades, numerous researchers have focused their attention on reducing the costs of treating cancer in general and the proper use of postsurgical critical care units specifically [1, 4–6]. HDU involves expensive technology and high-level nursing, so the actual savings from avoiding unnecessary admissions would be significantly greater than the amount calculated solely on the cost of a room. Aim of this study is to examine the impact of various preoperative and perioperative patients’ characteristics on the prolonged HDU stay. The question is whether patients admitted in the HDU for >24 h have different preoperative clinical conditions or intraoperative management compared with patients admitted for ≤24 h and if patients discharged to the gynecologic oncology ward on the first postoperative day need an HDU admission for receiving an adequate postsurgical care. In order to meet our goal we tried to develop a profile of preoperative and perioperative patients’ characteristics that would enable gynecologic oncologists to timely identify those patients who are more likely to benefit most from HDU admission.
Materials and methods Our institution is a tertiary care teaching hospital dealing with all kinds of gynecological and obstetrical care including major gynecological oncology surgery. About 30 % of the gynecologic procedures performed in our hospital are transfers from the rest of the country, mainly because our center is an ESGO approved Gynecologic Oncology referral institution. Our hospital has 24-hour on-site consultants in gynecology, anesthesia and intensive care. Laboratory, blood bank, hematology and radiology facilities are also available in the hospital. Ethical approval for this study was obtained from the Hospitals Health Ethics Committee. We retrospectively reviewed all gynecologic oncology patients that underwent surgical evaluation and management and were admitted postoperatively to our hospitals’ HDU from January 2006 to December 2010. All data were collected from HDU charts and the patient data system of the hospital. Patient evaluation for admission in the HDU was determined by the severity of illness, concomitant disease processes, need for pain control and the complexity of the surgical procedure. Selected patients undergoing cancer surgery were monitored in the HDU for the first or as needed postoperative
13
Arch Gynecol Obstet
days, and if stable were transferred to the ward for further postoperative care. Patients’ characteristics such as age, body mass index (BMI), medical history-prior medical condition, oncologic underlying disease process, type of surgery, estimated blood loss (EBL), duration of surgery, need for invasive hemodynamic monitoring (central venous line–arterial line), indications for HDU admission, length of HDU stay and need for ICU support were recorded. Patients were mainly classified into two groups according to the length of HDU stay. Length of stay in HDU is a very important index for hospitals as it is a major contributor to the overall cost of care. It seemed prudent to audit the postsurgical management of gynecologic oncology patients in order to avoid unnecessary admissions in the HDU, enabling resources to be used effectively. Identification of preoperative and perioperative patients’ characteristics with prolonged HDU stay may be the key issue for HDU admissions reduction, without increasing the complications and mortality rate. Statistical analysis Continuous variables are presented with mean and standard deviation (SD) or median and interquartile range (IQR), while quantitative variables are presented with absolute and relative frequencies. For the comparisons of proportions, Chi-square and Fisher’s exact tests were used. Student’s t tests were computed for the comparison of mean values. In order to find independent factors associated with prolonged HDU stay a stepwise multiple logistic regression analysis (p for removal was set at 0.1 and p for entry was set at 0.5) was conducted with dependent the variables presented HDU length of stay. Adjusted odds ratios with 95 % confidence intervals were computed from the results of the logistic regression analyses. Model diagnostics were evaluated using the Hosmer and Lemeshow statistic. All p values reported are two tailed. Statistical significance was set at 0.05 and analyses were conducted using SPSS statistical software (version 17.0).
Results A chart review yielded 1,823 gynecological oncology patients who had undergone surgical management during the study period. A total of 1,014 (55.62 %) patients were admitted to the HDU and were divided into two groups according to the length of HDU stay. Group A consisted of 840 (82.8 %) patients admitted to the HDU for ≤24 h and discharged to the gynecologic oncology ward on the first postoperative day. Group B consisted of 174 (17.2 %) patients, who remained in the HDU under close observation
Arch Gynecol Obstet
for >24 h. The HDU length of stay had mean equal to 1.3 days (SD = 1.0 day) and median equal to 1 day (IQR 1–1) with range 1 to 21 days. Comparison of preoperative and perioperative factors between the two study groups (Table 1) demonstrated that patients who had a prolonged HDU stay were older, required more often use of invasive hemodynamic monitoring (central venous line–arterial line), while surgical Table 1 Patients’ preoperative and perioperative characteristics
‡
Chi-square test
* Fisher’s exact test ** Student’s t test
procedures included frequently bowel resection or systematic lymph node dissection. In addition, the operation room time (p = 0.003) and the estimated blood loss (EBL) (p 24 h (Group B)
N (%)
N (%)
Age (years) 60.8 (15.4) 64.5 (14.6) 24.9 (4.8) 25.2 (5.1) BMI (kg/m2) Menopausal status Pre 198 (23.6) 30 (17.2) Post 642 (76.4) 144 (82.8) Diagnosis Uterine sarcomas 9 (1.1) 0 (0) Vulvar cancer 96 (11.4) 17 (9.8) Endometrial cancer 287 (34.2) 51 (29.3) Surgical complication 10 (1.2) 8 (4.6) Vaginal cancer 4 (0.5) 0 (0) Fallopian tubes cancer 2 (0.2) 0 (0) Cervical cancer 158 (18.8) 15 (8.6) Ovarian cancer 274 (32.6) 83 (47.7) Indications for HDU admission Hemodynamic monitoring 380 (45.2) 57 (32.8) Respiratory disease 30 (3.6) 10 (5.7) Cardiovascular disease 366 (43.6) 97 (55.7) Metabolic disorder 40 (4.8) 3 (1.7) Neurological disorder 13 (1.5) 2 (1.1) Renal insufficiency 11 (1.3) 5 (2.9) Invasive hemodynamic monitoring (central venous line–arterial line) No 765 (91.1) 115 (66.1) Yes 75 (8.9) 59 (33.9) Splenectomy No 835 (99.4) 171 (98.3) Yes 5 (0.6) 3 (1.7) Bowel resection No 801 (95.4) 146 (83.9) Yes 39 (4.6) 28 (16.1) Lymph node dissection No 397 (47.3) 121 (69.5) Yes 443 (52.7) 53 (30.5) ICU support No 833 (99.2) 160 (92) Yes 7 (0.8) 14 (8) Operating room time (min) 158.2 (42.4) 168.8 (46.6) Estimated blood loss (ml)
1,090.4 (678.1)
1,763.8 (862.1)
p χ2 test
0.003** 0.458** 0.069‡
0.372* 0.527‡ 0.216‡ 0.006* >0.999* >0.999* 0.001‡ 0.999* 0.171*
