Mini ICU
To test the idea, the University Hospitals head and neck surgery team conducted a retrospective study at the specialized OTOCare unit at University Hospitals Seidman Cancer Center, which opened in 2012. The study was led by UH otolaryngologist Chad Zender, MD, FACS, Associate Professor of Otolaryngology - Head & Neck Surgery at Case Western Reserve University School of Medicine. Also participating were Rod Rezaee, MD, FACS, Director of Microvascular Head and Neck Reconstructive Surgery at UH, and Pierre Lavertu, MD, Professor and Director of Head and Neck Surgery and Oncology at UH.
Results of the study showed that there was no statistical difference in length of stay, complication rate or readmissions between intensive care unit (ICU) and non-ICU care paths. However, using the dedicated unit yielded significant direct cost savings for the hospital - greater than $125,000 annually - while improving patient comfort and satisfaction. These results were presented at the 5th World Conference of the International Federation of Head and Neck Oncologic Societies and the 2014 American Head and Neck Society Meeting.
Head and neck free-flap transfer patients require close monitoring in the days following microvascular surgery. If problems arise, such as a thrombosis developing in vessels transplanted from the forearm to the tongue, it is essential to address them as quickly as possible to increase the chances of salvaging the graft. Additionally, free-flap transfer patients are typically older, with comorbidities. Although grafts are usually successful, patients require more acute postoperative nursing care than they would receive on a general floor.
"These patients require continual specialized monitoring checking the perfusion of grafts and frequent care of breathing tubes, but they're not necessarily medically unstable," says Dr. Rezaee. "If we're keeping these patients in an ICU designed for minute-to-minute, life-or-death situations, we're occupying resources that could be used for truly critically ill patients. That increases costs for the hospital and for healthcare overall. Our patients are not critical, they just need a higher level of specialty nursing care. The UH research team also believed that providing care on a specialized unit could improve patient outcomes.
"In a traditional ICU, free-tissue-transfer patients often remain intubated or ventilated for several days," says Dr. Zender. "Yet we know that early ambulation and extubation often leads to better outcomes. One goal of the specialty unit was to get patients awake on postoperative day zero and ambulating by postoperative day two. In addition, because the OTOCare unit is not a general ICU, we believed it would provide a more stable and comfortable environment for patients and their families."
The specialty OTOCare unit at UH includes 10 beds, supported by specific nursing ratios, new care path protocols coordination and education of staff. Although other centers have used specialty units for microsurgery patients, UH physicians were among the first to perform a rigorous cohort study of this care path.
In the year before the otocare unit opened, 29 percent of ENT patients utilized the ICU. In the year following, ICU utilization for ENT patients dropped substantially, to about 8 percent and have consistently remained low. These improvements translated to significant direct cost and resource savings - with shorter average length of stay and no increase in complication rates or rehospitalizations. With increasing maturity of this high-tech unit, we have been able to take care of patients of even higher acuity level with each subsequent year.
"The results speak for themselves," says Dr. Zender. "When looking at ICU utilization, bed availability, costs and the ultimate goal of improving patient care, I believe that more hospitals will follow suit in the coming years."