The liver transplant team at Mayo Clinic’s campus in Jacksonville has found that more than half of patients receiving a new liver can be "fast-tracked" to return to a surgical ward room following their transplant, bypassing a one- or two-day stay in the Intensive Care Unit.
"There are distinct advantages in avoiding the ICU when safely possible," says C. Burçin Taner, M.D., chair of transplant surgery at Mayo Clinic’s campus in Jacksonville. "Keeping a patient on ventilation in the ICU increases the risk of infection, and other complications can arise. Many more tests, such as routine X-rays, are ordered in the ICU, compared to post-transplant care in the surgical ward. So less intensive patient care can be done in those patients who do not need it," he says.
"And avoiding the very expensive care in the ICU helps the patient as well as the health care system. For each patient thousands of dollars can be saved when bypassing the ICU entirely." Additionally, patients who were fast-tracked had better survival compared to patients sent to the ICU.
When the Mayo Clinic transplant center in Florida began fast-tracking patients in 2002, the clinical decision for each patient was based on assessments made by attending transplant surgeons and anesthesiologists at the time of the liver transplant operation.
A team of physicians and researchers at Mayo examined 1,296 liver transplant patients treated at the center between 2002 and 2010. They found that 704 patients (54.3 percent) were successfully fast-tracked, meaning that they were sent to their rooms after approximately two hours spent in the post-anesthesia care unit (PACU), where anesthesia was withdrawn and patients were awoken. In contrast, only 592 (45.7 percent) went to the ICU after briefly staying in PACU.
The nine objective variables that determined patients who bypassed ICU were: being male, of younger age, lower body weight, having a first transplant, a shorter operative time, no time spent in the hospital before transplant, lower MELD score (a biological marker that indicates a patient's sickness), a lower use of blood transfusions, and little use of medication to increase blood pressure.
"Patients who receive a liver transplant have end-stage liver disease and are all very sick, so it is very important that we provide the highest quality care," Dr. Taner says. "With detailed analysis of our fast-track practice, we demonstrate that we can tailor the appropriate care according to the individual patient's medical needs.
"In the era of cost-containment, with this tailored approach we can have more control of resource utilization without sacrificing quality of care. Both individual patients and the health care system overall benefit from this approach," he says.