Designated Anesthesia Team for Liver Transplants Conserves Resources While Preserving Patient Outcomes

Bryan DeBusk, PhD

July 10, 2008

July 10, 2008 (Paris, France) — The evaluation of a model for providing anesthesia during liver transplants has shown that a dedicated anesthesia team reduces the need for blood transfusions and mechanical ventilation during and after surgery and is associated with decreases in the time patients spend in the operating room, in intensive care, and in the hospital.

Zoltan Hevesi, MD, associate professor of medicine and public health in the department of anesthesiology, and director of anesthesiology transplantation services at the University of Wisconsin, in Madison, presented the results of the study here at the 2008 Joint International Congress of ILTS, ELITA & LICAGE.

"A growing body of research confirms the existence of wide variations [in healthcare quality across the United States], which are attributable to differences in medical practices and are unrelated to the patient's preexisting medical condition," Dr. Hevesi told Medscape Transplantation. Dr. Hevesi cited a 2003 survey by the University Health System Consortium that revealed marked differences in perioperative liver transplant practices across the country. "Allocating the right level of anesthesiology personnel is a classic dilemma for a number of anesthesiology groups in the United States," he explained.

After evaluating their own practices in 2003, liver transplant personnel at the University of Wisconsin implemented a continuous quality-improvement (CQI) program for evaluating resource allocation to liver transplant recipients. The group periodically examined a number of resource-allocation end points, including the number of red blood cell (RBC) and fresh frozen plasma (FFP) units patients received, time spent in the operating room and intensive care, time spent on mechanical ventilation, and length of hospital stay.

Program administrators sequentially implemented evidence-based clinical guidelines for anesthesia and hired a director of transplant anesthesia. To improve resource-allocation end points, the director established a dedicated liver transplant team and increased the involvement of anesthesiologists in the function of the transplant service line.

Dr. Hevesi and his colleagues compared the allocation of resources to 217 transplant recipients before (from 2000 to 2002) and to 87 transplant recipients after (in 2005) the CQI program was implemented. Although patient illness severity scores, surgical group composition, and surgical technique were comparable between the 2 groups, patients treated after the program was implemented required fewer resources, as measured by all 6 resource-allocation end points (P < .05).

Patients in the post-CQI group required only about a third as many RBC units as those in the pre-CQI group (5.2 ± 5.4 units vs 14.9 ± 16.9 units), and patients in the pre-CQI group required more than 8 times as many FFP units (29.1 ± 21.2 units vs 3.4 ± 4.7 units). Patients in the post-CQI group spent an average of 63 minutes less in the operating room (469 ± 160 minutes vs 532 ± 181 minutes) and 1.5 fewer days in intensive care after surgery (3.0 ± 4.1 days vs 4.5 ± 6.1 days). Mechanical ventilation was removed an average of 1 day earlier (1.3 ± 3.3 days vs 2.3 ± 4.5) in the post-CQI group, and hospital stays were an average of 9 days shorter (14.0 ± 10.3 days vs 23.1 ± 23.6 days).

Michael Ramsay, MD, moderator of the session, president of the Baylor Research Institute, and chief of service for the department of anesthesiology and pain management at Baylor University Medical Center, in Dallas, Texas, told Medscape Transplantation that the findings make sense. "It's really the sort of thing you'd expect with a small, dedicated group," Dr. Ramsay explained. "Clearly, when you have high acute-care needs, [as patients undergoing liver transplants do], it makes a big difference. These people have more experience, and they are all on the same page when you implement specific policies and protocols."

Dr. Hevesi predicted that the gradual transformation at the University of Wisconsin will serve as an example for institutions with similar challenges, and noted that the program will likely pay for itself. "At the University of Wisconsin, the significantly reduced blood transfusions and shorter hospital stays more than covered the additional costs of maintaining a dedicated liver transplant anesthesia team," Dr. Hevesi concluded.

This study did not receive commercial support. Drs. Hevesi and Ramsay have disclosed no relevant financial relationships.

2008 Joint International Congress of ILTS, ELITA & LICAGE: Abstract 506. Presented July 10, 2008.


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