ICU Bottlenecks after Cardiac Surgery: The case for active clearance of chest tubes

shutterstock_270775046The world of heart surgery is fast paced for all involved. Elective patients are scheduled, emergent cases are added on, and both are sometimes bumped for emergency cases that present at the last moment and need immediate surgery. This makes it difficult to staff operating rooms and CVICUs in a manner that allows maximum efficiency of case throughput. Routine cases suffer the most delays when bottlenecks develop in the ICU. A bottleneck occurs when elective cases have to be delayed or rescheduled due to a lack of available beds in the CVICU. When this happens, teams go idle in the operating room and post ICU recovery wards, and patients and their families face unexpected delays that increase the stressfulness of the process for all. Ultimately, bottlenecks harm the hospital’s bottom line resulting in economic losses that impair the financial viability of the heart program.

This point was recently emphasized in a published paper by Almashrafi and colleagues at the Imperial College of London entitled “Systematic review of factors influencing length of stay in ICU after adult cardiac surgery.” (July 16, 2016)1 They noted that in many parts of the world, CVICUs are major bottlenecks, limiting downstream services such as operating rooms and recovery wards. They highlighted how postoperative complications, manifested in the ICU, can slow recovery and cause operating room shut down to wait for ICU beds to open. Simply extending ICU capacity may not be feasible, due to physical limitations, resources or government regulations. Ideally, limiting complications in the ICU can impact case throughput and program efficiency for all.

A recently published paper in the Journal of Thoracic and Cardiovascular Surgery by Balzer, et al, illustrates how retained blood can be a major source of ICU bottlenecking.2 Retained blood occurs when there is insufficient postoperative blood evacuation due to chest tube clogging.3 In this study of 6,909 patients undergoing heart surgery, 19% had retained blood, which was associated with a length of stay more than 13 days in the hospital (OR, 3.853; 95% CI, 2.882-5.206; P < .001) and 5 days in the intensive care unit (OR, 4.602; 95% CI, 3.449-6.183; P < .001). The OR for a time of ventilation greater than 23 hours was 3.596 (95% CI, 2.690-4.851; P < .001) and for incidence of renal replacement therapy was 4.449 (95% CI, 3.188-6.226; P < .001).

Active clearance of chest tubes can reduce this. In a propensity-matched study by Sirch, et al, also in the Journal of Thoracic and Cardiovascular Surgery, patients who had active clearance of chest tubes had a 43% reduction in retained blood and a 33% reduced incidence of postoperative atrial fibrillation.4 This included a significant reduction in the time on the ventilator postoperatively in the ICU.

A recent editorial emphasized how seemingly small complications can have big impacts on outcomes, and should not be ignored.5 How are you addressing your ICU bottleneck problem at your hospital? Maybe it’s time to take a look at Active Chest Tube Clearance.


  1. Almashrafi A, Elmontsri M, Aylin P. Systematic review of factors influencing length of stay in ICU after adult cardiac surgery. BMC Health Services Research. 2016;16:318. doi:10.1186/s12913-016-1591-3.
  2. Balzer, F., von Heymann, C., Boyler, E., Wernecke, K., Grubitzsch, H., and Sander, M. Impact of retained blood requiring reintervention on outcomes after cardiac surgery. J Thorac Cardiovasc Surg. 2016;152:595–601.
  3. Boyle, E.M., Jr., Gillinov, A.M., Cohn, W.E., Ley, S.J., Fischlein, T., and Perrault, L.P. Retained Blood Syndrome After Cardiac Surgery: A New Look at an Old Problem. Innovations (Phila) 2015;10:296-303.
  4. Sirch J, Ledwon M, Puski T, Boyle EM, Pfeiffer S, Fischlein T. Active Clearance of Chest Drainage Catheters Reduces Retained Blood. Journal of Thoracic and Cardiovascular Surgery. 2015 Oct 22. pii: S0022-5223(15)01970-4. doi: 10.1016/j.jtcvs.2015.10.015.
  5. Anselmi A, Flecher E. Minor postoperative morbidity should not be ignored. J Thorac Cardiovasc Surg 2016;152:602