AACN Advanced Critical Care
Volume 27, Number 1, pp. 29-39
Risk Factors and Outcomes Associated
With Readmission to the Intensive
Care Unit After Cardiac Surgery
Young Ae Kang, RN, MSN, CCN, CNS
ABSTRACT
Unplanned readmission to the intensive care
unit (ICU) is associated with poor prognosis,
longer hospital stay, increased costs, and
higher mortality rate. In this retrospective
study, involving 1368 patients, the risk factors
for and outcomes of ICU readmission after
cardiac surgery were analyzed. The readmis-
sion rate was 5.9%, and the most common
reason for readmission was cardiac issues.
Preoperative risk factors were comorbid con-
ditions, mechanical ventilation, and admis-
sion route. Perioperative risk factors were
nonelective surgery, duration of cardiopul-
monary bypass, and longer operation time.
Postoperative risk factors were prolonged
T o accommodate greater consumer interest
in the quality of medical services that has
resulted from the changing medical market-
place and higher incomes, the US Department
of Health and Human Services has begun
efforts to improve health care by evaluating
the quality of health care services offered by
hospitals. Performance indicators that can be
used to directly assess the outcomes of health
care services, such as mortality, morbidity,
incidence of sequelae, and reutilization of
services, are useful general measures. These
objective indicators may be effectively used to
evaluate treatment outcomes quantitatively
and are thus considered useful measures of
health care quality and effectiveness.1
According to the Quality Indicators Com-
mittee of the Society of Critical Care Medicine,
intensive care unit (ICU) readmission, which
is an unplanned admission within 48 hours
29
© 2016 AACN
mechanical ventilation time, new-onset
arrhythmia, unplanned reoperation, massive
blood transfusion, prolonged inotropic infu-
sions, and complications. Other factors were
high blood glucose level, hemoglobin level,
and score on the Acute Physiology and Chronic
Health Evaluation II. In-hospital stay was
longer and late mortality was higher in the
readmitted group. These data could help
clinical practitioners create improved ICU
discharge protocols or treatment algorithms
to reduce length of stay or to reduce
readmissions.
Keywords: readmission, cardiac surgery,
intensive care unit, risk factor
after previous discharge, is one of the indica-
tors of health care quality and effectiveness.2
Unplanned ICU readmissions may reflect
insufficient treatment of patients during the
previous ICU episode or premature discharge.2
However, ICU readmission has been more
associated with patients’ characteristics and
in particular with illness severity than with
the quality of treatment.3 Given the effect of
an ICU readmission on patients, unplanned
readmissions can be an important indicator
of health care quality.1 Moreover, ICU read-
mission is highly related to mortality and
Young Ae Kang is Clinical Nurse Specialist, Cardiovascular
Surgery ICU, Asan Medical Center, 88, Olympic-ro, 43-gil,
Songpa-gu, Seoul, 138-736, Korea (duddo75@gmail.com).
The author declares no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016451
KA NG
morbidity,4 and when patients are readmitted,
the increased length of stay due to the patient’s
worsening illness increases overall health
care costs.
ICU treatment is reportedly 3 times more
expensive than is care in general patient care
units.5 To shorten the ICU hospitalization
period, protocols that include initiatives such
as early extubation have been developed and
executed.6 However, readmission rates are
growing along with an increased incidence
of reintubations and complications, draw-
ing focused attention to the problems associ-
ated with potential premature discharge
from the ICU.7
Background
Most patients who undergo cardiac surgery
receive immediate postoperative care in the ICU
without being transferred to a post­anesthesia
recovery room.8 Upon discharge from the ICU,
they are transferred to general care units, where
the patients may be exposed to a treatment
environment that is less than optimal to address
the complex needs of patients recovering from
cardiac surgery. In general patient care units
where patients cannot be intensively monitored,
it may not be possible to rapidly detect changes
in the patient’s condition or to implement
early treatment appropriate to the patient’s
status. Accordingly, readmission to the ICU
from general care units is always a possibility.
Unplanned ICU admission is an unfortu-
nate experience for both patients and their
families. Most patients who are readmitted
to the ICU with deteriorating health have a
poor prognosis,9 require more time and
effort from medical teams,10 and show sig-
nificantly higher in-hospital mortality and
longer hospital stays than patients admitted
for the first time.11
Most patients are readmitted to the ICU
because they require intensive care.12 How-
ever, Nishi et al13 reported that 20.8% of the
readmitted patients in a surgical ICU would
not have been readmitted if they had received
proper treatment after a previous discharge and
that 4.6% were readmitted because of prema-
ture discharge. Thus, ICU readmission could be
prevented or reduced if the factors associated
with ICU readmission were identified and the
discharge time more appropriately determined.
Researchers in previous studies have
reported that readmissions to the ICU after
a previous discharge were associated with
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factors such as underlying condition, age,
and disease severity.8,14,15 Most patients were
readmitted to the ICU because of hemodynamic
problems such as respiratory and cardiac
insufficiency, and the duration of mechanical
ventilation during the initial ICU admission
was longer in readmitted patients.4,15
Several Korean studies have addressed ICU
readmission, and most of the previous studies
targeted patients in integrated ICUs. In a few
international studies, researchers compared
ICU readmission in patients who had under-
gone cardiac surgery with readmission rates of
all ICU patients. Therefore, an assessment of
the prognosis and readmission-related factors
according to diseases and departments in large
hospitals equipped with specialized ICUs
could help to target interventions in subsets
of patients at risk for readmission and to cre-
ate decision algorithms for optimal ICU dis-
charge time. Furthermore, the rate of premature
ICU discharge could potentially be decreased.
By targeting patients who underwent car-
diac surgery, the present study was intended
to help decrease ICU readmissions by analyz-
ing the factors associated with unplanned
ICU readmission and patients’ prognosis,
particularly to clarify patients’ predischarge
risk factors. In addition, a secondary purpose
of this study was to lay a foundation for the
optimal assessment of patients’ status before
ICU discharge for future use in establishing
standardized protocols for determining the
appropriate ICU discharge time for cardiac
surgical patients.
Methods
Design
This retrospective observational cohort study
was done to analyze the risk factors associated
with unplanned ICU readmission after car-
diac surgery and patients’ prognosis. This study
was approved by the institutional review board
of Asan Medical Center, Seoul, Korea, and
permitted by the relevant medical department.
Study Population
Ultimately, the present study included
1368 patients who had undergone cardiac
surgery and were hospitalized in the cardio-
vascular surgery ICU of a tertiary hospital
in Seoul, Korea, between January 1, 2012,
and June 30, 2013.
ICU readmission was defined as readmission
of a patient to the same ICU after discharge
VOLU ME 27 • N U MB ER 1 • JANUARY-M ARCH 2016 ICU RE A D M ISSION A FT E R CA RD IAC SURGE RY
All patients admitted to cardiovascular
surgery intensive care unit
Enrollment
(n = 1520)
Included
(n = 1372)
Nonreadmitted group
(n = 1287)
Analysis
Nonreadmitted group Unplanned readmitted group
(n = 1287)
Figure 1: Enrollment flow diagram.
to a general care unit during the same hospi-
talization.1,10,11,16 Patients who were unexpect-
edly readmitted to the cardiovascular surgery
ICU because of a deterioration or change in
their condition were included in the analyses
as “readmitted.”
All selected patients were older than 18
years and had been admitted to the ICU after
major cardiac surgery during the specified
study time frame, including all surgeries that
involved cardiopulmonary bypass (CPB),
off-pump coronary artery bypass graft (CABG),
and pericardectomy without CPB. The exclu-
sion criteria were as follows: (1) patients
whose readmission length of stay was less
than 4 hours, (2) patients who died in the
ICU during treatment or were transferred to
another hospital, and (3) patients transferred
to a different ICU to have continuous treat-
ment for a noncardiac illness after cardiac
surgery. Patients readmitted to the ICU at
different times of the study period because
of sequential surgery or treatments were also
included because they were regarded as indi-
vidual hospitalization cases, in accordance
with the above inclusion and exclusion crite-
ria. The flow diagram describing selection
of study participants is presented in Figure 1,
and the general characteristics of participants
are listed in Table 1.
Of the 1368 patients, 806 (58.9%) were
male, and the mean age was 58.7 (SD, 13.3)
years. A total of 134 patients (9.8%) had a
history of 2 or more cardiac surgeries, and a
previous cardiac problem was seen in 24.0%.
Excluded
Not meeting inclusion criteria
(n = 148)
Readmitted group
(n = 85)
Excluded
Planned readmissions
due to staged operations
during same hospitalization
(n = 81) (n = 4)
CABG surgery was performed in 29.6%, valve
surgery in 40.6%, aorta surgery in 11.2%,
and combined surgery (CABG/valve surgery,
CABG/aorta surgery) in 4.7%. The remaining
operations included heart transplant, pulmo-
nary thromboembolectomy, cardiac myxoma
excision, and congenital heart disease repair.
Data Collection
Data were collected from the electronic
medical records by using a standardized form
designed by the author. The preoperative
clinical information of patients included ICU
admission routes, diagnoses, type of operation,
preoperative arrhythmia, ejection fraction,
urgency of operation (elective or emergent),
operation time, and CPB time. Postoperative
information included mechanical ventilation
time, infusion time of inotropic drugs, new-
onset arrhythmia, newly developed compli-
cations, new implantation of cardiac support
devices, and blood transfusion. Laboratory
data, scores on the Acute Physiology and
Chronic Health Evaluation (APACHE) II,
and support drugs or devices at the time of
ICU discharge also were examined.
Statistical Analysis
Data were analyzed by using IBM SPSS
20.0 in both univariate and multivariate
models. Continuous data are presented as
mean (SD) or median (interquartile range
[IQR]), and categorical data are presented as
number (percentage). Logistic regression test-
ing was used to analyze risk factors
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Table 1: General Characteristics of the Table 2: Clinical and Therapeutic Charac-

Study Patients (N = 1368) teristics of the Study Patients (N = 1368)
a a
Characteristic Value Characteristic Value
Age, mean (SD), y 58.7 (13.3) Preoperative ejection fraction, 55.6 (12.9)
mean (SD), %
Sex
Male 806 (58.9) Preoperative arrhythmia 320 (23.4)
Female 562 (41.1)
Preoperative device
Body surface area, mean (SD), m2 1.69 (0.19) Ventilator 25 (1.8)
IABP, ECMO 22 (1.6)
Diabetes mellitus 311 (22.7)
Admission route
Hypertension 554 (40.5)
General care area 1206 (88.2)
Drinking 466 (34.1) ICU/ER 162 (11.8)
Smoking Surgery type
Current 280 (20.5) Elective 1151 (84.1)
Former 313 (22.9) Emergency 217 (15.9)
ICU admission history 426 (31.1) Operation time, mean (SD), h 4.8 (1.6)
Cardiac surgery history 134 (9.8) CPB
Operation with CPB use 1042 (76.2)
Comorbid condition
CPB time, mean (SD), min 148 (67.3)
Cardiac problems 329 (24.0)
Cerebrovascular disease 142 (10.4) Mechanical ventilation time, 10.0 (1.6-8050.2)
Respiratory disease 78 (5.7) median (IQR), h
Azotemia 94 (6.9)
Inotropic drugs
ESRD or hemodialysis 24 (1.8)
Patients receiving 944 (69)
Cancer 54 (3.9)
Infusion time, median (IQR), h 38 (0.2-932.1)
Surgery classification
Cardiac device support
CABG 405 (29.6)
IABP, ECMO 36 (2.6)
Valve surgery 556 (40.6)
Pacemaker 235 (17.2)
Aorta surgery 153 (11.2)
Combined surgery 64 (4.7) New-onset arrhythmia 553 (40.4)
Heart transplant 62 (4.5)
ICU events
Other 128 (9.4)
Reoperation 58 (4.2)
CPCR 13 (1.0)
Abbreviations: CABG, coronary artery bypass graft; ESRD, end-stage
renal disease; ICU, intensive care unit. Complication
a
Values are number (percentage) of patients unless otherwise speci- Cardiac 79 (5.8)
fied in first column.
Cerebrovascular 58 (4.2)
Respiratory 46 (3.4)
associated with unplanned readmission. The Bleeding 152 (11.1)
nonreadmission and readmission groups were New-onset CRRT or HD 23 (2.6)
compared by using c2 and Fisher exact tests. Abbreviations: CPB, cardiopulmonary bypass; CPCR, cardiopulmonary
A P value of .05 or less was considered statis- cerebral resuscitation; CRRT, continuous renal replacement therapy;
ECMO, extracorporeal membrane oxygenator; ER, emergency room;
tically significant. HD, hemodialysis; IABP, intra-aortic balloon pump; ICU, intensive
care unit; IQR, interquartile range.

Results
Clinical and Therapeutic
Characteristics of the Study Patients
Clinical and therapeutic characteristics of
the study participants are listed in Table 2.
Briefly, 11.8% of patients were admitted via
the ICU or emergency department, preopera-
tive arrhythmias were seen in 23.4% of
patients, and 1.8% of patients required
mechanical ventilation during preoperative
a
Values are number (percentage) of patients unless otherwise specified
in first column.
care. Two hundred seventeen patients (15.9%)
had emergent or urgent surgery, and the mean
operation time was 4.8 (SD, 1.6) hours. CPB
was used in 76.2% of patients, and the mean
CPB time was 148 (SD, 67.3) minutes.
During postoperative care, the median
duration of mechanical ventilation was 10

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Table 3: Characteristics and Outcomes of Patients Readmitted to the Intensive Care

Unit (n = 81)

Valuea
Characteristic Readmission No readmission χ2 and P
Reason for readmission
Cardiac 42 (51.9)
Respiratory 11 (13.6)
Cerebrovascular 4 (4.9)
Gastrointestinal 3 (3.7)
Sepsis 4 (4.9)
Reoperation 8 (9.9)
Wound infection 9 (11.1)
Time interval between readmission 172.3 (10.8-1306.5)
and ICU discharge, median (IQR), h
≤ 72 h 17 (21.0)
72 h-7 d 20 (24.7)
7-14 d 10 (12.3)
14-21 d 27 (33.3)
21-28 d 4 (4.9)
> 28 d 3 (3.7)
Second ICU LOS, median (IQR), h 43.9 (8.3-1288.4)
Third readmission 9 (11.1)
Hospital mortality 5 (6.2)
First ICU LOS, median (IQR), h 70.2 (17.9-948.4) 46.2 (4.2-8103.8) < .001
Total hospital stay, median (IQR), d 32 (6-273) 9 (3-172) < .001
Late mortality 18 (22.2) 41 (3.2) 66.916 (< .001b)

Abbreviations: ICU, intensive care unit; IQR, interquartile range; LOS, length of stay.
a
Values are number (percentage) of patients unless otherwise specified in first column.
b
Fisher exact test.

hours (IQR, 1.6-8050.2 hours), the median
infusion time for inotropic drugs was 38 hours
(IQR, 0.2-932.1), and 69% of patients received
inotropic drugs. Temporary or continuous
arrhythmia was newly diagnosed in 553
patients (40.4%). The major postoperative
complication was bleeding (11.1%), defined
as chest tube drainage after ICU admission of
greater than 200 mL/h, for more than 3 hours.
Cardiac problems such as a low cardiac out-
put state or arrhythmia occurred in 5.8% of
cases, respiratory complications such as failed
mechanical ventilator weaning or pneumonia
occurred in 3.4%, and new-onset hemodialy-
sis occurred in 2.6% of the patients.
Readmission Outcomes
Readmission characteristics and outcomes
are presented in Table 3. Of the 1368 patients
included in the study series, 81 patients were
readmitted to the ICU, resulting in a calculated
unplanned readmission rate of 5.9%. Nine
patients underwent a third readmission dur-
ing their hospitalization. Of these 81 patients,
readmission for cardiac causes occurred in 42
patients (51.9%); in 26 of these 42 patients,
the readmission was due to cardiac arrhythmia;
14 of these 26 patients required implanted
permanent pacemakers. Eight patients were
in a low cardiac output state. Eleven patients
were readmitted because of respiratory prob-
lems resulting from oxygen desaturation or
ineffective expectoration of secretions. Com-
plications included wound infection (11.1%),
reoperation (9.9%), cerebrovascular problems
(4.9%), sepsis (4.9%), and gastrointestinal
complications (3.7%).
The median time interval between ICU
discharge and readmission was 172.3 hours
(IQR, 10.8-1306.5), and 17 patients were
readmitted within 72 hours: 8 because of car-
diac problems, 4 because of cerebrovascular

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25
20
No. of patients
15
10
5
0
<72
hours
72 hours-
7 days
7-14
days
14-21
days
Time interval
Wound infection
Sepsis Gastrointestinal
Cerebrovascular
Cardiac
Figure 2: Causes of readmission according to the
time interval (n = 81).
complications, and 3 because of respiratory
problems.
Five patients (6.2%) died during hospitali-
zation. The in-hospital stay of readmitted
patients was significantly longer than that
of nonreadmitted patients (32 days [6-273]
vs 9 days [3-172], P < .001). Late mortality
was significantly higher in the readmission
group than in the nonreadmission group
(22.2% vs 3.2%, P < .001).
Thirty-seven patients (45.7%) were read-
mitted within 7 days after ICU discharge, and
22 patients of these patients were readmitted
because of cardiac problems: 13 patients had
arrhythmias and 8 patients were in a low
cardiac output state. Furthermore, 13 patients
with wound problems or sepsis were readmit-
ted after 7 days. Causes of readmission accord-
ing to the time interval are shown in Figure 2.
Univariate Analysis of
Risk Factors for Readmission
Preoperative factors univariately associated
with risk of ICU readmission after cardiac
surgery included comorbid conditions such
as cardiac problems, respiratory diseases,
and chronic kidney diseases such as end-stage
renal disease; preoperative mechanical venti-
lator care; and admission from another ICU.
Surgery-related risk factors included emer-
gent or urgent surgery (relative risk [RR],
1.95; 95% CI, 1.16-3.28; P = .01), more than
5 hours of operation time (RR, 1.65; 95%
CI, 1.05-2.58; P = .03), and more than 3
W W W.A ACNACCONLINE .ORG
hours of CPB (RR, 1.95; 95% CI, 1.05-3.63;
P = .04).
During the postoperative course, duration
of mechanical ventilation exceeding 10 hours
(RR, 2.54; 95% CI, 1.56-4.14; P < .001),
new-onset arrhythmia (RR, 2.66; 95% CI,
1.67-4.20, P < .001), unplanned reoperation
during ICU admission (RR, 4.15; 95% CI,
0.64-13.48; P < .001), and newly developed
postoperative complications were strong risk
21-28
days
> 28
days
factors for ICU readmission. Infusion of ino-
tropic drugs for more than 24 hours was
another risk factor, in particular, dobutamine
Reoperation infusion exceeding 10 µg/kg per minute (RR,
1.16; 95% CI, 1.04-1.29; P = .007). Massive
Respiratory transfusion of more than 20 units of blood
was another risk factor.
In laboratory testing during admission, the
blood glucose level, concentration of C-reactive
protein (CRP), hemoglobin level less than 8
g/dL, and the alanine aminotransferase level
were significantly related to readmission. In
addition, the APACHE II score on the day
of discharge to a general care unit was asso-
ciated with ICU readmission (Table 4).
Multivariate Analysis of
Risk Factors for Readmission
Because multivariate analysis would not
have been useful for analyzing the few patients
who were readmitted, the variables were
analyzed by subdividing the reasons for ICU
readmission into cardiac, respiratory, and
infectious causes. Thus, 43 patients were read-
mitted because of cardiac problems, including
a low cardiac output state, arrhythmia, and
ischemic colitis resulting from poor circulation
caused by severe hypotension; 12 patients
were readmitted because of respiratory prob-
lems, including oxygen desaturation, pneumo-
nia, and tracheoesophageal fistula; and 14
patients were readmitted for infectious causes,
including surgical wound infection and sepsis.
With regard to readmission due to cardiac
problems, nonelective surgery (odds ratio
[OR], 2.42; 95% CI, 1.14-5.14; P = .02),
new-onset arrhythmia after surgery (OR, 3.73;
95% CI, 1.75-7.98; P = .001), development
of cardiac complication (OR, 4.29; 95% CI,
1.76-10.46; P = .001), and the APACHE II
score on the day of discharge to the general
care area (OR, 1.09; 95% CI, 1.00-1.19;
P = .04) were significant risk factors.
The risk factors for readmission due to
respiratory problems were respiratory
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Table 4: Univariate Analysis of Risk Factors for Readmission to the Intensive Care Unit

Characteristic Relative Risk 95% CI P

Age ≥ 60 y 1.35 0.86-2.13 .19
Sex 0.88 0.56-1.40 .60
2
Body surface area, m
<1.6 0.94 0.58-1.52 .79
>1.9 0.68 0.30-1.53 .35
Diabetes mellitus 1.20 0.72-2.01 .48
Hypertension 1.32 0.84-2.07 .23
Smoking 0.05 0.87-2.14 <.001
Alcohol 0.06 0.90-1.72 <.001
Comorbid condition
Cardiac problems 1.63 1.01-2.63 .046
Cerebrovascular disease 1.39 0.72-2.69 .33
Respiratory disease 3.59 1.89-6.84 <.001
CKD with oliguria 2.56 1.33-4.91 .005
ESRD 4.39 1.60-12.08 .004
Preoperative arrhythmia 0.05 1.12-2.90 <.001
Preoperative ejection fraction, % 0.99 0.97-1.01 .99
Preoperative device
Ventilator 6.66 2.70-16.46 <.001
IABP 2.15 0.48-9.55 .32
ECMO 2.28 0.28-18.78 .44
Admission route, ICU 2.95 1.70-5.10 <.001
Cardiac surgery history 0.06 0.99-3.43 <.001
Surgery type, emergent 1.95 1.16-3.28 .01
CPB time, min
< 180 0.83 0.46-1.48 .52
≥ 180 1.95 1.05-3.63 .04
Operative time ≥ 5 h 1.65 1.05-2.58 .03
Mechanical ventilation time ≥ 10 h 2.54 1.56-4.14 <.001
Inotropic drug infusion time, h
24-71.9 1.82 1.05-3.17 .03
≥ 72 3.88 2.20-6.85 <.001
Maximum medication dose, µg/kg per min
Dopamine ≥ 10 1.73 0.94-3.18 .08
Norepinephrine ≥ 0.2 1.9 0.91-3.99 .09
Dobutamine ≥ 10 1.16 1.04-1.29 .007
Epinephrine ≥ 0.2 1.52 0.64-3.63 .34

Postoperative new-onset arrhythmia 2.66 1.67-4.20 <.001

ICU events
Reoperation 4.15 0.64-13.48 <.001
Reintubation 2.42 0.83-7.10 .11
Units of blood products transfused in ICU
> 5 but ≤ 20 1.12 0.63-2.00 .71
> 20 but ≤ 50 2.83 1.33-6.02 .007
> 50 4.7 1.61-13.73 .005
Continued
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Table 4: Univariate Analysis of Risk Factors for Readmission to the Intensive Care Unit
(Continued)

Characteristic Relative Risk 95% CI P

Postoperative complication
Cerebrovascular 2.86 1.17-7.02 .02
Respiratory 6.41 3.18-12.92 < .001
Cardiac 6.82 3.87-12.05 < .001
Bleeding 1.91 1.06-3.44 .03
Azotemia 2.45 1.33-4.52 .004
New-onset CRRT or HD 4.82 1.89-12.31 .001
Laboratory data
Maximum blood glucose ≥ 200 mg/dL 2.08 1.32-3.29 .002
Minimum blood glucose < 80 mg/dL 5.2 3.28-8.22 < .001
White blood cell count ≥ 20 000/µL 0.92 0.33-2.58 .87
Hemoglobin level, g/dL
≥ 8 but < 10 1.82 1.14-2.91 .01
< 8 10.00 2.43-41.23 .001
CRP, mg/dL
≥ 5 but < 15 2.54 1.36-4.78 .004
≥ 15 1.27 0.77-2.10 .35
AST ≥ 100 IU/L 1.07 0.58-1.98 .83
ALT ≥ 100 IU/L 2.98 1.46-6.09 .003
Total bilirubin ≥ 10 mg/dL  2.32 0.68-7.94 .18
APACHE II score 1.18 1.12-1.25 < .001

Abbreviations: ALT, alanine aminotransferase; APACHE, Acute Physiology and Chronic Health Evaluation; AST, aspartate aminotransferase;
CKD, chronic kidney disease; CPB, cardiopulmonary bypass; CPCR, cardiopulmonary cerebral resuscitation; CRP, C-reactive protein; CRRT, con-
tinuous renal replace therapy; DM, diabetes mellitus; ECMO, extracorporeal membrane oxygenator; ESRD, end-stage renal disease; HD, hemo-
dialysis; IABP, intra-aortic balloon pump; ICU, intensive care unit.

complications, unplanned reoperation during
ICU admission, maximum blood glucose
level, and concentration of CRP.
Statistically significant infection-related
risk factors were preoperative pulmonary
comorbidity, new-onset hemodialysis, and
maximum blood glucose level (Table 5).
Discussion
In the present study, 81 patients out of a
study population of 1368 experienced
unplanned ICU readmission. This readmis-
sion rate of 5.9% is lower than the rates
reported in previous studies.9,11 The difference
in readmission rates was most likely because
the previous studies were conducted on patients
readmitted to a medical or surgical ICU within
a mean of 7 days following a previous dis-
charge, whereas the current study selected a
single ICU. In the current patient series, 17
patients (1.2% of the total population) were
readmitted within 7 days. Of these 17 patients,
5 received inotropic drugs, 9 had received
oxygen supplementation, and 7 had received
temporary pacemakers. All of these patients
would have needed vigilant monitoring even
if transferred to general care units.
The timing of ICU discharge of patients to
a general care unit should be determined by a
medical team. Some premature ICU discharges
are inevitable and lead to the requirement of
more intensive monitoring in the general
care area. To handle the potential for patient
decompensation in situations where they may
have been prematurely discharged from the
ICU, general care units should be equipped
with monitoring systems, as in intermediate
care units, but this type of monitoring system
is not widely used in general care units in
Korea’s health care environment because of
its high costs. Professional staff would also
need to be trained in the use of this equipment.
Overall Risk Factors
Badawi and Breslow17 considered diagnosis
(including whether the patient had undergone
elective or emergent surgery), admission source,
age, body mass index, and severity of illness
to be risk factors predictive of ICU readmis-
sion or death after discharge. In the present

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Table 5: Multivariate Analysis of Risk Factors for Readmission to Intensive Care Unit

Cause of Readmission Variable Adjusted Odds Ratio 95% CI P

Cardiac Nonelective surgery 2.42 1.14-5.14 .02
New-onset arrhythmias 3.73 1.75-7.98 .001
Cardiac complications 4.29 1.76-10.46 .001
APACHE II score 1.09 1.00-1.19 .04
Respiratory Respiratory complications 2.76 2.12-76.96 .005
Reoperation for ICU days 8.40 1.44-48.87 .02
Maximum blood glucose level 1.01 1.00-1.02 .03
C-reactive protein level 1.10 1.00-1.21 .04
Infectious Pulmonary comorbid condition 12.56 2.63-60.08 .002
New-onset hemodialysis 76.38 10.00-583.43 < .001
Maximum blood glucose level 1.01 1.00-1.02 .02

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; ICU, intensive care unit.

study, however, body surface area and age
were not significant risk factors. This differ-
ence may be because the previous study
investigated various ICUs in multiple hospi-
tals, whereas we selected patients in a single
ICU of a single hospital, and our patients
with heart valve disease or congenital cardiac
diseases were mostly young. On the other
hand, the admission source and illness were
significant risk factors in this study.
In a meta-analysis, Frost and colleagues18
found a higher severity-of-illness score in
patients readmitted to the ICU. The hospital
in the present study has used the APACHE II
score to evaluate illness severity, but severity
is generally assessed only on certain days,
such as on postoperative days 1, 3, and 7,
and its accurate assessment is vital because
of variations among medical teams. Zimmer-
man19 asserted that no severity tool could be
used to evaluate the risks of ICU readmission
and predict emergent situations occurring in
general care units. Ball and colleagues20
highlighted the need for continuous follow-
up of patients by critical care staff after ICU
discharge. However, more accurate tools for
evaluation of illness severity need to be
developed to detect high-risk patients who
are likely to be readmitted to the ICU from
a general care unit that lacks monitoring
systems, and the appropriate use of severity-
of-illness scoring systems is necessary, even
for general care units.
Lai et al21 reported ischemic heart disease,
respiratory failure, pneumonia, cerebrovascu-
lar diseases, and sepsis as the major causes
of readmission in a study of multiple ICUs.
In contrast, Benetis et al22 considered arrhyth-
mia and ejection fraction to be preoperative
risk factors for readmission in a study of
patients who had undergone cardiac surgery.
The intraoperative risk factors included
length of operation, emergent surgery, and
CPB time; postoperative risk factors were
arrhythmia, respiratory failure, gastrointes-
tinal disorders (including bleeding), cardio-
pulmonary resuscitation, renal insufficiency,
hemodynamic instability, and sepsis.4,22,23
The major causes of readmissions were in
accordance with the present findings in
many ways.
Bleeding
Postoperative bleeding and surgical reex-
ploration were also postoperative predictors
of ICU readmission in a study by Litmathe
and colleagues4 and, in the current study, 42
patients required emergency surgery because
of surgery-related bleeding, accounting for
72.4% of total unexpected reoperations.
Salpeter et al24 reported decreases in com-
plications, rebleeding, infection, and mortality
following blood transfusion restrictions in
critically ill patients and patients with bleed-
ing, and earlier, Surgenor et al25 reported that
red blood cell transfusion after CABG was
highly related to the use of cardiac devices
such as intra-aortic balloon pumps, reinstitu-
tion of CPB after weaning in the operating
room, and infusion of inotropic drugs for
more than 48 hours during the recovery
process. Likewise, the present study showed a
strong link between blood transfusions and
ICU readmission.

37
KA NG
Blood Glucose
Blood glucose level was significantly asso-
ciated with ICU readmission. In particular,
multivariate analysis categorizing readmissions
into cardiac, respiratory, and infectious causes
showed that blood glucose level was signifi-
cantly related to readmissions, suggesting the
importance of controlling blood glucose level
after surgery. Lee et al26 reported a correlation
between the highest blood glucose level and
patients’ readmission within 30 days.
Mortality and Length of Stay
The in-hospital mortality of the present
study’s readmission group was 6.2%, with
the late mortality rate of the readmission group
being much higher than that of the nonread-
mission group (22.2% vs 3.2%). The result
was consistent with that of many previous
studies.4,11,21,27 Unplanned ICU readmission was
related to poor patient prognosis and, to pre-
vent unplanned readmissions, early detection
of “flagged” patient variables is critical for
patients’ recovery and prognosis. Also, in the
present study, the length of hospital stay of the
readmission group was 32 days, longer than
the 9 days in the nonreadmission group, which
was also consistent with previous results.3,4,22
The length of ICU stay and the total hospitali-
zation period were highly correlated in the
work of Kramer and Zimmerman,28 reflecting
a patient’s diagnosis and the need for treat-
ment. However, in the present study, the length
of the first ICU readmission was 70.2 hours
(IQR, 17.9-948.4 hours), longer than the
46.2 hours (IQR, 4.2-8103.8 hours) of the
nonreadmission group.
Length of stay is commonly used as an
indirect tool to measure ICU resource use
and economic costs. Prolonged length of stay
is related to high health care costs, poor
patient prognosis, and poor quality of life of
discharged patients. In particular, patients
who have a long ICU stay have a high mor-
tality and low quality of life after discharge.29
Unplanned ICU readmissions would lead
to high medical costs because of the prolonged
length of stay. With the current emphasis on
decreasing length of stay, more patients may
be transferred to general care units earlier
while they still require inotropic drugs and
support devices, which can eventually serve
as risk factors for readmission, causing a
vicious cycle. Hence, appropriate assessment
of ICU discharge time should allow patients
38
W W W.A ACNACCONLINE .ORG
to receive treatment in the optimal environ-
ment, and premature discharge from the ICU
should be prevented. Detection of patients
with problems and rapid responses to these
cases are required even after the patients are
transferred to general care units. This is done
through monitoring of the patient’s clinical
status to prevent deterioration and enable
speedy recovery, thus reducing the length of
the hospital stay.
Through this study, risk factors for
unplanned ICU readmission at our institu-
tion were identified and provide us with a
foundation of evidence upon which to develop
and test decision algorithms for determination
of appropriate discharge time. ICU readmis-
sions have contributed to increased duration
of hospitalization, which also affects rehabili-
tation of critically ill patients after discharge
from hospital. Replicated inquiry about ICU
readmissions will clarify discrete and optimal
therapeutic decisions for patients at high risk
for ICU readmission, and treatment planning
about their rehabilitation during hospitaliza-
tion will have to be considered.
Limitations
The outcomes of this study involved patients
in just 1 ICU for a short period, and the
factors found to be significant in univariate
analysis were not significant in multivariate
analysis owing to the small number of patients
readmitted. It is recommended that future
research be conducted to replicate our find-
ings, using larger populations of patients after
cardiac surgery.
Conclusions
In the case of patients readmitted within 7
days of a previous ICU discharge, the major
cause of readmission was cardiac problems,
whereas the major cause of readmission after
7 days was infectious causes. The frequency
of postoperative health problems varies
according to the length of hospital stay. Thus,
medical teams should monitor and evaluate
all clinical aspects of their patients, including
underlying diseases, for early detection of
problems. Identifying the causes of unplanned
ICU readmissions can help to determine which
patients are at high risk for deterioration,
lay the foundation for elucidation of the opti-
mal ICU discharge time, monitor patients
requiring special continuous and intensive
attention in general care units, and provide
VOLU ME 27 • N U MB ER 1 • JANUARY-M ARCH 2016 ICU RE A D M ISSION A FT E R CA RD IAC SURGE RY
these patients with high-quality treatment
and care by early identification of warning
signs. Furthermore, the knowledge of the risk
factors associated with ICU readmission
could be used to target intervention in sub-
sets of patients at risk for readmission and
create decision algorithms or protocols for
appropriate discharge time.
ACKNOWLEDGMENTS
This study was supplemented and revised
from the author’s thesis and was presented
before the Seoul Nurse Association in South
Korea. Special thanks to professor Young Sun
Jung and Hye Ran Choi, who provided com-
ments and support.
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