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Postanesthesia Care Unit Costs Are Heterogeneous Among Hospitals, Principally Determined by Delays in Patient Admission From Operating Rooms.

June 2019 • Volume 128 • Number 6 www.anesthesia-analgesia.org 1065 DOI: 10.1213/ANE.0000000000004110 In the current issue of Anesthesia & Analgesia, Grabitz et al1 examined the effect of postoperative residual neuromuscular blockade on the incidence of unplanned intensive care unit admission and on hospital costs. The authors studied a cohort of patients who underwent general anesthesia including administration of a nondepolarizing neuromuscular blocking agent between 2008 and 2013 at Massachusetts General Hospital. Their independent variable was postoperative residual neuromuscular blockade on admission into the postanesthesia care unit (PACU).1 Their definition of residual neuromuscular blockade was the presence of a train-of-four ratio <0.9, measured using accelerometry.1 The incidence of unplanned intensive care unit admission was greater among patients who were not fully reversed, 3.3% vs 1.5%. The adjusted odds ratio of intensive care unit admission was 3.03, with 95% CI of 1.33– 6.87. In addition, they previously reported that in the cohort through 2010, the PACU time was greater in the patients with postoperative residual neuromuscular blockade, mean 323 minutes (SD = 299 minutes) vs 243 minutes (SD = 185 minutes).2 The mean difference between groups of 80 minutes was reasonable for the extra PACU time associated with medical causes.3–5 Nevertheless, the authors report in their current study1 that there was no significant difference in total hospital costs between groups, with the adjusted ratio equaling 1.04, with 95% CI of 0.98–1.11. The authors treated direct variable costs as those varying with the patient’s specific care (eg, medications). The adjusted ratio for direct variable costs was 1.03, with 95% CI of 0.96–1.11. The authors did not identify reasons why the greater incidence of admission into the intensive care unit and longer times in the PACU was not associated with detectably greater costs.1,2 Thus, precisely what accounted for their findings cannot be determined from their reported data. However, their cost result makes sense, conceptually. First, the greater odds of intensive care unit admission associated with partial paralysis show concurrent validity of the authors’ finding. Postoperative residual neuromuscular blockade has safety consequences for patients. However, the patients were admitted to the intensive care unit for further monitoring, not additional procedures such as mechanical ventilation.1 Thus, the intensive care unit admission was effectively, for many patients, equivalent to a longer stay in the PACU.1 There would be only small increases in costs for the entire population because the difference in the incidence of intensive care unit admission was only 1.8%.1 The cohort studied was all patients; consequently, the absolute number of admissions is the relevant end point economically. The value is 2 extra patients per year.a That would be too few patients to influence intensive care unit staffing. Furthermore, from the authors’ discussion: