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Ann Thorac Surg 1999;67:363-369
© 1999 The Society of Thoracic Surgeons

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Original Articles

Ultra–fast track hospital discharge using conventional cardiac surgical techniques¹

^a Southwest Cardiology Associates, Albuquerque, New Mexico, USA

Address reprint requests to Dr Walji, 1101 Medical Arts Ave NE, Albuquerque, NM 87102

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra–fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection).

Methods. From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively.

Results. A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients operated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra–fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra–fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether.

Conclusions. Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
During the past few years, fast-track recovery protocols have received widespread acceptance and have contributed to significant reduction in postoperative hospital length of stay after conventional cardiac surgical procedures [1–3]. Typically, however, these pathways have been applied to younger patients undergoing elective and isolated coronary artery bypass grafting (CABG). The Society of Thoracic Surgery database has documented a steady decline over the past decade in this length of stay for patients undergoing cardiac surgical procedures in the United States. In 1997, the mean postoperative length of stay for isolated, primary, elective CABG was 6.4 days, whereas in more complex cases, such as first-time elective mitral valve replacement combined with CABG, it was 10.4 days [4].

Recent innovations in cardiac surgical techniques, popularized as minimally invasive surgical procedures, have emphasized the advantage of allowing even earlier hospital discharges to occur compared with previously published fast-track protocols using conventional cardiac surgical techniques. These techniques have included avoidance of a median sternotomy or omission of cardiopulmonary bypass, or both [5–7]. Despite its obvious appeal, the current absence of long-term data and the limited applicability, presently estimated to be 5% to 30% of all potential cardiac surgical procedures, has raised some concerns [8, 9]. Accordingly, we chose an alternative approach. Instead of minimally invasive procedures, we focused on maximal precision and optimal operative strategies provided by conventional cardiac surgical procedures and attempted to determine the feasibility, efficacy, and safety of ultra–fast track (UFT) discharges in this clinical setting.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We undertook a retrospective analysis of our cardiothoracic surgical experience using data that were prospectively entered. During that period, conventional cardiac surgical techniques were used. A median sternotomy was uniformly used to allow the precision achieved through maximal exposure and access, with cardiopulmonary bypass and hypothermic cardiac arrest (28° to 32°C) to accomplish a stationary and bloodless field, while using optimal strategies of myocardial protection. We defined UFT discharges as those occurring within postoperative days (PODs) 1 to 4, in contrast to the traditional 5-day clinical pathways [10].

From September 25, 1995, to January 5, 1998, coinciding with the start-up of a new two-person cardiac surgical subprogram at Presbyterian Hospital in Albuquerque, New Mexico, a total of 258 consecutive, nonselected patients underwent cardiac surgical procedures by a single surgeon (SW). The operations performed (Table 1) included elective, urgent, and emergent procedures; both isolated coronary and valve procedures; and combined and more complex procedures. A UFT protocol was gradually initiated once the program achieved some maturity.

Once the patient arrived on the floor, an assessment was made by extrapolation from the patient’s clinical progress and stability to date to determine whether the patient was a candidate for UFT discharge. Those who qualified for discharge that same day (POD 1) were started on an accelerated recovery protocol. Ambulation and pulmonary toilet were emphasized. If the patient’s heart rate at rest permitted, low-dose propanolol (10 mg orally four times a day) or digoxin, or both, was started for prophylaxis against atrial fibrillation (AF) or to achieve a more controlled ventricular response rate, respectively, but their usage was not constant or protocol driven. Atrial fibrillation was generally managed by the individual cardiologist’s preference, usually with an initial loading dose of intravenous procainamide or intravenous diltiazem, followed by oral dosing as indicated for maintenance. With the release of ibutilide, its use for the conversion of AF (or flutter ) proved useful on occasion. Gastrointestinal tract stimulants to restore motility and stool softeners or laxatives were only given on an as-needed basis. A brief postdischarge period of supplemental nasal oxygen was prescribed if room air oxygen saturations were less than 90% with activity at time of discharge. Only very small doses of diuretic drugs were prescribed, unless otherwise indicated.

The discharge criteria developed were not dissimilar from the fast-track protocols published elsewhere and are consistent with proper patient care:

1. Uneventful postoperative recovery
   
2. Stable rhythm for 24 hours
   
3. Ambulatory
   
4. Adequate oral intake
   
5. Stable pulmonary function
   
6. Afebrile
   
7. Wounds satisfactory
   
8. Patient and family comfortable with discharge
   
9. Social support available
   
10. Next-day office visit arranged
    

These criteria served as guidelines. The most powerful and effective determinant for discharge remained clinical judgment. Once discharge was deemed medically safe and feasible, the final decision was determined by the patient’s own enthusiasm and willingness and by the family’s comfort level and support capabilities. However, because these discharges truly entailed leaving the hospital facility, rather than merely being transferred to another "hotel" wing of the hospital, all patients and their families were carefully informed that the UFT discharge was an unconventional and potentially risky undertaking and did not represent the current standard of practice at our hospital or in the community.

Those patients who were discharged between PODs 1 and 4 were seen daily as outpatients until POD 5 by the surgeon (S.W.), along with our nurse coordinator (P.N.) or the physician assistant. Blood work (electrolytes and complete blood count), an electrocardiogram, and standard two-view chest x-ray films (posteroanterior and lateral) were obtained during each visit to confirm the clinical impressions of well-being. These visits also afforded an opportunity for further interaction and education. The surgeon was available physically or by telephone without fail at all times during this initial postoperative period. Out-of-town patients stayed in some local accommodation at their own expense until allowed to return to their homes, and their local cardiologist assumed their care. Continued telephone consultation with the surgical service was available when necessary. A subsequent postoperative visit at 2 to 3 weeks was generally arranged with the surgeon.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Of a total of 258 patients (the entire surgical group) undergoing cardiac surgical procedures requiring cardiopulmonary bypass during this entire study period, 144 (56%) were discharged according to the UFT protocol (Fig 1). The numbers of patients and the types of operations performed for each POD discharge group are summarized in Table 2. During the past 12 months of the study (January 5, 1997, to January 5, 1998), in the 1997 group, 76 (70%) of 108 patients achieved UFT discharges. This greater proportion reflected both our growing experience as well as our increasing comfort level. The mean length of postoperative stay in the entire group was 5.4 ± 5.9 days, whereas it was 4.3 ± 6.3 for the 1997 group alone. However, if a single, extremely high-risk patient with congestive heart failure requiring mitral valve replacement with CABG in 1997, who underwent operation on compassionate grounds (and who died on POD 53) is excluded, the mean postoperative length of stay for the 1997 group was 3.8 ± 4.1 days. Operations in this group of UFT patients ranged from single-vessel CABG to a type I aortic dissection operated on with total circulatory arrest and retrograde cerebral perfusion (discharged on POD 3). The ages ranged from 24 to 78 years compared with the age range of 41 to 84 years in the non-UFT group (Fig 2). Of the entire UFT group, 14 patients (age range, 45 to 74 years) with procedures that included multivessel CABG were discharged on POD 1.

View larger version (30K): [in this window] [in a new window]   Fig 1. Postoperative length of stay (LOS) of the 258 patients, showing the number of patients discharged on each postoperative day.

View larger version (28K): [in this window] [in a new window]   Fig 2. The ages for all the patients are shown. The overlap in the age range between the ultra–fast track (Ultra-FT) and the non–ultra–fast track (Non-UFT) groups is evident.

View larger version (15K): [in this window] [in a new window]   Fig 3. Preoperative left ventricular ejection fraction (LEVF) in the 258 patients is plotted against the respective postoperative day of discharge. A trend line is also depicted.

View larger version (27K): [in this window] [in a new window]   Fig 4. Number of readmissions occurring among the 144 ultra–fast track (UFT) discharged patients, grouped according to their original postoperative day (POD) of discharge, and the reasons leading to readmission are shown. (GI = gastrointestinal; MVA = motor vehicle accident.)

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Previously published fast-track protocols have tended to focus on patients undergoing isolated CABG, and typically these protocols have been applied to younger, more elective patients without impaired LV function. In the present study, we extended the practice of accelerated recovery pathways to all ages, regardless of LV ejection fraction or elective or emergency status and to a broader spectrum of cardiac procedures. Our approach offered us the option for complete revascularization in coronary cases as well as an optimal strategy in noncoronary cases. Although the entire sample size was small, we believe that the variety of cases is representative of an average cardiac surgical practice in this country and indeed elsewhere. The usual risk factors of smoking, chronic obstructive pulmonary disease, diabetes, hypertension, dyslipidemias, vascular disease, renal insufficiency, cardiomyopathy, pulmonary hypertension, recent myocardial infarction, previous thrombolytic therapy, preoperative cardiac arrhythmias, and LV dysfunction were frequently observed, as subsequently quantified by Parsonnet risk stratification. Minimally invasive operation could have clearly offered an option for early discharge in some cases but, in our estimation, the subgroup of patients in this study suitable for such an approach would have been smaller.

Intraoperative extubation has been proposed as a means of further reducing or eliminating an ICU stay. However, all our patients underwent extubation in the ICU. The ICU extubation times did not seem to have affected the UFT recovery subsequent to extubation or transfer from the ICU. An overnight ICU stay, along with full monitoring options, additionally allowed us to document respiratory, cardiac, and detailed hemodynamic stability, and in turn guide the discharge decisions.

Albuquerque is at 5,000 feet (1,500 m) above sea-level, and many of our patients resided at more than 7,000 feet (2,100 m). Our reluctance to use blood transfusions on a routine basis often meant that some of our patients had postoperative hemoglobin values of less than 10 g/mL. The combined effects of smoking-related pulmonary dysfunction (documented with tests showing impaired preoperative pulmonary function) frequently seen in our group, along with the high altitude and mild postoperative anemia commonly resulted in transient postoperative hypoxemia requiring supplemental nasal oxygen. We therefore did not hesitate to send patients home with a short postdischarge weaning protocol of 2 to 3 L/min of nasal oxygen.

Cardiopulmonary bypass has been thought to have many deleterious effects. The interaction between blood and foreign surfaces in the cardiopulmonary bypass circuit activates complement and neutrophils to produce a whole-body inflammatory response [12]. Leukocyte filters in the bypass circuits have been used by some investigators, and various doses of steroids for varying lengths of time have been advocated by others [1, 2], to blunt this effect. Neither measure was used in our patient group.

Short duration of aortic cross-clamp and cardiopulmonary bypass times have been thought by some to be important to allow early discharges to occur [13]. In our study, patients with more involved operations requiring a longer duration of cross-clamp and bypass times were not excluded from UFT discharges. With improved strategies of myocardial protection and improvements in bypass circuit, particularly membrane oxygenator technology, the actual length of cross-clamp and bypass time is likely to become less critical. Instead, the quality and precision of surgical techniques and the duration of nonprotected ischemic times may become recognized as better determinants of clinical outcomes.

New onset of postoperative AF significantly affects the timing of discharge in all patients. We cannot explain the lower incidence of AF in our entire series compared with the reported 1997 national incidence of 19.4% (CABG only) to 31.4% (CABG with mitral valve replacement) [4]. Onset of AF clearly resulted in delayed discharges. A stable baseline rhythm for at least 24 hours was deemed essential before a patient could be discharged. Prophylactic use of amiodarone or triiodothyronine has been reported as efficacious in decreasing the incidence of AF [14, 15]. These agents were not used in this study, however.

Accelerated recovery pathways have been described in pediatric patients with as short as 2-day hospital stays after complex congenital cardiac surgical procedures [16]. However, the adult UFT discharges initiated in the present study were not in practice either at our hospital or in our community. To our knowledge, adult patients after extensive conventional cardiac surgical procedures had not been discharged on POD 1 or 2 elsewhere either. Ethically, a detailed verbal informed consent was therefore thought to be also essential. The medicolegal implications of undertaking a departure from the standard of care were clearly substantial. One has to have an enormous clinical comfort level to discharge a patient after four-vessel CABG on POD 1. The precise, uncompromised, and time-tested techniques of conventional cardiac surgical procedures, as we were all trained to do, provided us this required reassurance. Detailed hemodynamic data obtained during a closely monitored overnight ICU stay served to validate this clinical judgment or to alert us of unsuspected potential problems.

Those patients assessed for discharge on POD 1 or 2 required accelerated recovery pathways. Because of compressed timelines, attention to details became even more crucial. The recovery protocols in our study were surgeon driven, but because the surgeon was part of an integrated cardiology–cardiac surgery group, the territorial concerns were significantly diminished, and coordinated patient care was perhaps more smoothly achieved.

Although no written questionnaires were sent, we had ample verbal and written feedback from both the patients and their families. The patients in the UFT groups were uniformly pleased with their accelerated discharges and felt they would do it again.

Patient readmissions can provide valuable feedback for our discharge strategies. To validate our clinical judgments, therefore, our threshold for readmissions was intentionally set low. Readmission rates of up to 8.3% have been commonly reported for cardiac surgery programs [3]. Our readmission rate of 5.6%, despite our lowered readmission threshold, made us conclude that longer initial hospital stays may not have prevented readmissions. Most important, however, the lack of mortality in the UFT group provided the required moral justification to continue with these accelerated discharges.

An appropriately timed hospital discharge after cardiac surgical procedures is a confirmation of the patient’s functional and clinical recovery. The length of hospital stay documented here was merely a quantifiable derivative and provided a time index of reaching this clinical outcome. The protocols in this practice were initiated entirely voluntarily, without any economic pressure from the hospital. Managed care and managed cost groups could unfortunately misrepresent our intentions. Our goal was to obtain a quality result, and the real emphasis was to provide our patients with a durable and potentially long-lasting therapeutic intervention. There are many ways of reaching that goal in an appropriate length of time. Conventional techniques, we believe, lend themselves to a wider and broader-based application in cardiac surgical procedures. Ours was not a prospective study to compare minimally invasive cardiac surgical techniques with conventional cardiac surgical procedures, and any comparative conclusions would therefore be unwarranted.

In summary, conventional cardiac surgical procedures, without requiring the additional burden of new training, implied learning curves, or expensive equipment, already have the potential for UFT discharges while retaining the valuable advantages of precision, safety, and time-tested surgical techniques. There is sufficient promise in these UFT results to warrant further investigation.

	Acknowledgments

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank all the Southwest Cardiology Associates, as indeed all the referring physicians and consultants, for their assistance, support, and faith in this project; and Dennis Fischer, PAC, and Richard Jackson, PAC, for their role in the care of these patients. Doctor Walji dedicates this report to his former mentor, the late Dr George H. A. Clowes, Jr, former Professor of Surgery at Harvard Medical School, who pioneered the membrane oxygenator and who believed that cardiopulmonary bypass would one day become safe for patients.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
¹ This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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