Asian Cardiovasc Thorac Ann 2007;15:139-143
© 2007 Asia Publishing EXchange Ltd
Fast-Track Cardiac Surgery: Application in an Australian Setting
Julian Gooi, FRACS,
Silvana Marasco, FRACS,
Michael Rowland, FRACS,
Don Esmore, FRACS,
Justin Negri, FRACS,
Adrian Pick, FRACS
CJOB Cardiothoracic Department, Alfred Hospital, Melbourne, Australia
For reprint information contact: Julian Gooi, FRACS, Tel: 44 1480 830 541, Fax: 44 1480 364 898, Email: julian.gooi{at}bigpond.com, 28 Batman Street, North Fitzroy, Victoria 3068, Australia.
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ABSTRACT
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In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.
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INTRODUCTION
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The current state of healthcare in Australia is such that there is greater demand for fewer economic resources. Cardiac surgical units are expected to perform more procedures with fewer economic resources, while encouraging greater throughput and shorter lengths of stay. The amalgamation of intensive care units (ICUs) and loss of specialist cardiac ICUs in most Australian hospitals has left most cardiac surgery patients competing for the general pool of ICU beds on a daily basis. Furthermore, in many adult cardiac surgical units, high-risk patients have become more common. They are generally older with multiple comorbidities and undergoing repeat or complex procedures.1,2 This group is characterized by prolonged ICU and hospital stays that consume a greater proportion of hospital and unit resources.
The concept of fast-track (FT) cardiac surgery has been utilized worldwide with the aim of helping patients recuperate more rapidly and shorten the period of critical care without compromising outcomes.3–9 By promoting greater throughput of patients whilst decreasing the occupancy of ICU beds, FT cardiac surgery enables a unit to maintain its caseload while minimizing costs and its reliance on ICU beds.10,11 Our unit has had an FT policy in place since January 2000. This is defined as patient discharge from the ICU within 9 hr (one ICU nursing shift). In addition, on certain days of the week, our recovery ward (post-anesthetic care unit) can care for FT cardiac surgery patients provided they are discharged to the ward within 9 hr. To facilitate this FT policy, our general cardiac surgery ward can accept high-dependency patients who may be on low-dose inotropics (noradrenaline and dopamine) only.
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PATIENTS AND METHODS
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Patient data was prospectively collected in our cardiac surgery database of all patients undergoing routine cardiac surgery (coronary artery bypass, valves, or both) between July 2001 and June 2004. All patients considered for FT recovery were identified, and their clinical outcomes examined. These results were compared with those of the remaining cohort of patients. Prior to July 2001, patients were considered suitable for FT cardiac surgery if they were less than 65 years of age, with few comorbidities, normal ejection fraction, and undergoing elective coronary artery bypass or valve procedures. From July 2001 onwards, the criteria were broadened to include patients of any age who fulfilled the remaining criteria. Patients were excluded from FT if they were undergoing combined or more complex procedures (aortic root surgery or double-valve procedures) or required emergency or salvage procedures. Patients were deemed eligible for Fast-track cardiac surgery following discussion and evaluation by both the treating anesthetist and cardiac surgeon. Fast-track candidates were placed first on the operation lists for that day, if possible.
All FT candidates received a fentanyl- and propofol-based anesthetic with pancuronium as a paralyzing agent.12–14 At the conclusion of surgery, patients were returned sedated and ventilated to the ICU or post-anesthetic care unit. Sedation was maintained by infusion of propofol 1–2 mg·kg–1·hr–1 with morphine 1–2 mg·hr–1 for analgesia. Patients were usually warmed with an air-warming blanket.12 Once hemodynamic stability was achieved and absence of bleeding confirmed, sedation was discontinued and the patient was assessed for extubation. If deemed stable, the patient was extubated. If all hemodynamic and respiratory parameters remained stable, the patient was transferred to a lower-dependency ward, in most cases, the cardiothoracic unit ward.12,14,15
Results are presented as the median value and range, or mean ± standard deviation. Statistical analysis of the data was performed with StatView version 5.0 software (SAS Institute Inc, Cary, NC, USA). The Student t test was applied to analyze normally distributed continuous data. Nonparametric data were analyzed using the Mann-Whitney U test.
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RESULTS
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Cardiac surgery (excluding ventricular assist devices or transplants) was performed in 1,488 patients during this period. Of these, 342 (23%) were identified as FT cardiac surgery patients. Table 1
summarizes the patient characteristics. Those in the FT group were younger and more likely to be male. The non-FT group patients were more likely to have peripheral and cerebrovascular diseases. Mean EuroSCORE for the FT group was significantly lower.16 The majority of patients in the FT group had a normal ejection fraction and were treated electively. Table 2 summarizes the perioperative details of the 2 groups. The FT group had significantly shorter ventilation time, lengths of ICU and hospital stay, with acceptable mortality. Coronary artery bypass grafting predominated in both groups; however, significantly more of these operations were performed in the FT group (80.7% vs 72.6%; p = 0.002). More combined procedures were performed in the non-FT group (13.7% vs 6.1%; p = 0.0002). A significantly greater proportion of off-pump operations were carried out in the FT group: 59 (17.2%) vs 80 (7%); p < 0.0001. Table 3 lists the postoperative complications in both groups. The FT group had a significantly lower rate of re-operation for bleeding or tamponade. Readmissions to ICU were low in both groups, but lower in the FT group. Interestingly, the incidences of reintubation and postoperative pneumonia were similar (5%) in the non-FT group. The FT group had a 10.5% rate (36 patients) of readmission to hospital within 30 days compared to 14.1% (162 patients) in the non-FT group (p = 0.084). Figure 1 illustrates the reasons for readmission to hospital within 30 days. A greater proportion of non-FT patients were readmitted for treatment of pneumonia after discharge (p = 0.001).
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Figure 1. Reasons for readmissions to hospital within 30 days of discharge. Other = social issues, pain-related investigations, electrolyte abnormalities. *p = 0.02.
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DISCUSSION
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At present, cardiac surgery is faced with 2 distinct populations of patients. One comprises low-risk relatively young patients undergoing first-time coronary artery bypass or valve procedures. In contrast, the other is generally older patients with multiple comorbidities who are undergoing repeat or complex procedures.1,2 This group is characterized by prolonged ICU and hospital stays that consume a much greater proportion of hospital and unit resources. Previously, postoperative cardiac surgical care involved prolonged periods of sedation and ventilation, and as a result, prolonged ICU stay.16,17 Numerous studies have determined that there is no benefit in prolonged sedation and ventilation, and it may be detrimental with increased rates of pneumonia and ventilator-related complications.6,10,17 This is supported by our finding that the non-FT group had a significantly greater proportion of patients developing postoperative pneumonia (p = 0.001), and relatively more being readmitted within 30 days for treatment of pneumonia (p = 0.023). In addition, studies have also shown that extubation in the operating room does not result in significantly shorter ICU or hospital stay.18 Extubation in the operating room may place additional functional and metabolic stress on a postcardiotomy patient, and it may have detrimental effects on outcome.6,10,18,19 Delaying extubation by 3–4 hr after surgery minimizes the risks of cardiorespiratory instability but allows time to identify excessive postoperative bleeding. The protocol for early extubation in the FT group had no effect on readmission to the ICU and reintubation rates, with both being significantly more likely in the non-FT group (p < 0.0001 for reintubation, p = 0.001 for readmission to ICU). This study revealed that low-risk cardiac surgery patients of any age can be accurately selected for FT recovery with acceptable morbidity and mortality.
The FT policy requires selection of patients with a normal ejection fraction and minimal comorbidities undergoing an elective procedure. It requires organization of the surgical list with the lowest-risk patient operated on first, using an anesthetic technique aimed at early awakening and tracheal extubation, whilst maintaining stable hemodynamics and other organ function, followed by intensive monitoring and care during the early postoperative period, and step down to a high-dependency area with a decreased nurse/patient ratio, as required. The protocol for the FT policy at our institution was developed with input from all departments involved. It is only with a true multidisciplinary approach that an FT policy can be effectively implemented. Accurate patient selection is ensured by thorough patient work-up and assessment, followed by consultation between the anesthetic and surgical teams. The timing of surgery is also important as placing FT patients first on the operating list allows sufficient ICU and post-anesthetic care unit time for recovery and assessment. By ensuring that the cardiothoracic ward is staffed with suitably experienced medical and nursing staff, we can provide a more intensive level of care. Provision of high dependency or step-down beds in our cardiothoracic ward where low-dose inotropics and invasive monitoring can be accepted also enables patients to be discharged earlier from the ICU. Our institution has a policy of discharging ICU patients at any time of the day or night, and the step-down beds enable more patients to be discharged early from the ICU, thus freeing up ICU beds.
This FT policy not only decreases our reliance upon ICU beds but also provides substantial economic benefits. On average, an ICU bed costs AUD$3,000 (US$2,250) per day to run and staff, while a bed in our cardiothoracic ward costs approximately AUD$750 (US$562) per day. At present we operate on approximately 120 FT cases a year, resulting in a potential saving of AUD$540,000 (US$405,000) per year.
It was concluded from this study that the FT protocol accurately identified low-risk cardiac surgery patients suitable for less intensive support during postoperative recovery, with acceptable morbidity and mortality. This allows greater throughput of patients with less reliance on ICU beds and more efficient use of resources. Cardiac surgery units should consider such a fast-track policy to ensure caseloads and patient outcomes are maintained.
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ACKNOWLEDGMENTS
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The authors are indebted to the major contribution of Ms. Sharon Daly, Data Manager, CJOB Cardiothoracic Department, Alfred Hospital, for her assistance in the preparation of this manuscript.
Presented at the Annual Meeting of the Australian Society of Cardiothoracic Surgery, Noosa, Queensland, Australia, October 19–24, 2004.
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ABSTRACT
INTRODUCTION
