Patients discharged three days after open heart surgery are not at increased risk of complications, an analysis of discharge patterns has shown. S Chris Malaisrie (Northwestern Medicine, Chicago, USA) unveiled the findings at the 56th Annual Meeting of the Society of Thoracic Surgeons (STS 2020; 25-28 January, New Orleans, USA).
Malaisrie said: “We have shown that long hospital stays after heart surgery are no longer necessary, and patients can go home safely after just a few days in the hospital. This information helps pave the way for the introduction of a cardiac enhanced recovery after surgery (ERAS) programme, proving that the use of such a strategy is feasible.”
Researchers examined data from 478 patients who underwent nonemergency coronary artery bypass grafting (CABG) surgery or valve surgery (that is, patients had both mitral and aortic surgery) between July 2004 and June 2017 at Northwestern Memorial Hospital. The patients were separated into two groups: 357 patients with a length of stay (LOS) >three days and 121 patients with a LOS <three days. Aside from postoperative atrial fibrillation rates (2% in the ≤three day LOS group and 19% in the >three day LOS group), rates of other complications, 30-day readmissions, and mortality rates were comparable.
“Patients can go home after a shorter length of stay in the hospital without increased risk of complications and rehospitalisations,” said Malaisrie. “Because we found no detrimental effect of accelerated discharge, both patients and physicians should not be averse to discharging patients when medically ready.”
ERAS is a multidisciplinary treatment programme designed to achieve quicker recovery for patients undergoing major surgery and offers sustainable improvement in the overall quality of care. As a result of their findings, Malaisrieet al are developing Northwestern’s first cardiac ERAS program, which will offer standardised approaches for optimising surgical outcomes. The programme will include a suite of modern care protocols based on the recently published guidelines from the ERAS Cardiac Society for optimal, evidence-based perioperative care in heart surgery.
The published recommendations describe 22 potential interventions, separated into sections that cover all phases of surgical care—preoperative, intraoperative, and postoperative—and each principle is graded according to strength and level of evidence. Some of the recommendations include the cessation of drinking alcohol and smoking, avoidance of prolonged fasting, the concept of “prehabilitation” (exercise training, nutrition optimisation, and anxiety reduction), strategies for reducing opioid use and dependence after surgery, and the use of urinary biomarkers to identify patients at increased risk for acute kidney injury. The guidelines are meant to be flexible and individually tailored for each programme.
Malaisrie noted: “Multiple interventions are required for the success of an ERAS program. There is no single magic bullet. Instead, it is through cumulative efforts that ERAS is successful for the patient. We would like to see the care of heart surgery patients be focused more on improving outcomes from the patient’s perspective and less from the physician’s.”
Malaisrie anticipates that the Northwestern Medicine cardiac ERAS program will result in faster recoveries, reduced complications, decreased time in the hospital, lower costs, and improved patient/family satisfaction. In the future, the researchers plan to closely examine both traditional clinical endpoints and patient-reported outcomes from the program.
“Expectations for recovery after cardiac surgery are being reset in the current era,” he said. “What does this mean for patients? It means that prolonged or taxing recovery is no longer required. Patients should know that recovery from heart surgery is not only quicker, but also better with ERAS programmes.”
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