Original Articles
Fast-Track Cardiac Surgery in a Department of Veterans Affairs Patient Population

https://doi.org/10.1016/S0003-4975(97)00248-8Get rights and content

Abstract

Background. “Fast-track” (FT) cardiac surgery is popular in the private and university sectors. This study was designed to examine its safety and efficacy in the Department of Veterans Affairs elderly, male patient population, a population with multiple comorbid risk factors, often decreased social functioning, and impaired support systems.

Methods. Time to extubation, hospital length of stay, perioperative morbidity, and mortality were studied in two consecutive cohorts undergoing cardiac operations requiring cardiopulmonary bypass before (pre-FT: n = 255, January 1992 to September 1993) and after (FT: n = 304, October 1993 to October 1995) institution of an FT protocol at a university-affiliated teaching Department of Veterans Affairs medical center. Preoperative risk factors, including a Department of Veterans Affairs risk-adjusted estimate of operative mortality, and perioperative surgical and anesthetic processes of care were evaluated.

Results. The mean Department of Veterans Affairs risk estimate of perioperative mortality was not different between the pre-FT and FT cohorts (3.5% versus 3.7%, p = 0.13). In the FT cohort, median time to extubation decreased significantly (19.2 versus 10.2 hours; p < 0.001) along with median surgical intensive care unit stay (96 versus 49 hours; p < 0.001) and total postoperative length of stay (222 versus 167 hours; p < 0.001). Median postoperative day of hospital discharge decreased from day 10 to 7 (p < 0.001). One patient (0.3%) required emergent reintubation directly related to early extubation. Reintubation for medical reasons was unchanged between pre-FT and FT groups (6.3% versus 5.0%; p = 0.48). Postoperative morbidity was similar between groups except for nosocomial pneumonia, the rate of which decreased significantly in the FT cohort (14.7% versus 7.3%; p < 0.005). Thirty-day (3.9% versus 4.6%; p = 0.69) and 6-month mortality (6.7% versus 6.9%; p = 0.91) were unchanged.

Conclusions. An FT cardiac surgery protocol has been instituted in a university-affiliated teaching Department of Veterans Affairs medical center, with decreased length of stay and no significant increase in postoperative morbidity, 30-day mortality, or 6-month mortality. It was associated with a lower rate of nosocomial pneumonia, a finding that must be validated in a prospective study.

Section snippets

Study Design

After Institutional Review Board approval (9/15/95), retrospective data collection was instituted for this project. All patients undergoing cardiac operation at the Denver Veterans Affairs Medical Center requiring cardiopulmonary bypass (CPB) (with the exception of planned circulatory arrest) from January 14, 1992, to October 1, 1995, were entered into a database. Patients were stratified into two consecutive sequential cohorts: pre-FT (January 14, 1992 to September 30, 1993; n = 255) and FT

Results

Patient risk factors are presented in Table 1. The CICSP risk estimate of operative mortality was not statistically different between the pre-FT and FT cohorts (3.5% versus 3.7%; p = 0.13). There were, however, statistically significant differences in several factors used to calculate this estimate (peripheral vascular disease, cardiomegaly, preoperative digoxin use, and preoperative diuretic use). Three variables independently evaluating preexisting lung disease—clinical diagnosis of chronic

Comment

This study reports on FT cardiac surgical management in a Department of Veterans Affairs population. The FT protocol is associated with a reduction in time to extubation along with SICU, intermediate care, and ward LOS. We have documented that patients may be managed with a FT protocol safely, as no major changes in postoperative mortality or morbidity were observed. In addition, our data suggest that this practice may be associated with a reduction in the frequency of nosocomial pneumonia.

Acknowledgements

We acknowledge the dedication and hard work of Sharon Del Hotal, secretary, Anesthesia Section, without whom this study would not have been performed. We also acknowledge the contributions of Elizabeth Munoz with data entry, Donald Huckaby, computer programmer, and Micheal B. Jones, Chief, Information Resources Management Service, for length of stay data extraction; John Hawk, PharmD, for operating room pharmacy records; Judith Wilson, RN, for support from the Nursing Service; Douglas

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