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Ann Thorac Surg 1997;64:706-709
© 1997 The Society of Thoracic Surgeons

Original Article: Cardiovascular

A Coronary Artery Bypass "Fast-Track" Protocol Is Practical and Realistic in a Rural Environment

Robert L. Quigley, MD PhD, Felice L. Reitknecht, MD

Cardiothoracic Section, Department of Surgery, Guthrie Clinic, Sayre, Pennsylvania

Accepted for publication March 28, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. In this study we determine retrospectively whether assignment of all patients undergoing coronary artery bypass grafting to a "fast-track" protocol (FT) is practical and realistic in our rural institution.

Methods. We compared the outcome of 266 consecutive patients undergoing coronary artery bypass grafting who were fast-tracked in 1996 with that of 266 consecutive patients who were managed conventionally (NFT) in 1994. The surgical techniques were comparable in both groups; however, FT anesthesia used inhalational agents and short-acting narcotics. All comparisons were performed using the Student's t test or the {chi}2 test.

Results. Postoperatively 95% of the FT group were extubated by 24 hours compared with 0% in the NFT group (p< 0.0001). The mean intensive care unit length of stay in the FT group was 1.7 ± 0.8 days, whereas it was 2.6 ± 0.6 days in the NFT group (p< 0.001). The mean postoperative length of stay was 6.4 ± 1.2 days in the FT group compared with 7.5 ± 0.9 days in the NFT group (p< 0.001). There were no significant differences in 30-day morbidity/mortality. There was a substantial cost savings in the FT group.

Conclusions. The fast-track protocol can be successful without any compromise of patient care. Early discharge from the hospital, however, is not always feasible.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
The concept of rapid recovery from coronary artery bypass grafting (CABG) operations is not new [1]. However, it was the introduction of managed care that served as a catalyst to develop protocols for this process [2, 3]. Ironically, the implementation of critical pathways including "fast-tracking" of patients undergoing CABG was not associated with an increase in morbidity and mortality [4–6]. In fact, in a very recent report of a prospective, randomized trial, the "fast-track" protocol (FT) has been shown to improve outcome [7].

Historically healthcare reform is usually initiated in metropolitan area academic centers [8]. Now that managed care has been introduced into the rural communities, similar healthcare delivery strategies are required. In this report we retrospectively review our rural heart center experience with "fast-tracking" 266 consecutive patients undergoing CABG during a 7-month period in 1996. We compare our results with those of 266 consecutive patients who underwent CABG at our institution in 1994 when conventional weaning and discharge protocols were practiced (ie, no fast-track [NFT]). Although we introduced the FT protocol in 1995, it was not completely implemented until the latter quarter of that year.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Study
In a retrospective fashion we compared the outcome of 266 consecutive CABG patients who were "fast-tracked" in 1996 with 266 consecutive CABG patients who were managed conventionally in 1994.

Fast-Track Protocol/Chronology (Established 1995)

  1. Preoperative education of patient and family with expectation of early discharge.
  2. Perioperative fluid restriction.
  3. Tracheal extubation within 6 hours of the operation.
  4. Limiting intensive care unit time to less than 24 hours.
  5. Encouragement for early ambulation and physical activity postoperatively including out of bed the first postoperative morning.
  6. Encouragement for bowel regulation with metoclopramide HCl three times daily (Reglan; AH Robbins Co, Richmond, VA) and docusate sodium twice daily (Colace; Meade Johnson, Evansville, IN).
  7. Discharge under the following circumstances:
    1. Afebrile
    2. Normal sinus rhythm
    3. Completion of ten laps (1 mile over 12-hour shift)
    4. Intact wounds
    5. Stable hematocrit
    6. Patient/family and physician all in agreement regarding readiness for discharge
    7. Arrangement for weekly telephone checks by a nurse and a follow-up appointment with a cardiologist in 4 weeks
    8. Demonstration of understanding of tell-tale warning signs that would require notification of physician

Inclusion/Exclusion Criteria
There were no preoperative exclusion criteria. All patients undergoing CABG were enrolled whether the operations were performed as elective, urgent, emergency, or redo. Intraoperative exclusion criteria included the requirement for inotropic agents for cardiopulmonary bypass weaning (exception = 1 to 3 µg • kg-1 • min-1 of dopamine) or placement of an intraaortic balloon pump. Immediate postoperative exclusion criteria included myocardial ischemia/infarction as indicated by electrocardiographic changes, cardiac rhythm disturbances (requiring pharmacologic correction), cardiac index of 2.0 L • min-1 • m-2 or less, and inspiratory oxygen requirement of 60% or greater to maintain an arterial oxygen saturation of 90% or greater.

Operation
All patients were treated comparatively with nonpulsatile bypass and membrane oxygenation (Sarns Turbo 440; 3M, Ann Arbor, MI). The following were performed in both groups (FT and NFT):

  1. Systemic cooling was to 28°C.
  2. Cardioplegia was accomplished with antegrade crystalloid solution and topical ice.
  3. Conduit consisted of one or more internal mammary arteries and/or saphenous vein graft "snake" [9]. Eighty-eight percent of the FT patients and 84% of the NFT patients were grafted with at least one internal mammary artery graft.

NON–FAST-TRACK ANESTHESIA.

  1. Premedication = 70 to 100 µg/kg of diazepam (Valium; Schein Pharmaceutical, Florham Park, NJ) orally and 50 to 100 µg/kg of morphine (Astra USA Inc, Westborough, MD) intramuscularly.
  2. Induction = sufentanil citrate (Sufenta; Janssen Pharmaceutica, Piscataway, NJ) in a bolus intravenous injection of 4 to 10 µg/kg and midazolam HCl (Versed; Roche Laboratories, Nutley, NJ) in an intravenous Bolus of 0.05 to 0.1 mg/kg.
  3. Maintenance = intermittent intravenous administration of 50 to 100 µg/kg of Sufenta and continuous infusion of up to 0.5 µg • kg-1 • min-1 of Versed. Inhalational agents were rarely used.

FAST-TRACK ANESTHESIA.

  1. Premedication = 5 to 10 mg (0.07 to 0.12 mg/kg) of intramuscular morphine and 2 to 4 mg (0.025 to 0.04 mg/kg) of intramuscular Versed.
  2. Induction = 2 µg/kg of Sufenta and 0.07 mg/kg of intravenous Versed and 0.15 mg/kg of intravenous pancuronium (Pavulon; Organon Inc, West Orange, NJ) for tracheal intubation.
  3. Maintenance = 0.2% to 1.5% sevoflurane (Ultane; Abbott Laboratories, Northbrook, IL) and oxygen before cardiopulmonary bypass. After initiation of cardiopulmonary bypass, an inhalation agent is titrated to maintain an appropriate and stable blood pressure. After cardiopulmonary bypass, Ultane is titrated to maintain a stable systolic blood pressure.

Statistics
Significance tests for FT versus NFT reported were either student's t or {chi}2 tests. Both tests were used in Figures 1, 2, and 3GoGoGo. In Figure 1Go the mean ± standard deviation was calculated for FT and NFT and the differences were compared using the t test. Extubation at 24 hours was compared using the {chi}2 test. In Figure 2Go the mean ± standard deviation was determined and compared using Student's t test. The length of stay (LOS) in the intensive care unit was compared at day 1, day 2, and day 3 using the {chi}2 test. In Figure 3Go the mean postoperative LOS ± standard deviation was compared in the two groups using Student's t test.



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  		Fig 1. . Extubation time.

 


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  		Fig 2. . Intensive care unit length of stay.

 


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  		Fig 3. . Postoperative length of stay.

 

   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The epidemiologic data of the two groups (FT versus NFT) are outlined in Table 1Go. Nine variables in each group were compared without demonstration of any statistically significant differences. Age and left ventricular function, two variables considered to be important prognostic indicators, were actually very similar in the two groups [10]. There were more diabetics in the FT group. A greater percentage of patients had preoperative intraaortic balloon pumping in the FT group than the NFT group (7.8% versus 4.51%).


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  		Table 1. . Preoperative Patient Data
 
The CPB and cross-clamp times were significantly shorter in the FT group, although there was not a difference in the average number of bypass grafts/patient (Table 2Go).


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  		Table 2. . Operative Patient Data
 
The mean extubation time in the FT group was 10.16 ± 10.8 hours, whereas it was 38.4 ± 6.38 hours in the NFT group (p < 0.0001). At 24 hours 95% of the FT group was extubated, whereas none were extubated in the NFT group (p < 0.0001). The mean intensive care unit LOS in the FT group was 1.7 ± 0.8 days, whereas it was 2.6 ± 0.6 days in the NFT group (p < 0.001). Fifty-two percent of the FT group were transferred on day 1 compared with an NFT transfer rate of 0 (p < 0.0001). Eighty-two percent of the FT group were transferred by day 2 compared with 48% of the NFT group (p < 0.02). On day 3 comparisons, no significant difference was noted. The mean postoperative LOS was 6.4 ± 1.2 days in the FT group compared with 7.5 ± 0.9 days in the NFT group (p < 0.001).

The 30-day complication rate for FT and NFT patients is listed in Table 3Go. There were no significant differences noted in the four variables assessed including mortality.


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  		Table 3. . Thirty-Day Complication Data
 
The transfer of 52% of the 266 patients from the intensive care unit on the first postoperative day represented a savings for the hospital on these 266 patients of approximately $172,900.00 (approximately $1,250.00/day charge in the intensive care unit). This figure is only a fraction of the total savings in this cohort, which would be influenced by early hospital discharge and a decrease in professional fees (doctors, nurses, respiratory therapists).


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Implementation of a critical pathway, such as FT, by definition should decrease LOS while simultaneously using resources effectively and efficiently [11]. Our results indicate that indeed our protocol was successful. Specifically, we were able to optimize our resources and ultimately save the hospital significant money without compromising patient care or our results. Such a program requires tremendous cooperation and communication between all of the components of a heart center, which include the cardiologists, the surgeons, the anesthesiologists, the nurses (intensive care unit and floor), and the social services. Just as important, however, is dynamic education of the patient and family regarding expectations for early discharge. We accomplished the latter with preoperative videos and perioperative literature.

Although we were very pleased with the success of our program (see Figs 1, 2GoGo), we believe that our rural location did interfere in some instances with early discharge from the hospital (see Fig 3Go). Because our facility services an area covering a radius of more than 240 km, the attending surgeon was not always comfortable discharging patients of advanced age or without family. These patients, who would not have access to an intermediate care facility, not to mention a primary care physician, were kept in the hospital for longer recovery times. This time never exceeded 3 days and applied to less than 15% of the FT population. These gestures may have adversely affected our overall results. We have hypothesized that the construction of an intermediate care facility on the premises of our institution may serve to resolve this latter issue. Such a facility would be staffed by a skeleton staff of medical personnel with a wide nurse/patient ratio to reduce costs.

Some reports have indicated that the use of steroids for 24 hours after cardiopulmonary bypass has facilitated the FT protocol [4, 6]. We routinely administer only a single dose of 250 mg of methylprednisolone sodium succinate (Solu-medrol; Upjohn, Kalamazoo, MI) after anesthesia induction (in both FT and NFT patients). We have not been able to demonstrate any "acute phase response" during cardiopulmonary bypass where we have historically maintained a cardiac index of 2.4 L • min-1 • m-2 or more during nonpulsatile normothermic bypass (37°C) and 1.8 L • min-1 • m-2 or more during nonpulsatile hypothermic bypass (28°C) with strict adherence to a perfusion pressure of 60 mm Hg or greater [12].

Almost twice as many patients in the FT group had preoperative intraaortic balloon pumping compared with the NFT group. We have not changed our indication for such an intervention over the last 4 years; however, it is interesting to note that patients with severe left ventricular dysfunction who undergo CABG may benefit from preoperative intraaortic balloon pumping: such an intervention has been shown to improve survival, reduce hospital LOS, and be more cost-effective [13].

We have not been able to demonstrate that accelerated recovery and hospital discharge after CABG results in a significant decrease in morbidity and mortality as has been shown elsewhere [4, 7]; however, our FT protocol definitely has not compromised patient care or outcome. Reasons for readmission were similar in both groups and included dyspnea, syncope, infection, and failure to thrive. There was no indication that any of these cases of readmission could have been avoided with a longer LOS.

Over the last 12 months we have extended our FT protocol to include all open heart cases and we are initially very satisfied with the results. Without any doubt implementation of this critical pathway (FT) has caused us to reassess and redefine many of our traditional practices that had never previously been challenged including early ambulation, early shower (48 hours postoperatively), and early feeding. In summary, this report documents use of a fast-track protocol in a rural environment. We did not adversely affect our morbidity or mortality statistics while we were able to show significant cost savings.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Quigley, Cardiothoracic Section, Department of Surgery, Guthrie Clinic, Guthrie Square, Sayre, PA 18840.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Klineberg PL, Geer RT, Hirsh RA, Aukburg SJ. Early extubation after coronary artery bypass grafting surgery. Crit Care Med 1977;5:272–4.[Medline]
  2. Taylor GJ, Mikell FL, Moses HW, et al. Determinants of hospital charges for coronary artery bypass surgery: the economic consequences of postoperative complications. Am J Cardiol 1990;65:309–12.[Medline]
  3. Engelman RM. Mechanisms to reduce hospital stays. Ann Thorac Surg 1996;61:526–9.
  4. Krohn BG, Kay JH, Mendez MA, Zubiate P, Kay GL. Rapid sustained recovery after cardiac operations. J Thorac Cardiovasc Surg 1990;100:194–7.[Abstract]
  5. Butler J, Chong GL, Pillai R, Westaby S, Rocker GM. Early extubation after coronary artery bypass surgery: effects on oxygen flux and haemodynamic variables. J Cardiovasc Surg (Torino) 1992;33:276–80.[Medline]
  6. Engelman RM, Rousou JA, Flack JE, et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 1994;58:1742–6.[Abstract]
  7. Cheng DCH, Karski J, Peniston C, et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg 1996;112:755–64.[Abstract/Free Full Text]
  8. Marquez J, Magovern J, Kaplan P, Sakert T, Gravlee GP. Cardiac surgery "fast-tracking" in an academic hospital. J Cardiothorac Vasc Anesth 1995;9(Suppl 1):34–6.[Medline]
  9. Sewell WH, Sewell KV. Technique for the coronary snake graft operation. Ann Thorac Surg 1976;22:58–65.[Abstract]
  10. Curtis JJ, Walls JT, Boley TM, Schmaltz RA, Demmy TL, Salam N. Coronary revascularization in the elderly: determinants of operative mortality. Ann Thorac Surg 1994;58:1069–72.[Abstract]
  11. Zander K. Toward a fully-integrated caremap and case management system. The New Definition 1993;8(2):1–3.
  12. Quigley RL, Caplan MS, Perkins JA, et al. Cardiopulmonary bypass with adequate flow and perfusion pressures prevents endotoxemia and pathologic cytokine production. Perfusion 1995;10:27–31.[Abstract/Free Full Text]
  13. Dietl CA, Berkheimer MD, Woods EL, Gilbert CL, Pharr WF, Benoit CH. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg 1996;62:401–9.[Abstract/Free Full Text]



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