Gen Thorac Cardiovasc Surg (2007) 55:445–449 DOI 10.1007/s11748-007-0162-2

ORIGINAL ARTICLE

Feasibility of the fast-track recovery program after cardiac surgery in Japan Makoto Yanatori, MD · Shinji Tomita, MD Youichi Miura · Youichirou Ueno, MD

Received: 9 March 2007 / Accepted: 25 July 2007 © The Japanese Association for Thoracic Surgery 2007

Abstract Objectives. The purpose of this study was to determine if a fast-track recovery protocol that is applied in other countries can be used in the present Japanese medical system. Second, we wanted to evaluate the differences if the protocol was adapted from the viewpoint of cost saving, postoperative hospital stay, and adverse complications. Methods. We retrospectively analyzed 94 consecutive patients who underwent cardiovascular surgery with conventional techniques on cardiac arrest requiring cardiopulmonary bypass between July 1, 2004 and June 30, 2006. We started our fast-track recovery protocol from July 1, 2005. We compared the results of the conventional group (before July 1, 2005) and the fast-track recovery protocol group (after July 1, 2005). Moreover, we used a unique questionnaire and investigated how the patients in the fast-track group felt about the short hospital stay postoperatively. Results. The mean postoperative hospital stay was 36.7 ± 6.0 days for the conventional group and 15.0 ± 12.4 days for the fast-track group, with a statistically significant difference (P = 0.01). The mean cost fell by almost half, from 712 545 yen to 383 268 yen (P = 0.038). The difference in complication rates was not statistically significant.

M. Yanatori · S. Tomita (*) · Y. Miura · Y. Ueno Department of Cardiovascular Surgery, Nagara Medical Center, 1300-7 Nagara, Gifu 502-8558, Japan Tel. +81-58-232-7755; Fax +81-58-295-0077 e-mail: [email protected]

Conclusion. A fast-track recovery protocol can be safely adapted to patients in the Japanese system without increasing the mortality or morbidity rate. Based on our unique questionnaires, the most important factor was sufficient and repeated explanations preoperatively to the patients and their family members. Second, good pain control with routine use of acetaminophen and sporadic morphine orally has a great effect on the patients’ recovery. Key words Fast track recovery · Cardiac surgery · Postoperative rehabilitation

Introduction During the last few decades, fast-track recovery protocols have become widespread throughout the world and have contributed to significant reductions in the postoperative hospital stay and cost without any increase in postoperative mortality and morbidity.1–8 In Japan, however, patients stay in hospital much longer than in North America and Europe because of the Japanese medical system. The longer patients stay in hospital, the more money the hospital gets. However, this is not a good direction, and we need to get used to a fast-track pathway to make full use of a limited health care budget. We investigated whether our fast-track recovery protocol could have a good effect on our patients. We determined if the protocol increases mortality and morbidity by comparing the conventional group and the fast-track recovery protocol group in regard to postoperative length of stay, morbidity, mortality, and cost.

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Subjects and methods We undertook a retrospective analysis of our cardiovascular surgical experience. A total of 94 consecutive scheduled cardiac surgical procedures were performed in our hospital from July 1, 2004 to June 30, 2006. We started a fast-track recovery protocol from July 1, 2005. Altogether, 40 patients were treated using a conventional protocol (C-group) and 54 using a fast-track recovery protocol (F-group). During this period, conventional surgical techniques were used and were similar for the two groups. Median sternotomy was uniformly used to allow maximum exposure and access. Cardiopulmonary bypass was involved to accomplish the least bloody surgical field. Myocardial protection was accomplished by intermittent tepid blood minicardioplegia, which was delivered through an antegrade, with or without retrograde, fashion. For the fast-track recovery protocol (Fig. 1), patients are admitted approximately 4 days before the surgery. After admission to our hospital, they receive standard preoperative education by nurses, surgeons, and the rehabilitation staff to help them envision their postoperative course. At that time, we tell them that they may be discharged on postoperative day 7 (POD 7) unless they have a postoperative problem. When the surgery is over, patients are transferred to the intensive care unit (ICU), where they stay at least one night with intravenous propofol until the next morning. On POD 1, the propofol is ceased, and we confirm the patient’s vital stability and consciousness and remove the endotracheal tube. Most patients start drinking and dining with careful observation. We use 1500 mg of acetaminophen routinely and oral morphine against sporadic wound pain. We usually remove the drains and alleviate the pain to help them rehabilitate as soon as possible. A criterion for removing drains is that the bloody discharge is less than 100 ml during the previous 8 h. On POD 2, if the patients ingest more than 50% of the meal orally, any intravenous lines that are in place are removed. They are encouraged to go to the toilet beside the bed. On POD 3, they may walk around in the room unless any serious arrhythmia or fluctuation of blood pressure occurs. On POD 4, the pacing wire is removed, and patients undergo an echocardiographic check. They are permitted to take a shower. On PODs 5 and 6, patients walk in the ward for about 100 m with the rehabilitation staff. If they have had coronary artery bypass grafting (CABG), they undergo postoperative coronary angiography on POD 6. On POD 7, they are discharged from the hospital and go home directly. They return follow-up for 1 week and 1 month after discharge in the outpatient clinic.

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We focused on two important areas during the hospital stay. One was preoperative education. The other was daily encouragement, from the inception of postoperative rehabilitation until discharge. Discharge criteria are similar to those noted by Walji et al.6 The most decisive factor for discharge is clinical judgment. Once discharge is permitted with medical safety, the patients’ own willingness and their family’s comfort and support capability are the basis of the final decision making. Satisfaction of the patients in the fast-track group was assessed just before discharge using our unique questionnaire. The results of the F-group were compared to those of the C-group using Student’s unpaired t-test and the chi-squared test. Statistical significance was defined as P < 0.05. All values were expressed as means ± SD.

Results There were no significant differences in the male/female ratio or the mean age (Table 1). In the C-group, none of the patients was discharged within 10 PODs. However, in the F-group, 26 (50%) followed a good postoperative course and were discharged within 10 PODs. The mean postoperative hospital stay was 36.7 ± 6.0 days for the C-group and 15.0 ± 12.4 days for the F-group, with the difference statistically significant (P = 0.01). The mean cost fell by almost half, from 712 545 ± 173 496 yen to 383 268 ± 169 263 yen (P = 0.038) (Table 2). The incidence of postoperative complications was comparable for the two groups, as shown in Table 3. One patient in the F-group suddenly arrested and died in the ward for unknown reasons. The frequency of reoperation due to bleeding, cerebral infarction, mediastnitis, adverse arrhythmia, wound infection/delayed wound healing, and other factors did not lead to any statistical significance between the two groups. The first days of walking in the room (10 m) and in the ward (100 m) were 3.0 ± 1.8 and 5.6 ± 1.1 in the Cgroup and 2.82 ± 1.51 and 4.67 ± 2.35 in the F-group, respectively. No significant differences were found at the point of rehabilitation. No patient required hospitalization within 1 month after discharge. A total of 27 patients dropped out of the fast-track recovery course in the F-group. The reasons were leg wound infection (n = 10), postoperative atrial fibrillation (n = 5), pleural effusion (n = 4), death (n = 1), bleeding (n = 2), pseudomembranous colitis (n = 2), deep sternal infection (n = 1), stroke (n = 2), and others (n = 2). According to our unique questionnaire, 52% of the F-group answered that pain associated with the opera-

Fig. 1 Clinical patholgy sheet for our cardiovascular team

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tion was less than expected, and 41% felt pain as expected; only 7% had more pain than they expected before surgery. We think that this can be attributed to the routine use of acetaminophen and sporadic morphine use. We found that 65% of the fast-track recovery group selected “sufficient preoperative explanation” including the normal postoperative course as the most important factor for them to be discharged as scheduled. The second most important factor was the patients’ positive attitude to discharge; and the third was good pain control with the routine use of acetaminophen and sporadic morphine without any nonsteroidal antiinflammatory drugs. No one had a gastrointestinal bleeding problem.

Discussion The fast-track recovery protocol enabled our cardiovascular patients in the Japanese system to be discharged earlier than the conventional group, but there are no statistical differences between two groups in some items associated with rehabilitation. The postoperative hospital stay significantly shortened, from 36.7 ± 6.0 days to 15 ± 12.4 days. The main reasons for this reduction are pacing wire removal on POD 4, early coronary angiography on POD 6, and enough encouragement to the patients and their family members. Altogether, 26 patients (48%) in the fast-track group discharged within 10 days postoperatively. Although postoperative rehabilitation did not differ significantly in the F-group, they were discharged early because they received enough education about the surgery preoperatively and its postoperative aftermath to achieve their confidence. There were no significant adverse consequences of any complication, such as arrhythmias, infection, or reoperation for bleeding, suggesting that our protocol itself did not increase mortality and morbidity. The cost savings shown with a fast track recovery protocol may disappear if there is an associated increase in serious complications because the cost for such morbidity would exceed the savings achieved by the fast track recovery protocol.9 There was great cost saving in the F-group. The difference in of cost per patient between the two groups was 329 277 yen, which is a 46% reduction, with no severe complications. A suspicion of superficial cost saving with the fast-track recovery protocol

Table 1 Patients’ characteristics and operative variables Parameter

Conventional group

Fast-track group

Age (years) Male/female CABG AVR MVR/P AVR + MVR Valve + CABG Aortic surgery Atrial septal defect CABG + AAA Total

66.2 ± 7.4 24/16 17 4 7 4 4 1 2 1 40

64.8 ± 11.6 39/15 24 9 8 3 6 0 4 0 54

CABG, coronary artery bypass grafting; AVR, aortic valve replacement; MVR/R, mitral valve replacement/repair; AAA, abdominal aortic aneurysm

Table 2 Rehabilitation and cost comparison of the groups Parameter

Conventional group

Fast-track group

P

Walk in the room (day) Walk in the ward (day) Discharge within 10 days (case) Postoperative stay (days) Cost (yen)

3.0 ± 1.8 5.6 ± 1.1 0 36.7 ± 6.0 712 545 ± 173 496

2.82 ± 1.51 4.67 ± 2.35 26 15.0 ± 12.4 383 268 ± 169 263

0.606 0.065 0 0.01 0.038

Table 3 Operative morbidity Morbidity

Conventional group

Fast-track group

P

Any complication (case) Death within postoperative 30 days Mediastinitis Reoperation for bleeding Arrhythmia Postoperative cerebral infarction Wound infection/healing delay Others

18 0 0 0 7 2 3 9

27 1 1 4 9 2 10 10

0.68 1 1 0.134 1 0.573 0.145 0.796

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was described in one article because readmission after cardiac surgery was common and frequent (49%).9,10 To avoid this possibility, we scrutinize the status of the patients carefully before discharge. Some authors have reported that one-fifth of the patients undergoing cardiac surgery were readmitted to outside hospitals.1,9 We did not have any readmission within 1 month after discharge. Although the hospital stay was shorter and the cost reduced in the F-group, the postoperative days of each stage in the rehabilitation process did not differ significantly. We distributed a unique questionnaire to identify the factors that encourage the patients to be discharged earlier and identified that one of the factors was that we encourage our patients more aggressively to be discharged so long as their condition is good and stable. The limitation of this work is that it is a retrospective study and excluded emergent operations. We still do not know if a fast-track recovery protocol contributes to patients’ recovery physically and mentally after going home. This protocol needs to be modified by the feedback from patients.

Conclusion This study found that a fast-track recovery protocol can be applied to our patients and contributed to a reduction in the hospital stay and the cost with no increase in complications. However, the hospital stay should not be shortened without due consideration of the patient’s condition because it may lead to an increase in readmissions with a concomitant decrease in patient satisfaction. Acknowledgment We thank each member of our rehabilitation team for supporting this study.

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