Results from an enhanced recovery program for cardiac surgery

Michael C Grant; Tetsuro Isada; Pavel Ruzankin; Glenn Whitman; Jennifer S Lawton; Jeffrey Dodd-O; Viachaslau Barodka; Johns Hopkins Enhanced Recovery Program for the Cardiac Surgery Working Group

doi:10.1016/j.jtcvs.2019.05.035

Results from an enhanced recovery program for cardiac surgery

J Thorac Cardiovasc Surg. 2020 Apr;159(4):1393-1402.e7. doi: 10.1016/j.jtcvs.2019.05.035. Epub 2019 Jun 7.

Authors

Michael C Grant¹, Tetsuro Isada², Pavel Ruzankin³, Glenn Whitman⁴, Jennifer S Lawton⁴, Jeffrey Dodd-O², Viachaslau Barodka²; Johns Hopkins Enhanced Recovery Program for the Cardiac Surgery Working Group⁵

Collaborators

Johns Hopkins Enhanced Recovery Program for the Cardiac Surgery Working Group:
Michael C Grant⁶, Tetsuro Isada², Stephanie Ibekwe⁷, Andreas Bauer Mihocsa², Pavel Ruzankin³, Allan Gottschalk⁸, Cecillia Liu⁴, Glenn Whitman⁴, Jennifer S Lawton⁴, Kaushik Mandal⁹, Jeffrey Dodd-O², Viachaslau Barodka²

Affiliations

¹ Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Md. Electronic address: mgrant17@jhmi.edu.
² Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md.
³ Sobolev Institute of Mathematics, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia.
⁴ Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
⁵ Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Md; Sobolev Institute of Mathematics, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia; Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md; Department of Anesthesiology, Cardiovascular Division, Baylor College of Medicine at BTGH, Houston, Tex; Department of Neurosurgery, The Johns Hopkins Medical Institutions, Baltimore, Md; Department of Surgery, Division of Cardiac Surgery, Pennsylvania State University Milton S Hershey Medical Center, Hershey, Pa.
⁶ Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Md.
⁷ Department of Anesthesiology, Cardiovascular Division, Baylor College of Medicine at BTGH, Houston, Tex.
⁸ Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md; Department of Neurosurgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
⁹ Department of Surgery, Division of Cardiac Surgery, Pennsylvania State University Milton S Hershey Medical Center, Hershey, Pa.

PMID: 31279510
DOI: 10.1016/j.jtcvs.2019.05.035

Abstract

Objective: Enhanced recovery programs are multidisciplinary perioperative bundles of evidence-based process measures. Following the design and implementation of preanesthesia and intraoperative enhanced recovery programs for cardiac surgery guidelines, we evaluated the association between compliance and key clinical outcomes.

Methods: Consecutive patients undergoing cardiac surgery at a single tertiary medical center from September 2017 to June 2018 were included. Patients were stratified into low (0-4 measures) and high (5-7 measures) compliance groups and then 1-to-3 propensity matched on the basis of 15 patient and surgical covariables. The primary outcome of interest was time to postoperative extubation. Secondary outcomes included interval time point extubation rates and intensive care unit, floor, and hospital lengths of stay.

Results: A total of 451 patients were included in the study. After propensity matching (n = 315), patients in the high compliance group (n = 84) had a significant reduction in time to extubation (P < .001), floor length of stay (P = .01), and hospital length of stay (P = .03) compared with patients in the low compliance group (n = 231). Patients in the high compliance group were more likely to be extubated in the operating room (odds ratio, 35.8; 95% confidence interval, 10.66-168.75; P < .001) and within 6 hours of surgery (odds ratio, 2.6; 95% confidence interval, 1.18-6.07; P < .02). High compliance was associated with a median estimated time reduction of 3.4 hours to postoperative extubation (P < .001) and 19.4 hours in hospital length of stay (P = .01) compared with low compliance counterparts. There were no reintubations reported among patients extubated in the operating room (0/62 patients).

Conclusions: There is value in developing phase-specific enhanced recovery programs guidelines, which improve rates of early extubation and affect the duration of stay after cardiac surgery. These results are hypothesis generating, and further prospective study is necessary to identify clinical impact of further program expansion.

Keywords: bundled health care; cardiac surgical pathways; enhanced recovery after surgery; perioperative medicine; quality improvement.

MeSH terms

Aged
Airway Extubation
Cardiac Surgical Procedures / rehabilitation*
Cardiovascular Diseases / mortality
Cardiovascular Diseases / surgery*
Enhanced Recovery After Surgery*
Female
Guideline Adherence
Hospital Mortality
Humans
Length of Stay
Male
Middle Aged
Treatment Outcome