P0400 - Multidisciplinary Fast Track Recovery Pathway for Cardiothoracic Surgery Patients

Purpose:
Post-operative cardiac surgical care can be complicated by a multitude of factors. Communication among numerous members of the care team, inadequate patient pain or nausea management, and occasionally bed availability can lead to delays in patient recovery and prolong post-operative length of stay (LOS). This can result in emotional and financial distress for patients and families, and increase the cost of healthcare. The objective of our project was to decrease total LOS (TLOS) in a safe and effective manner for congenital cardiac patients with two ventricle physiology.

Methods:
We created a Fast Track Recovery Pathway (FTRP) with scheduled anti-emetics to improve nausea and vomiting control, a multimodal pain regimen (including acetaminophen, non-steroidal anti-inflammatory medications, opioids and bowel promotility), and early ambulation. Patients were initially identified as FTRP candidates with the inclusion and exclusion criteria (see below) at our pre-surgical conference. Inclusion was re-evaluated at three stages: 1) anesthesia pre-operative visit, 2) time of post-operative transesophageal echocardiogram, and 3) upon the patient’s arrival to the intensive care unit (ICU).

Inclusion criteria included: 1) age at time of surgery >1 year, 2) two ventricle physiology, 3) elective surgery, and 4) cardiac bypass time <120 minutes. Exclusion criteria included: 1) genetic abnormalities, 2) respiratory issues, 3) history of anesthesia complications, and 4) post-operative instability (cardiac arrhythmia, inadequate cardiac output, high vasoactive support, poor ventilation/oxygenation, significant bleeding requiring blood product transfusion and/or severe pulmonary hypertension).

Several Plan-Do-Study-Act (PDSA) cycles were undertaken and post-intervention data was collected for 22 months. We conducted a retrospective review comparing FTRP patients with those treated prior to the initiation of the FTRP for extubation timing, ICU LOS, TLOS, readmission, admission weight, and distance from the surgical center.

Results:
61 patients met the initial inclusion criteria; 19 patients were excluded based on criteria. A total of 42 patients were followed on the FTRP compared to 46 patients treated prior to implementation of the pathway. The average TLOS pre-FTRP was 3.5 days compared to 3.0 days post-FTRP. By surgical type, TLOS in secundum atrial septal defect, partial anomalous pulmonary venous connection, vascular ring, and subaortic membrane resection were all reduced in the post-FTRP group (Figure 1B). There was no change in 30-day readmission rates (pre-FTRP 2.2 vs post-FTRP 2.4%). However, due to the low number of patients, no results were statistically significant.

Conclusion:
Initiation of the FTRP has demonstrated encouraging results. Patients experienced a more streamlined recovery process with decreased length of stay without an increase in readmission rates. Future improvement strategies may include recommendations for more aggressive diuretic management and chest tube removal guidelines.