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Eur J Cardiothorac Surg 2000;18:22-26
© 2000 Elsevier Science NL

Early discharge following coronary bypass surgery: is it safe?

M. Loubani, N. Mediratta, M.S. Hickey, M. Galiñanes

Division of Cardiac Surgery, Department of Surgery, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK

Received 14 January 2000; received in revised form 11 April 2000; accepted 18 April 2000.

Corresponding author. Tel.: +44-116-250-2450; fax: +44-116-232-1282
e-mail: mg50{at}le.ac.uk


   Abstract
Top
 Abstract
1. Introduction
2. Materials and methods...
 3. Results
4. Discussion
References
 
Objectives: Early discharge has been proposed as a means of containing the escalating cost of health care in cardiac surgery. The aim of this study was to investigate whether shortening the length of hospital stay after coronary artery bypass surgery is safe and cost effective. Methods: Patients (n=198) undergoing elective bypass surgery by two surgeons for a period of 12 months were prospectively entered into the study but not randomized. The anaesthetic and surgical treatments were identical in all patients with the exception that one of the surgeons used intermittent cold crystalloid cardioplegia (‘normal discharge’ group; n=119) and the other used intermittent ischaemia without cardioplegia (‘early discharge’ group; n=79). Previous to the study both surgeons discharged patients on the 7th–8th postoperative day. For the present study, one of the two surgeons adopted the new policy of discharging patients on the 4th postoperative day (‘early discharge’ group). The criteria for hospital discharge included: presence of sinus rhythm, absence of pyrexia and wound infection, normal routine blood tests, satisfactory chest X-ray and ECG and full mobility. Results: The clinical characteristics were identical in the two groups. The number of grafts per patient was 2.8±0.8 and 3.2±1.0, and the total ischaemic time 47±13 and 46±14 min in the normal and early discharge groups, respectively (P=NS in each instance). In the normal discharge group the mean hospital stay was 7.7±3.3 days whereas in the early discharge group it was 4.7±2.0 days (P<0.0001) with 73.5% of the patients being discharged within the first 4 days following surgery. The shortening of hospital stay resulted in a mean reduction of costs of £750/patient. There was no operative mortality (<30 days following surgery) and the incidence of non-fatal perioperative complications were similar in the two groups, with the exception that the incidence of supraventricular arrhythmias was significantly higher in the normal discharge group than in the early discharge group (33% vs. 6.3% respectively; P<0.0001). These rhythm abnormalities occurred within the first 4 days in 89% of patients following surgery and were the cause of readmission in only one patient in the normal discharge group. There were a total of ten (8.4%) readmissions in the normal discharge group and three (3.8%) in the early discharge group. Conclusion: Shortening the postoperative hospital stay to 4 days following elective coronary bypass surgery appears to be safe and can be a means of reducing the cost of care. This in turn may result in a greater availability of resources and in an effective way of reducing waiting lists.

Key Words: Cardiac surgery • Hospital stay • Safety • Cost effectiveness


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods...
 3. Results
4. Discussion
References
 
Shortening the length of postoperative stay has been advocated as a means of reducing the escalating cost of surgery in general and following cardiac surgery in particular. Major improvements in preoperative work up, anaesthesia, myocardial protection, intensive care and postoperative management have contributed to a decline in the morbidity and mortality associated with cardiac surgery [1]. This has resulted in patients being considered for early discharge [2], and a number of studies [3–5] have investigated predictors and determinants of length of stay, which included a number of preoperative, intraoperative and postoperative factors. Thus, the introduction of early safe extubation following cardiac surgery has resulted in shortening of intensive care unit stay [6] and subsequently the concept of fast tracking patients has since become widely accepted [7]. In some units there is a change from the use of traditional intensive care units to cardiac surgical recovery areas [8] which have been shown to be safe and effective alternatives. In this prospective study we examine the safety of early discharge following coronary artery bypass graft surgery which remains controversial.


   2. Materials and methods
Top
 Abstract
 1. Introduction
2. Materials and methods...
3. Results
4. Discussion
References
 
All consecutive patients (n=198) undergoing elective coronary graft surgery by two surgeons during a 12 month period entered this prospective but not randomized study. Patients undergoing emergency surgery or any other concomitant procedures were excluded.

Before the study, the policy of both surgeons was to discharge patients on the 7th to 8th postoperative day. For this prospective study one of the surgeons adopted a policy of early discharge (‘early discharge’ group; n=79) while the other surgeon continued his normal practice (‘normal discharge’ group; n=119).

The anaesthetic and surgical techniques were identical in both groups with the only exception that intermittent cold crystalloid cardioplegia was used in the normal discharge group whereas intermittent ischaemia without cardioplegia was used in the early discharge group.

Patients in the early discharge group were selected for discharge on the third or fourth postoperative day. All patients had their central lines and urinary catheters removed on the second postoperative day and were mobilized. Full blood count plasma urea and electrolytes, ECG and chest X-ray were performed on the day of discharge. The criteria for early discharge included normal pulse, normal blood pressure, absence of pyrexia, haemoglobin greater than 8 g/dl, normal white cell count, urea and electrolytes, and satisfactory ECG and chest X-ray. All patients had to be fully mobile.

Patients were seen by a nurse prior to discharge and at least once in the home following discharge. At the home visit the nurse checked for cardiac arrhythmias, weight gain, pain management and wound infection. An algorithm for the patients’ management after discharge is set out in Fig. 1 .



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  		Fig. 1. Protocol for the management of patients after discharge from hospital.

 
2.1. Statistical methods
All the data are expressed as mean±standard deviation. Statistical significance was determined by the Mann–Whitney test for the comparison of continuous variables, and {chi}2 test and Fisher's exact test were used when appropriate. Any P-value <0.05 was taken to be significant.


   3. Results
Top
 Abstract
 1. Introduction
2. Materials and methods...
 3. Results
4. Discussion
References
 
Table 1 shows that the clinical characteristics were identical in the two study groups. It also demonstrates that intraoperative factors were also similar in the two groups in terms of number of grafts per patient and total ischaemic period; however, mean cardiopulmonary bypass time was significantly longer in the early discharge group.


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  		Table 1. Patients preoperative clinical characteristics and operative dataa

 
There was no operative mortality in either group and, as seen in Table 2, the incidence of non-fatal postoperative complications was similar in the two groups. The only exception was the incidence of postoperative supraventricular arrhythmias, which was significantly higher in the normal discharge group than in the early discharge group (P<0.0001). Fig. 2 shows that the rhythm abnormalities occurred within the first four postoperative days in 89% of the cases.


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  		Table 2. Postoperative complicationsa,b

 


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  		Fig. 2. Time of onset of postoperative supraventricular arrhythmia.

 
The mean hospital stay of 7.7±3.5 days in the normal discharge group, was significantly decreased to 4.7±2.0 days in the early discharge group (P<0.0001). As seen in Fig. 3 , 73.5% of the patients in the early discharge group were discharged within the first 4 postoperative days. This shortening of hospital stay resulted in a mean reduction of costs of £750/patient. In spite of a longer hospital stay in the normal discharge group, there were more readmissions in this group (8.4%) than in the early discharge group (3.8%), however this difference did not achieve statistical significance (P=0.20). Table 3 lists the causes of these readmissions.



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  		Fig. 3. Time of discharge from hospital following coronary artery bypass graft surgery.

 

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  		Table 3. Causes for readmission

 

   4. Discussion
Top
 Abstract
 1. Introduction
2. Materials and methods...
 3. Results
4. Discussion
References
 
As the cost of hospital stay makes up a large fraction of the total costs of surgical treatment there has been a drive towards reducing the total length of stay of patients undergoing cardiac surgery. Preoperative stay has been successfully reduced in some centres, including ours, by admitting selected patients to the hospital on the very day of their operation. Although this may eliminate a day or more of hospitalization, it is not favoured by many as it takes away some of the opportunity for doctor-patient discussion prior to the surgery.

Yet another possibility to reduce total hospitalization is the shortening of postoperative hospital stay [7,9,10]. Both Krohn et al. [9] and Engelman [10] followed a protocol that involved preoperative education of patients and their families, specific perioperative pharmacological manipulation, rapid postoperative extubation, aggressive early mobilization, and follow up support from nurses and surgeons. With this approach a median postoperative hospital stay of 4 days was achieved with no adverse consequences in terms of morbidity, re-hospitalization rate, or mortality. However more than 50% of the families expressed some dissatisfaction with the approach and felt the patients were released too early. In the present study we achieved a similar duration of postoperative stay (3–5 days with a median stay of 4 days); however, in contrast with these studies we did not employ specific pharmacological manipulation such as steroids, digoxin, sodium docusate, metoclopramide, or ranitidine/cimetidine which they routinely used. Nevertheless it should be emphasized that in our study, patients in both groups received comprehensive preoperative information from all disciplines: surgeons, anaesthetists, nurses, physiotherapists and discharge co-ordinator. Patients were informed in depth of the anticipated course of events and daily targets and expectations. Anaesthetic and intensive care management in both groups were identical. Both sets of patients were weaned from ventilatory support as soon as possible (<8 h), as advocated by Aps et al. [11] and others [12,13] provided the criteria for extubation were met. The physiotherapists and nurses together actively started physical activity and mobilization from the first postoperative day thus minimizing the risk of postoperative pulmonary atelactasis. Full mobilization was aimed for by the third or fourth postoperative day. Prior to leaving the hospital, patients in both groups and their families were invited to a ‘discharge talk’ given by specially trained nurses reinforcing daily expectations and issuing guidance regarding further rehabilitation. For those patients discharged early or patients with any outstanding clinical or social concern, arrangements were made for a district nurse to review the patients at home the day after discharge. The patients were given a direct line telephone number to the surgical ward to discuss any concerns after discharge with the nurses or surgeons.

It is of interest to note (Table 3) that patients in the early discharge group did not have a greater rate of re-hospitalization than that in the normal discharge group. On the contrary, the rate of re-hospitalization was lower in early discharged patients (3.8%) than in those discharged later (8.4%). Similar readmission rates have been reported by Krohn et al. [9] and by Engelman [10]. A closer examination of the indications for hospital readmission reveals that neither the complication nor the readmission could have been avoided by a later discharge from hospital; a finding that is also supported by other investigators [9,14].

One limitation of our study is that it compares the practice of two different surgeons, albeit the patient population was matched between the two study groups and they underwent a similar procedure over the same time period. Inevitably, differences in perioperative techniques and practices between two surgeons might have had an impact on postoperative recovery and clinical outcome. However, the postoperative morbidity was similar in both groups. The only exception to this was the greater incidence of supraventricular arrhythmias in the normal discharge group (Table 2). It should be mentioned that most of these rhythm disturbances occurred on the first and second postoperative days (Fig. 2) and therefore did not per se delay discharge of patients in this group. This significant difference in the postoperative supraventricular arrhythmias may be related to the method of myocardial protection employed by the two surgeons. Another limitation of this study may be the relative low mean age of the operated patients as compared with the present general trend to operate in old people. Certainly, old age, association of disease and also the distance between the cardiac centre and the patient's home may be limiting factors for the adoption of early discharge.

Amongst our criteria for discharge we sought stable sinus rhythm and absence of pyrexia. It is worth noting however that there is some evidence from Soloman et al [15] that patients with new-onset arrhythmia after cardiovascular surgery may be discharged in atrial fibrillation without any adverse morbidity in terms of readmission, thromboembolic or haemorrhagic events. Moreover, Engelman [10] permitted discharge of patients in spite of mild pyrexia up to 37.8°C if no infective cause was identified. Therefore, we might have achieved earlier discharge on more patients in the early discharge group if we had relaxed our criteria with respect to pyrexia and atrial fibrillation. The existence of pericardial effusions may be the source of serious complications in the postoperative period and yet another criteria that may be considered for early discharge is a normal echocardiogram.

Cost saving by shortening hospital stay has been advocated by the proponents of minimally invasive surgery [16] as one of it's attractions but we have shown here that even with conventional surgery we can still make cost savings by having a similar postoperative length of stay. Our study demonstrates that it may be safe to reduce postoperative hospital stay by addressing patient and family education, attention to surgery and anaesthetic management, early ambulation and the assistance of a nurse–hospital liaison system. No specific pharmacological manipulation is necessary nor is there a significant strain on hospital medical or primary health care personnel. The average cost of hospital stay per day in our unit is £250, and we therefore achieved a mean saving of £750 per patient discharged earlier. If this policy were applied across the United Kingdom it would lead to a saving of £21 374 250 for the 28 499 coronary bypass operations carried out over the financial year 1997/8 as reported by the UK cardiac surgical register. Extrapolating this to North American figures would yield an estimated saving of £133 million (174 806 coronary artery bypass operations in America and 3500 in Canada in 1998, Society of Thoracic Surgery database). It may be argued that additional resources are needed for the home support system but these are invariably much less than the costs of extended stay in hospital.


   References
Top
 Abstract
 1. Introduction
2. Materials and methods...
 3. Results
4. Discussion
References
 

  1. Yusuf S., Zucker D., Peduzzi P., Fisher L.D., Takaro T., Kennedy J.W., Davis K., Killip T., Passamani E., Norris R., Morris C., Mathur V., Varnauskas E., Chalmers T.C. Effect of coronary artery graft surgery on survival: overview of 10 year results from randomised trials by the Coronary Artery Bypass Graft Trialists Collaboration. Lancet 1994;344:563-570.[Medline]
  2. Sternlieb J.J. Exploring the risk of early dismissal following cardiac operations. J Cardiovasc Surg 1987;28:120-123.[Medline]
  3. Huysmans H.A., Van Ark E. Predictors of perioperative mortality, morbidity and late quality of life in coronary bypass surgery. Eur Heart J 1989;10:10-12.
  4. Ferraris V.A., Ferraris S.P. Risk factors for postoperative morbidity. J Thorac Cardiovasc Surg 1996;111:731-741.[Abstract/Free Full Text]
  5. Weintraub W.S., Jones E.L., Craver J., Guyton R., Cohen C. Determinants of prolonged length of hospital stay after coronary bypass surgery. Circulation 1989;80:276-284.[Abstract/Free Full Text]
  6. Reyes A., Vega G., Blancas R., Morato B., Moreno J.L., Torrecilla C., Cereijo E. Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass. Chest 1997;112:193-201.[Abstract/Free Full Text]
  7. Keon W.J., Sherrard H. Early release after cardiac surgery. Coronary Artery Dis 1997;8:235-241.[Medline]
  8. Chong J.L., Pillai R., Fisher A., Grebenik C., Sinclair M., Westaby S. Cardiac surgery: moving away from intensive care. Br Heart J 1992;68:430-433.
  9. Krohn B.G., Kay J.H., Mendez M.A., Zubiate P., Kay G.L. Rapid sustained recovery after cardiac operations. J Thorac Cardiovasc Surg 1990;100:194-197.[Abstract]
  10. Engelman R.M. Mechanisms to reduce hospital stays. Ann Thorac Surg 1996;61:S26-S29.
  11. Aps C. Fast-tracking in cardiac surgery. Br J Hosp Med 1995;54:139-142.[Medline]
  12. Chong J.L., Grebenik C., Sinclair M., Fisher A., Pillai R., Westaby S. The effect of a cardiac surgical recovery area on the timing of extubation. J Cardiothorac Vasc Anaes 1993;7:137-141.[Medline]
  13. Westaby S., Pillai R., Parry A., O'Regan D., Giannoponlos N., Grebenik K., Sinclair M., Fisher A. Does modern cardiac surgery require conventional intensive care?. Eur J Cardio-thorac Surg 1993;7:313-318.[Abstract]
  14. Beggs V.L., Birkemyer N.J., Nugent W.C., Dacey L.J., O'Conner G.T. Factors related to re-hospitalization within thirty days of discharge after coronary artery bypass grafting. Best Pract Benchmark Healthcare 1996;1:180-186.
  15. Soloman A.J., Kouretas P.C., Hopkins R.A., Kats N.M., Wallace R.B., Hannan R.L. Early discharge of patients with new-onset atrial fibrillation after cardiovascular surgery. Am Heart J 1998;135:557-563.[Medline]
  16. Arom K.V., Emery R.W., Nicoloff D.M., Flavin T.F., Emery A.M. Minimally invasive direct coronary artery bypass grafting: experimental and clinical experiences. Ann Thorac Surgery 1997;63(Suppl 6):548-552.[Abstract/Free Full Text]



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