New techniques put post-ops on the fast track
Nurses can cut cardiac patients’ recovery time
Surgical breakthroughs are enabling postoperative cardiac patients to achieve faster recovery time even for complex procedures that once involved lengthy inpatient stays. But what are the drawbacks to fast-tracking traditional ICU patients, and why should nurses even consider guiding their cases into such accelerated treatment and recovery protocols?
Today, patients generally spend less time than ever in recovery, thanks chiefly to minimally-invasive surgical techniques and new anesthetic agents such as Proponol that have shorter half-lives. Patients can even circumvent a long stay in a post-anesthesia care (PACU) or med-surg unit followed by a two-or-three day ICU admission. Instead, the ICU-stay, even when necessary, is much shorter, often lasting less than 12 hours. In some cases, the ICU can be avoided completely.
The patient usually feels better; and in almost all cases, he or she is discharged to a home care program in less than 24 hours. Although these techniques are becoming well known, fast tracking can be fraught with concerns. The drawbacks have chiefly involved patient safety in light of scant, though growing research into streamlining post-operative care.
Post-op patients spend too long in recovery
Most of the research has been based on a growing belief that cardiac post-op patients typically spend far too much time in a traditional recovery unit, says Myrna Mamaril, RN, MS, a nurse manager at St. Joseph Medical Center in Towson, MD. According to some estimates, patients spend up to three times longer than necessary in recovery. Several reasons are responsible. Most focus on a lack of willingness by clinicians to change long-established medical practice, says Mamaril.
Interest is growing in the development of new pathways, or care maps, that will allow eligible patients to be discharged sooner than later. The longer a patient stays in the hospital, the longer he or she will take to achieve normal recovery, says Mamaril, an advocate of carefully monitored and planned fast tracking.
Streamlining patient care in this manner is something of a balancing act. It involves knowing, with reasonable clinical certainty, when a patient is ready for discharge and making sound, educated predictions that he or she will not develop medical complications that may require a second hospital admission within days.
The threat always looms that the patient may have to return with a serious co-morbidity, says Vallire D. Hooper, RN, MSN, an instructor in the department of adult nursing at the Medical College of Georgia in Augusta.
The complications are likely to occur with a certain percentage of post-op cardiac patients, regardless of the length of their in-hospital recovery.
This factor should not discourage nurses from working with patients toward a prompt, appropriate discharge, Hooper says. The protocol "can work for the right post-op case and should be explored as a way to improve outcomes and ease the potential for ICU overcrowding," Hooper says. Nursing factors to take into account include:
• Strong pre-op assessment.
Generally healthy patients with no history of chronic disorders or potential for medical complications following surgery make the strongest candidates for the pathway, says Hooper. The level of complexity of the surgery itself is also a factor. Complex procedures generally reduce the predictability of an appropriate recovery.
The patient’s history and physical should rule out the existence of pulmonary defects, circulatory problems such as hypertension, or other chronic disorders — including diabetes — that would give rise to future complications. Strong family support and the patient’s psychological state of mind also should be evaluated prior to determining pathway eligibility, Hooper adds.
• Well-conceived and supported care maps.
The clinical team, including physicians, nurses and anesthesiologist, is ultimately responsible for determining eligibility for the fast track pathway. The pathway itself has to be well defined, reasonably designed, yet sufficiently detailed to enable nurses to look for specific clinical criteria such as blood pressure and heart rate that may rule out the patient during recovery, says Mamaril.
The team can devise the care map for each type of surgical procedure based on the surgical department’s past experience with patients and their outcomes. The map also should anticipate unexpected complications during in-hospital recovery that may require a longer length of stay.
• Close bedside monitoring and patient education.
Bedside monitoring in a PACU or ICU should focus on helping the patient move toward becoming independent as soon as possible. If the patient responds, the nurse can offer instructions on how to change dressings and help with aspects of daily living such as bathing and medication schedules. The patient and family members have to be receptive to such education support, Hooper cautions. "There are no cookie-cutter approaches here," she says.
• Post-discharge planning.
Part of the process involves a well-defined home care program and discharge planning that includes regular physician office visits. The home care plan must be tailored to the individual patient and must be monitored by the critical and acute care staff for weeks following discharge.
"There is a high potential for re-hospitalization with certain patients," Hooper says. A community outreach program can coordinate the home care plan while monitoring the patient’s post-discharge progress.
Research supports one-day admission as safe
While there is some complexity to fast tracking, a growing body of clinical research supports the effectiveness and benefits of these efforts. In 1995, researchers at Sewickley Valley Hospital in Sewickley, PA, documented results of their efforts to develop a pathway for streamlining the length of stay of patients who underwent an elective carotid endarterectomy.
In a review of cases involving 186 patients, researchers concluded that a one-day admission was a "safe, highly cost-effective" protocol, resulting in efficient use of ICU resources, according to a published report.1
Of the patients studied, 157 were discharged within 24 hours of the procedure. The average length of stay was 1.27 days. Of the discharged group, one patient died from cardiac causes on the 28th day following discharge. There was no hospital readmission within the study period, which ran from Jan. 1, 1991 to June 30, 1994.
Twenty-six percent of the patients who underwent the operation were diagnosed as asymptomatic, while 74% had either transient symptoms or a prior stroke. Thirteen percent were operated on under general anesthesia.
Furthermore, the hospital realized significant cost savings. For each patient in the discharged group, the institution saved an average of $3,000 in total patient-care costs calculated from a comparison of dollar amounts that would have been paid under the procedure’s allowable diagnosis-related group (DRG).
The study cited neurological complications, ICU admission, and an increasing length of inpatient stay as factors that typically drive up the cost of performing the carotid endarterectomy. These factors were not significant enough to affect costs in the discharged patients, according to the study’s author.
Hospital, staff must buy into the process’
A second study supported Sewickley Hospital’s findings. In 1993, surgeons at Baystate Medical Center in Springfield, MA, initiated a fast-track protocol aimed at a one-day hospital stay following carotid endarterectomy.2 In the majority of cases, the stay did not involve the minimum one night for ICU monitoring, which was the norm prior to the study.
Between 50% and 61% of the 152 cases studied were discharged within the first two post-op days. Eighty-seven percent went home by the second day. However, 60 cases did go to the ICU, but only 18 were admitted. Of the total, 21 patients experienced complication. Three patients died within 30 days, and five had reported neurological deficits. Fourteen patients had to be readmitted to the hospital, but none was related to the discharge on the first or second post-op day.
Excluded from the study were patients whose endarterectomy involved a coronary revascularization, and those who underwent the first part of a staged bilateral endarterectomy performed in the same hospitalization.
Both hospital studies point to the importance of selective screening of patients for eligibility. Throughout, advocates have cautioned that the streamlining process must be managed and planned carefully for each patient before the surgery. Efforts not achieving expected results are those that fail to achieve a unified multi-disciplinary approach, Hooper says.
Physicians, critical care nurses, and acute care personnel must support the organizational effort. "Everyone has to buy into the process for this to make any sense," she adds.
The process of identifying patients who are suitable fast-track candidates has to begin as early at the pre-op testing stage. Fast tracks work best, according to Hooper and others, when nurses adhere to a formal, detailed clinical pathway, and patients are carefully selected and monitored during the tracking period.
1. Collier PE. Are one-day admissions for carotid endarterectomy feasible? Am J Surg 1995; 170:140-143.
2. Kaufman JL, Frank D, Rhee, SW, et al. Feasibility and safety of a 1-day postoperative hospitalization for carotid endarterectomy. Arch Surg 1996; 131:751-755.