Guidelines cut lung surgery length of stay

Most patients go home after three or four days

A set of daily guidelines for patients undergoing lung surgery can significantly reduce their length of stay in the hospital while at the same time increasing quality of care and patient/ family satisfaction, according to a study published in the August 2001, Journal of Thoracic and Cardiovascular Surgery.1

In a study of 500 chest patients, Robert Cerfolio, MD, associate professor of surgery, division of cardio thoracic surgery at the University of Alabama at Birmingham (UAB), found that setting a very specific daily treatment regimen allowed most patients to go home within three to four days. "In studies at Mass General and Hopkins, they had lengths of stay of six and seven days," he notes.

Cerfolio performed 500 consecutive pulmonary resections through a thoracotomy over a period of two years and nine months at UAB. The patients were extubated in the operating room and sent directly to their hospital rooms.

Chest tubes were placed and — if there was no air leak and drainage was less than 400 mL/d — were removed on POD 2 (postoperative day two). Epidural catheters were used and also were removed POD 2. Each daily plan and discharge plans were reviewed with the patients and their families during rounds. The patients went home the day the last chest tube was removed; persistent air leaks were treated with Heimlich valves.

Of the 500 patients, 482 were extubated in the OR and 380 were sent to their hospital rooms. The remaining 120 were sent to the intensive care unit (ICU) for a median of one day. Complications occurred in 107 patients, and operative mortality was 2%. A total of 327 of the patients left the hospital on POD 4 or sooner. In response to a survey taken at discharge, 97% of the patients said they had excellent or good satisfaction with their care. In a two-week follow-up contact, 91% said they were "extremely happy" or satisfied.

These results led the researchers to conclude that "Most patients who undergo elective pulmonary resection can be extubated immediately after operation, go directly to their room and avoid the intensive care unit, be discharged on postoperative day three or four, and have minimal morbidity and mortality. . . ."1

Cerfolio notes this protocol deviates significantly from what he has seen in other institutions. "The main reason [for longer lengths of stay at other hospitals] is that they have more air leaks, and so the chest tubes have to stay in longer so the patient is in the hospital longer," he says. "Also, I get my pain catheter out of the back on POD 1 instead of POD 4 like they do at The Mayo Clinic, where I trained. This way, patients get controlled by pills so they can go home sooner on pills by mouth."

While clearly concerned with quality of care, Cerfolio says that satisfaction — for both patient and family — also were paramount in his mind. "I avoid the ICU; it’s better for the family because they can be there at all times without limiting visiting hours," he notes. The researchers addressed this issue in great detail as they discussed the results of the study.

"We believe the ICU could be avoided for most patients who undergo elective pulmonary resection," they asserted. "Moreover, the ICU seemed to decrease patient and family satisfaction because of the limitation of visiting hours and the lack of control the families experience in caring for their loved ones. We believe the family provides an important type of extra care for the patient, especially when they sleep in the room with the patient.

"Patients also seem less confused with their family members around," the researchers explained. "We therefore developed a postoperative protocol that highlighted the selected use of the ICU and targeted a four- to five-day length of stay after thoracotomy."1

They went on to note that this protocol in no way compromised patient safety. "Our study found the ICU could be safely avoided," they asserted. "There seemed to be no added morbidity or mortality with its elimination. When a patient has an arrhythmia or falling oxygen saturation levels, early recognition and treatment are crucial. This can only be accomplished in a non-ICU setting with proper monitoring."1

Cerfolio concedes, however, that the situation at UAB is perhaps unique. "I do more surgery than anybody in North America," he notes, "so we do quick, efficient surgery and have a protocol and team that is set up to handle seven or eight operations a day. The team makes a huge difference."

Reference

1. Cerfolio RJ, Pickens A, Bass C, et al. Fast-tracking pulmonary resections. J Thorac Cardiovasc Surg 2001; 122:318-324.

Need more information?

For more information, contact:  Robert Cerfolio, MD, Associate Professor of Surgery, Division of Cardio Thoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd., Birmingham, AL 35294. Telephone: (205) 934-5937. E-mail: Robert. cerfolio@ccc.uab.edu.