MECHANISMS TO REDUCE HOSPITAL STAYS

Background. The present era of medicine is concerned to a large measur e with cost containment and the advent of managed care. For these reas ons the concept of reducing hospital stays with a concomitant reductio n in hospital cost is very attractive. The role of fast track is to en sure that we are not placing the patient at any additional risk and in fact are improving recovery and patient well-being. Methods. Fast tra ck is based on a specific protocol that is followed for each patient. Intensive preoperative education of patient and family familarize them with early discharge. Anesthetic technique is modified to effect earl y (4 to 8 hours) postoperative extubation. Steroids are administered p erioperatively to improve myocardial function and reduce the release o f inflammatory mediators. Digoxin is given prophylactically as are the bowel-mediating drugs metoclopramide, docusate, and ranitidine. The f ast-track protocol is associated with aggressive ambulation of the pat ients and cardiac rehabilitation, so that the patient is out of bed th e first day after operation, walking in the hall the second day, and u p a night of stairs the third day. Results. A shift to fast track in 1 992 permitted comparison between 282 non-fast-track patients and 280 f ast-track patients undergoing coronary artery bypass grafting. The res ults showed no adverse consequences of fast track. Forty-eight percent of fast-track patients were discharged at 3 to 5 days compared with 2 6% of non-fast-track patients. No significant differences were found b etween the two groups with respect to infection (1%), operative mortal ity (approximately 4%), and 30-day hospital readmission (7% non-fast-t rack and 8% fast-track). A postdischarge questionnaire addressed issue s of patient and family satisfaction. The early discharge patient had a 77% comfort level, whereas their family members felt satisfied with a 3- to 5-day hospital stay in only 54% of cases. These data suggest t he need for better communication, education, and additional postdischa rge support systems. Conclusions. A fast-track protocol allows faster recovery and earlier discharge from both the intensive care unit and t he hospital without apparent increased risk. Complicated patients can also be fast tracked, and the desire to do so may actually expedite re covery.