FAST-TRACK CARDIAC-SURGERY IN A DEPARTMENT-OF-VETERANS-AFFAIRS PATIENT POPULATION

Background. ''Fast-track'' (FT) cardiac surgery is popular in the priv ate and university sectors. This study was designed to examine its saf ety and efficacy in the Department of Veterans Affairs elderly, male p atient population, a population with multiple comorbid risk factors, o ften decreased social functioning, and impaired support systems. Metho ds. Time to extubation, hospital length of stay, perioperative morbidi ty, and mortality were studied in two consecutive cohorts undergoing c ardiac operations requiring cardiopulmonary bypass before (pre-FT: n = 255, January 1992 to September 1993) and after (FT: n = 304, October 1993 to October 1995) institution of an FT protocol at a university-af filiated teaching Department of Veterans Affairs medical center. Preop erative risk factors, including a Department of Veterans Affairs risk- adjusted estimate of operative mortality, and perioperative surgical a nd anesthetic processes of care were evaluated. Results. The mean Depa rtment of Veterans Affairs risk estimate of perioperative mortality wa s not different between the pre-FT and FT cohorts (3.5% versus 3.7%, p = 0.13). In the FT cohort, median time to extubation decreased signif icantly (19.2 versus 10.2 hours; p < 0.001) along with median surgical intensive care unit stay (96 versus 49 hours; p < 0.001) and total po stoperative length of stay (222 versus 167 hours; p < 0.001). Median p ostoperative day of hospital discharge decreased from day 10 to 7 (p < 0.001). One patient (0.3%) required emergent reintubation directly re lated to early extubation. Reintubation for medical reasons was unchan ged between pre-FT and FT groups (6.3% versus 5.0%; p = 0.48). Postope rative morbidity was similar between groups except for nosocomial pneu monia, the rate of which decreased significantly in the FT cohort (14. 7% versus 7.3%; p < 0.005). Thirty-day (3.9% versus 4.6%; p = 0.69) an d 6-month mortality (6.7% versus 6.9%; p = 0.91) were unchanged. Concl usions. An FT cardiac surgery protocol has been instituted in a univer sity-affiliated teaching Department of Veterans Affairs medical center , with decreased length of stay and no significant increase in postope rative morbidity, 30-day mortality, or 6-month mortality. at was assoc iated with a lower rate of nosocomial pneumonia, a finding that must b e validated in a prospective study. (C) 1997 by The Society of Thoraci c Surgeons.