One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program

Abstract

Objective: Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the United States.

Methods: The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre- and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data.

Results: Comparing the pre- (N = 489) with the post- (N = 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P < .01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P < .01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P < .05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P < .01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P = not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement.

Conclusions: Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.

Keywords: cardiac surgery; complications; enhanced recovery; outcomes; perioperative care; value.