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Fast-track paediatric cardiac surgery: the feasibility and benefits of a protocol for uncomplicated cases
Felicity Howard1, Kate L Brown, Vanessa Garside
1Cardiac Unit, Great Ormond Street Hospital for Sick Children, Great Ormond Street, London, UK.
Insights
Implementing a fast-track protocol for pediatric open-heart surgery safely reduces hospital stays. Experience with the fast-track program improves outcomes, with morning surgeries showing better results.
Area of Science:
- Pediatric Cardiac Surgery
- Intensive Care Medicine
- Healthcare Management
Background:
- Fast-track pathways are established in adult cardiac surgery and essential in developing countries.
- This study focuses on adapting fast-track protocols for pediatric open-heart surgery.
- The protocol was implemented in a UK tertiary pediatric cardiac surgical center.
Purpose of the Study:
- To introduce and evaluate a fast-track protocol for uncomplicated pediatric open-heart surgery.
- To assess the impact of the protocol on patient readiness for intensive care unit (ICU) discharge and hospital length of stay.
- To identify factors influencing the success of the fast-track program in pediatric patients.
Main Methods:
- A fast-track protocol was introduced in January 2006 for children over 6 months undergoing uncomplicated open-heart procedures.
- Data were prospectively collected on patient fitness for ICU discharge and hospital length of stay.
- Statistical analysis included odds ratios and regression to identify influencing factors.
Main Results:
- 79% of 194 pediatric patients were fit for ICU discharge on the day of surgery.
- Specific conditions (ventricular septal defect, left ventricular outflow tract obstruction) and afternoon surgeries were associated with delayed discharge.
- Hospital length of stay decreased with increased experience with the protocol.
Conclusions:
- A fast-track program can be safely and effectively implemented in pediatric cardiac surgery with appropriate support.
- Increased experience with the fast-track protocol leads to reduced hospital stays for eligible children.
- Performing fast-track cases in the morning is recommended for optimal outcomes.
Objective:
Fast-track patient pathways for cardiac surgery are used in adult practice and by necessity is a mainstay in the developing world. We aimed to introduce a fast-track protocol for uncomplicated paediatric open-heart surgery cases and to subsequently review the results of this change in practice.
Methods:
A fast-track protocol co-ordinated by the Advanced Nurse Practitioners was introduced in January 2006 for children aged over 6 months undergoing uncomplicated open-heart procedures. We conducted a review of prospectively collected data on all included patients. The setting was a tertiary paediatric cardiac surgical centre in the UK. The outcome measures for audit were: patient fitness to leave the intensive care unit (ICU) on the day of surgery and hospital length of stay.
Results:
Included children had a mean age 6 (standard deviation (SD) 4.9) years and mean weight 22.7 (SD 17.6) kg. Of the 194 patients included, 153 (79%) were fit to leave the ICU on the day of surgery. Patients undergoing surgery for ventricular septal defect: odds ratio (OR) 2.8 (95% CI: 1.2-5.6) P=0.01 and left ventricular outflow tract obstruction: OR 5.5 (95% CI: 1.4-21.2) P=0.01, were more likely to be unfit than atrial septal defect and right ventricular outflow tract obstruction. Patients undergoing surgery in the afternoon were more likely to be unfit than those undergoing surgery in the morning: OR 2.3 (95% CI: 1.2-4.8) P=0.03. No relationship was found between age or weight and fitness to fast track. Median length of hospital stay for the whole cohort was 3 (range: 2-11) days. After adjustment for case mix, there was significant evidence that length of hospital stay reduced as experience with the protocol increased over the series of patients RC -0.02 (95% CI: -0.01 to -0.03) P<0.01.
Conclusion:
A fast-track programme can be implemented safely and effectively if the appropriate support including a step-down ward area is put in place. Greater experience with this type of protocol leads to reductions in the length of hospital stay for children aged over 6 months undergoing uncomplicated open-heart surgery. Fast-track cases should be performed in the morning.
