Mechanisms to reduce hospital stays

The present era of medicine is concerned to a large measure with cost containment and the advent of managed care. For these reasons the concept of reducing hospital stays with a concomitant reduction in hospital cost is very attractive. The role of fast track is to ensure that we are not placing the patient at any additional risk and in fact are improving recovery and patient well-being.

Fast track 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 early (4 to 8 hours) postoperative extubation. Steroids are administered perioperatively to improve myocardial function and reduce the release of inflammatory mediators. Digoxin is given prophylactically as are the bowel-mediating drugs metoclopramide, docusate, and ranitidine. The fast-track protocol is associated with aggressive ambulation of the patients and cardiac rehabilitation, so that the patient is out of bed the first day after operation, walking in the hall the second day, and up a flight of stairs the third day.

A shift to fast track in 1992 permitted comparison between 282 non-fast-track patients and 280 fast-track patients undergoing coronary artery bypass grafting. The results showed no adverse consequences of fast track. Forty-eight percent of fast-track patients were discharged at 3 to 5 days compared with 26% of non-fast-track patients. No significant differences were found between the two groups with respect to infection (1%), operative mortality (approximately 4%), and 30-day hospital readmission (7% non-fast-track and 8% fast-track). A postdischarge questionnaire addressed issues 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 the need for better communication, education, and additional postdischarge support systems.

A fast-track protocol allows faster recovery and earlier discharge from both the intensive care unit and the hospital without apparent increased risk. Complicated patients can also be fast tracked, and the desire to do so may actually expedite recovery.