Nathalie Roy1, M Fernanda Parra2, Morgan L Brown3, Lynn A Sleeper4, Meena Nathan5, Brenda A Sefton2, Christopher W Baird5, Kshitij P Mistry4, Pedro J Del Nido5. 1. Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: nathalie.roy@cardio.chboston.org. 2. Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass. 3. Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Mass. 4. Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass. 5. Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
Abstract
OBJECTIVE: We hypothesized that a new enhanced recovery after surgery (ERAS) program would accelerate functional recovery after congenital heart surgery and reduce length of stay and complications. METHODS: Evidence-based interventions in perioperative care were evaluated for relevance, and components of the ERAS cardiac program were determined. The target patient population included infants to adults with low comorbidities. Major outcomes were compared to a pre-ERAS era cohort using propensity matching. RESULTS: From October 1, 2018, to February 28, 2019, 155 of 448 patients were eligible for the ERAS program. The median age was 3.6 years (interquartile range, 0.5-12.3). Key metrics included early extubation (<8 hours), achieved in 84 patients (54%; median 7.6 hours; interquartile range, 3.8-12.3), and multimodal pain regimen used in all patients (100%) postoperatively, but in only 88 of 155 patients (57%) intraoperatively. Opioid analgesia was highest the night of surgery (oral morphine equivalent: 0.36 mg/kg/12 hours; interquartile range, 0.21-0.57). In matched analysis, raw median mechanical ventilation time was 7.6 hours (interquartile range, 3.8-12.2) in ERAS versus 8.2 (interquartile range, 4.0-17.0) in pre-ERAS era (P = .001 log-hours). Raw median intensive care unit length of stay was shorter with ERAS: 1.12 days (interquartile range, 0.93-2.01) versus 1.28 days (interquartile range, 0.96-2.09) pre-ERAS (P = .046 log-days), but there was no difference in hospital length of stay. There was no increase in Society of Thoracic Surgeons-reported complications, readmissions, and reinterventions. CONCLUSIONS: This represents the initial implementation experience of an enhanced recovery after surgery program after congenital surgery at a large pediatric hospital. Adherence to the program component metrics is not yet optimized, but monthly sharing of quality metrics allows multidisciplinary collaboration, provider engagement, and opportunities for research and process improvement.
OBJECTIVE: We hypothesized that a new enhanced recovery after surgery (ERAS) program would accelerate functional recovery after congenital heart surgery and reduce length of stay and complications. METHODS: Evidence-based interventions in perioperative care were evaluated for relevance, and components of the ERAS cardiac program were determined. The target patient population included infants to adults with low comorbidities. Major outcomes were compared to a pre-ERAS era cohort using propensity matching. RESULTS: From October 1, 2018, to February 28, 2019, 155 of 448 patients were eligible for the ERAS program. The median age was 3.6 years (interquartile range, 0.5-12.3). Key metrics included early extubation (<8 hours), achieved in 84 patients (54%; median 7.6 hours; interquartile range, 3.8-12.3), and multimodal pain regimen used in all patients (100%) postoperatively, but in only 88 of 155 patients (57%) intraoperatively. Opioid analgesia was highest the night of surgery (oral morphine equivalent: 0.36 mg/kg/12 hours; interquartile range, 0.21-0.57). In matched analysis, raw median mechanical ventilation time was 7.6 hours (interquartile range, 3.8-12.2) in ERAS versus 8.2 (interquartile range, 4.0-17.0) in pre-ERAS era (P = .001 log-hours). Raw median intensive care unit length of stay was shorter with ERAS: 1.12 days (interquartile range, 0.93-2.01) versus 1.28 days (interquartile range, 0.96-2.09) pre-ERAS (P = .046 log-days), but there was no difference in hospital length of stay. There was no increase in Society of Thoracic Surgeons-reported complications, readmissions, and reinterventions. CONCLUSIONS: This represents the initial implementation experience of an enhanced recovery after surgery program after congenital surgery at a large pediatric hospital. Adherence to the program component metrics is not yet optimized, but monthly sharing of quality metrics allows multidisciplinary collaboration, provider engagement, and opportunities for research and process improvement.