<div><i>Corresponding Author:</i></div><div>John S. Ikonomidis, MD, PhD</div><div>Professor and Chief</div><div>Division of Cardiothoracic Surgery</div><div>University of North Carolina at Chapel Hill</div><div>3034 Burnett Womack Building</div><div>160 Dental Circle</div><div>Chapel Hill, NC 27599-7065</div><div>Phone: 919-966-3381</div><div>Fax: 919-966-3475</div><div>Email:
john_ikonomidis@med.unc.edu</div><div>I read with interest the study<sup>1</sup> by Son and colleagues
regarding outcomes of cardiac surgery patients discharged from hospital
on post-operative day three. The impetus for this single-center
retrospective review was the interest in implementing an Enhanced
Recover After Surgery (ERAS) program at Northwestern University
Hospital, Chicago, IL but a concern existed regarding potential untoward
effects of earlier patient discharge, a downstream positive effect
reported by programs already implementing ERAS protocols. The analysis
consisted of review of patients undergoing elective cardiac surgery with
cardiopulmonary bypass between July of 2004 and June of 2017 with
exclusion of trans-catheter approaches, ventricular assist devices,
transplants, and trauma. Patients were divided into two cohorts by
length of stay (LOS), one with shorter hospitalizations (LOS≤3 days) and
one with longer hospitalizations (LOS&gt;3 days). A 1:3
propensity score matching (PSM) algorithm was implemented in an effort
to eliminate potential confounding variables and differences between the
two groups were compared. Of a total of 5,987 patients surveyed, 131
(2.2%) patients had LOS≤3d with a median Society of Thoracic Surgeons
(STS) Risk score of 1.2. Propensity matching identified 357 comparison
patients with a LOS&gt;3 days. The results showed that the
patients with LOS≤3 days had lower rates of post-operative atrial
fibrillation (2% vs. 19%, p&lt;0.001) and major in hospital
complications (0% vs. 9%, p=0.001); however, 30-day readmissions (8%
LOS≤3 days vs. 6% LOS&gt;3 days, p=0.66) and mortality rates
(0% vs. 0%) were comparable between the two groups. The authors
concluded that LOS≤3 days was associated with less post-operative atrial
fibrillation and fewer major in-hospital complications, but not with
increased re-hospitalization or mortality.</div><div>ERAS programs constitute a comprehensive perioperative patient
management strategy that incorporates multiple patient care components
working efficiently in order to improve the patient care experience and
achieve significant benefits for both the patient and the hospital. The
components are broken down into 3 areas: pre-operative, intra-operative,
and post-operative. Pre-operative strategies include counseling,
education identification of potential barriers to hospital discharge,
nutrition and pre-emptive pain control regimens. Intra-operative
strategies include use of short-acting anesthetics and regional nerve
blocks, judicious fluid management and enhanced use of less invasive
surgical approaches. Post-operative strategies include early extubation
including in the operating room where appropriate, early mobility of
patients, pain control, nutrition, gastrointestinal function, and
post-operative fluid and blood product management.</div><div>There are a few reports regarding the use of ERAS in cardiac surgery
which have appeared in the last 2-3 years.<sup>2-8</sup> As seen
with application of ERAS programs in other surgical specialties, the
results have been positive and include decreased hospital and intensive
care unit lengths of stay, improved perioperative pain control,
improvements in early postoperative mobility and oral diets and
reduction in some specialty specific complications such as
post-operative atrial fibrillation. These early results indicate that
all programs performing cardiac surgery should consider the creation of
a formal ERAS pathway.</div><div>The present study which focused primarily on early discharge has some
limitations. The STS risk score is a reasonable marker of perioperative
risk, but it does not code for factors such as frailty, socioeconomic
status, and need for post-discharge care, all of which can affect
post-operative stay times. It is further unclear whether propensity
matching would effectively adjust for these differences. Patients were
screened over a 13 year period; significant advances in care have
occurred over this time period which may have confounded the results,
especially if the patients in each group were not distributed evenly
over the time period analyzed. LOS&lt;3 days patients had
procedures associated with shorter cross-clamp and bypass time, and a
higher percentage of “other” surgical procedures which were not
delineated (Table 2). It is not surprising that the LOS&lt;3 days
patients had less atrial fibrillation (2%) and post-operative
complications (0%), both of which would contribute to a shorter length
of stay, but these results are so low as to be an unreasonable
expectation for a large cohort of surgical patients. Finally, the choice
to separate patients at post-operative day three is interesting, since
patients discharged at this time point comprised only 131 of 5987 or 2%
of the patients cared for in the overall cohort. While the average
length of stay of the total patient cohort was not explicitly stated in
the article, it is unlikely that an implementation of an ERAS protocol
would result in a consistent reduction of hospital stays to 3 days. The
current literature suggests that ERAS reduces LOS by 1 to 4 days
depending to some extent on the baseline LOS; however no study to date
has reported a reduction in LOS to three days.</div><div>Nevertheless, the results of this study<sup>1</sup> did show
positive effects and no untoward sequelae of shorter hospital stays, and
provide further support of development and implantation of ERAS programs
in cardiac surgery patients.</div>