WakeMed Health & Hospitals prepares patients before heart surgery to improve outcomes

The use of enhanced recovery protocols for surgery has been commonplace in the U.S. since the concept was first introduced in the 1990s for colorectal procedures. The approach, which involves specific steps before and after surgery, has a strong track record of helping patients recover faster and improving overall outcomes including reduced complications and length of stay.

But despite the popularity and extensive literature showing the protocols work, there is one area of surgery in which the tactics haven’t been adopted until recently: cardiology.

In early 2017, WakeMed Health & Hospitals in Raleigh, N.C., pioneered the use of enhanced recovery tactics for heart surgery and has reported impressive outcomes. The average total time heart surgery patients spend in the intensive-care unit at WakeMed decreased from 45 hours to 28. Additionally, ICU readmission rates have fallen by nearly 30% and opioid use has dropped 40%. Overall cost savings are estimated to be significant, said Dr. Judson Williams, a cardiovascular surgeon at WakeMed who led the implementation of the protocols along with colleague Gina McConnell, a cardiothoracic ICU nurse at WakeMed.

Cardiology has likely been slow to adopt enhanced recovery protocols because much of the focus has been on getting the technical aspects of the surgery right, Williams said. “The historical mindset around cardiac surgery was that the operations were so big and the patients were so complex that all of these enhanced recovery pathways were really too difficult to apply to cardiac surgery.”

Cardiology is also incredibly siloed with clinicians working separately, which makes enhanced recovery protocols hard to implement, McConnell added.

But Williams saw an opportunity to change the status quo after he came across research showing that just 20% of morbidity outcomes for heart surgery are determined by what goes on in the OR. The remaining 80% is the result of what happens before and after surgery. “For me, as a surgeon, that was an inspiration to see what enhanced recovery could do for heart surgery,” he said.

Williams and McConnell began working together in early 2016. The first step was gathering research about enhanced recovery protocols that would best apply to heart surgery patients. The process took a year. Once complete, they began the effort to get buy-in from clinical staff about protocols they would agree to.

One of the first protocols the clinical team agreed on was giving the patients a drink loaded with carbohydrates two to four hours before heart surgery. Research shows this helps control blood glucose levels and reduces the risk of complications. But anesthesiologists were initially weary of the change. Standard protocol is usually for the patient to fast after midnight before surgery.

In order to convince them that this was the right way to go, an anesthesiologist was assigned to the group who communicated the evidence supporting the change and that outcomes would be closely monitored and shared. This practice was done with every department until everyone agreed on the same pathway. 
Staff buy-in got stronger after they saw the positive outcomes, Williams said.

In addition to carb-loading patients prior to surgery, clinicians give them around-the-clock opioid-alternative painkillers from different drug classes, a concept called multimodal analgesia. The technique reduces the use of opioids after surgery.

Smoking and alcohol cessation counseling also occurs. Although WakeMed always advised patients not to smoke or drink alcohol prior to surgery, it didn’t happen in any systematic way. Now, nearly all members of the care team talk to patients about how important it is to stop smoking and drinking, which improves compliance.

After surgery, the protocol involves removing endotracheal tubing as soon as possible, starting breathing exercises, administering food 12 to 18 hours after surgery, and mobilizing the patient. Because the patients are given fewer opioids, they are less groggy and can more quickly get out of bed and eat, McConnell added.

The protocols are applied for all types of heart surgery. In emergency situations where the pre-operative protocols couldn’t be initiated, the team still follows the post-operative ones.

Since WakeMed started the protocols, other academic medical centers have followed suit and JAMA Surgery recently published guidelines. Williams is a co-author.