Highlights
- •This article describes the application of enhanced recovery after surgery principles to a unique surgical population with a known prolonged length of stay.
- •Comprehensive enhanced recovery after surgery protocol for patients with a left ventricular assist device improves postoperative outcomes, including a decrease in the number of patients discharged on opioid medications or to the rehabilitation facilities.
- •Supporting team awareness, vigilance, and ownership of specific protocols improves implementation.
Abstract
Introduction
We sought to develop and implement a comprehensive enhanced recovery after surgery
(ERAS) protocol for patients implanted with a left ventricular assist device (LVAD).
Methods and Results
In this article, we describe our approach to the development and phased implementation
of the protocol. Additionally, we reviewed prospectively collected data for patients
who underwent LVAD implantation at our institution from February 2019 to August 2020.
To compare early outcomes in our patients before and after protocol implementation,
we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts)
separated from each other by 6 months to allow for staff adoption of the protocol.
Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46
patients in the ERAS period. Preoperatively, the patients` characteristics were similar
between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube
output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach
(P < .01). Furthermore, the number of patients discharged to a rehabilitation facility
decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between
the groups.
Conclusions
ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary
approach to care with multiple potential benefits. In this article, we describe the
details of the protocol and early positive changes in clinical outcomes. Further studies
are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical
pathways that ensures the use of best practices and decreased variation in perioperative
care. Multidisciplinary teams work together on ERAS, thereby enhancing communication
among health care silos. ERAS has been used for more than 30 years by other surgical
services and has been shown to lead to a decreased length of stay, fewer complications,
lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our
goal was to translate these benefits to the perioperative care of complex patients
with a left ventricular assist device. Early results suggest that this goal is possible;
we have observed a decrease in transfusions, discharge on opioids, and discharge to
a rehabilitation facility.
Key Words
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Article info
Publication history
Published online: May 25, 2021
Accepted:
May 14,
2021
Received in revised form:
May 13,
2021
Received:
February 26,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
