- (1)Patients should be discharged home when the following criteria are met:
- (a)Be afebrile with stable vital signs without arrhythmias for at least 36-48 hours before discharge.
- (b)The sternum should be stable and all surgical incisions should have no signs of infection.
- (c)Patients should tolerate a regular diet with regular bowel movements.
- (d)Patients should be on a stable discharge medication schedule.
- (e)The discharge weight should be within 1-2 kg of the preoperative weight.
- (f)A discharge chest radiograph should be devoid of any significant pleural effusions.
- (g)Patients discharged on Coumadin should attain a stable international normal ratio (INR) and have adequate plans for follow-up at a Coumadin clinic or physician’s office.
- (h)Patients should be able to ambulate without assistance and be educated on sternal precautions.
- (i)Patients should be on a stable pain medication regimen.
- (2)Rehabilitation facilities should only be used for patients requiring extended periods of postoperative hospitalization. Most cardiac surgery patients can be discharged home within 7 days of surgery. However, a significant percentage of patients may not meet discharge criteria on postoperative day 7. For those patients who require 1-3 days of in-patient stay to meet discharge criteria, it is safer and more cost-effective to keep them in the hospital rather than send them to a rehabilitation facility that results in “cost shifting” and increases medical cost.5Furthermore, those patients requiring aggressive respiratory care should be transferred to the appropriate facility so that they can receive the proper pulmonary toilet to prevent pneumonia that results in an extended period of in-hospital length of stay.6
- (3)Early after discharge follow-up. Patients may develop issues after discharge that are only identified when seen on their first postoperative visit 2-3 weeks after discharge. Some programs have sent their physician assistants (PAs) on home visits within a week after surgery. Although this has the potential to reduce readmissions, it adds to medical costs and puts additional strain on PA manpower. It is nonsustainable and is rarely practiced today. Early postoperative visits also add to cost, may be difficult for patients and their families, and are not necessary in the majority of patients. A workable strategy is to have in-house PAs, and nurse clinicians call patients within the first week after discharge. This can allay anxieties amongst patients and help to identify those issues that might need to be addressed in an outpatient visit.
- (4)The cardiac surgeon must be the gate keeper for all readmissions. This is one area where cardiac surgery readmissions can be significantly decreased. Too often, patients are readmitted through the emergency department or through a community hospital without the surgeon, or a member of the surgical team actually seeing the patient. These noncardiac surgery providers are not familiar with postoperative changes to determine whether chest pain is cardiac or noncardiac, the normal appearance of a sternotomy or leg incision, and the normal changes on a postoperative chest radiograph. Emergency department physicians should not be permitted to directly admit a postoperative cardiac surgical patient unless a member of the surgical team has evaluated the patient.
- A clinical risk scoring tool to predict readmission after cardiac surgery: an Ontario administrative and clinical population database study.Can J Cardiol. 2018; 34: 1655-1664
- Predicting readmission risk shortly after admission for CABG surgery.J Card Surg. 2018; 33: 163-170
- 30-day readmissions after coronary artery bypass graft surgery in New York State.JACC Cardiovasc Interv. 2011; 4: 569-576
- United States Department of Health and Human Services. Hospital Compare.(Available at:)Accessed December 1, 2017)
- Early discharge following CABG: are patients really going home earlier?.J Thorac Cardiovasc Surg. 2001; 121: 943-950
- Preventing postoperative pneumonia: spending a buck will save a buck.J Thorac Cardiovasc Surg. 2017; 154: 553-554
See article by Tam et al., pages 1655–1664 of this issue.
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