Abstract
Background: Pre-operative evaluation of elective cardiovascular (CV) surgery patients is limited by varying electronic health records and primary care physician adherence to guideline recommendations. A standardized pre-operative evaluation protocol may optimize medical management prior to elective surgery and reduce common post-operative complications, such as atrial fibrillation (AF), which is associated with increased adverse events and length of stay (LOS). Methods: In April 2013, a quality improvement program was implemented at a high volume center to standardize pre-operative evaluation of elective CV surgery patients. A comprehensive real-time decision support tool was developed based on consensus recommendations for optimal care. Patients qualifying for prophylactic amiodarone based on the PAPABEAR trial received prescriptions upon pre-operative evaluation. Using a shared electronic medical record we reviewed all elective coronary artery bypass graft and/or valve surgeries from April-December 2013. Any complication, post-operative AF, stroke, observed/expected mortality, LOS and percent geometric mean LOS were compared between patients with 1) pre-operative evaluation + amiodarone; 2) pre-operative evaluation + no amiodarone; 3) no pre-operative evaluation + no amiodarone. Results: Among 190 elective CV surgery cases, 28 (14.7%) patients received standardized pre-operative evaluation and qualified for prophylactic amiodarone, 100 (52.6%) received pre-operative evaluation without amiodarone and 62 (32.6%) received no pre-operative evaluation or amiodarone. Pre-operatively evaluated patients receiving amiodarone had the lowest any complication (p=0.009) and post-operative AF (p=0.047). Mean LOS, percent geometric mean LOS and observed/expected mortality were lower but did not reach statistical significance. There were no differences in post-operative stroke (Figure). Conclusions: A standardized pre-operative evaluation protocol in combination with prophylactic amiodarone in appropriate patients was associated with lower overall complications and a reduction in post-operative AF and LOS. Standardized protocols may enable health care providers to optimize pre-operative management of elective surgery patients and improve care quality and outcomes.
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