Clinical trial NCT06257745: Audit of the Revised PACU Centric ERACS Program
Official title: Evaluation of the Revised Enhanced Recovery After Cardiac Surgery Protocol. A Prospective Audit.
Study type: OBSERVATIONAL
Overall status: RECRUITING
Conditions: Enhanced Recovery After Surgery
Cardiac Surgical Procedures
Lead sponsor: Universitaire Ziekenhuizen KU Leuven
Sponsor class: OTHER
First posted: 2024-02-14
Enrollment: 350
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: PROBABILITY_SAMPLE
Study population: any patient undergoing cardiac surgery in our hospital and requiring admittance to a high-depency unit for overnight stay.

Brief summary: A previous audit (S63843) found an association between improved compliance with these interventions and postoperative outcomes (hospital length of stay (LOS) and presence of ≥1 postoperative complication). The investigators found that every 10% increase in compliance was associated with an increased risk (HR=1.25, p=0.0008) for early discharge. In addition, improved compliance was also associated with a reduction (OR=0.60, p=0.0003) of postoperative complications. Based on these findings, improving compliance with current guidelines remains a hurdle that clinicians should overcome. The investigators previous retrospective study was unable to identify the reason for non-compliance and the relation to postoperative outcomes. Therefore, a prospective audit is warranted to assess reach, fidelity, and dose of the different interventions.

Detailed description: Trial Design:

Prospective audit in patients undergoing cardiac surgery and planned for overnight stay within our post-anesthesia care unit (PACU) enhanced recovery after cardiac surgery (ERACS) program. The medical records of all patients will be evaluated for the implementation of various interventions of our ERACS program (primary objective). For the secondary objective the investigators will assess the occurrence of postoperative complications and hospital LOS.

For benchmarking (third objective), the investigators will compare the findings with the results of a previous audit (S63843).(4) Data in this retrospective audit was collected from the electronic patient registry (KWS = Klinisch Werk Station). This included all interventions described in the ERACS guidelines. In addition, postoperative complications that occurred up to 7 days were also collected.

Data management:

Data will be obtained, according to the strategy used in the previous audit (S63843), by a research collaborator and an anesthesiologist using the medical records of the included patients. Appropriate data will also be collected from the preoperative anesthesia evaluation sheets (digitally stored in the hospital information system, KWS Nexus health) and from all intra- and postoperative anesthesia records up to 30 days after the index surgery.

Statistics:

The investigators aim for a convenience sample of 1-year recruitment, from January 1st 2024 until December 31st 2024 and expect to include approximately 350 cardiac surgical patients in this ERACS audit.

Patient characteristics will be tabulated as absolute numbers, percentages, mean and standard deviation, Objective 1 95% confidence intervals will be reported for the mean (or median) percentage compliances well as for each of the interventions separately, the proportion of patients who adhere to the intervention.

Objective 2 Logistic regressions will be used to verify the relation between the percentage adherence and the presence of a complication (for each complication separately and for the composite endpoint). Odds ratios and 95% confidence intervals will be reported. These analyses will also be performed for the adherence at each intervention separately (fidelity and dose). Spearman correlations and MWU tests will be used to explore relations between adherence (percentage and each intervention separately) and length of hospital stay. Given the possible presence of in-hospital mortality, a LOS value higher than the maximal observed value of the discharged patients will be given to patients who die in the hospital when applying these rank-based methods. Further, Cox regressions will be used to model the cause-specific hazard in presence of in-hospital mortality and hazard ratios (with 95%CI) will be given. A multivariable logistic regression will be used to verify if the relation between protocol adherence and postoperative complications is not confounded by patient (e.g. EuroSCORE II) and procedural (e.g. type of surgery being valvular, bypass or minimally invasive) characteristics. To verify the independent impact of protocol adherence on length of stay, a multivariable Cox regression will be used.

Objective 3 For benchmarking purposes, the percentage adherence will be compared between current sample and the data of the retrospective study using a linear normal model, correcting for potential differences in patient-mix (patient and procedural characteristics) between both periods. Note however that differences are expected to be minimal, since the same inclusion criteria were used, and the accrual period covered a full year. To compare the adherence to each intervention separately and to compare the complication rate(s) a logistic regression will be used.

A p-value of less than 0.05 will be considered statistically significant. Given the large number of planned statistical tests, a single significant p-value will be interpreted with caution.

Eligibility criteria: Inclusion Criteria:

* Included in our post anesthesia care unit centric ERACS program during 2024

Exclusion Criteria:

* Patients transferred to the PACU but awaiting planned admission to the intensive care unit following cardiac surgery

Primary outcomes:
measure: Overall percentage of compliance with the 24 interventions of the ERACS guidelines
timeFrame: From 6 week prior to surgery up to 1 month after surgery
Secondary outcomes:
measure: Hospital length of stay following the index surgery
timeFrame: From date of surgery until the date of hospital discharge or date of death from any cause, whichever came first, assessed up to 30days.
measure: Occurrence of each postoperative complication during the first 7 days
timeFrame: From date of surgery up to 7 postoperative days
measure: Composite endpoint of 1 or more postoperative complications
timeFrame: From date of surgery up to 7 postoperative days
measure: Percentage of patients in whom each ERACS intervention was performed as intended (referred to as fidelity)
timeFrame: From 6 week prior to surgery up to 1 month after surgery
measure: Percentage of patients in whom each the frequency of ERACS intervention was performed as planned (referred to as dose)
timeFrame: From 6 week prior to surgery up to 1 month after surgery
Other outcomes:
measure: Benchmarking purpose
timeFrame: From 6 week prior to surgery up to 1 month after surgery
Locations:
city: Leuven
country: Belgium
facility: University Hospitals Leuven
Study officials:
affiliation: Anesthesiology
name: Danny Feike Hoogma, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019 Aug 1;154(8):755-766. doi: 10.1001/jamasurg.2019.1153.
citation: Hoogma DF, Croonen R, Al Tmimi L, Tournoy J, Verbrugghe P, Fieuws S, Rex S. Association between improved compliance with enhanced recovery after cardiac surgery guidelines and postoperative outcomes: A retrospective study. J Thorac Cardiovasc Surg. 2024 Apr;167(4):1363-1371.e2. doi: 10.1016/j.jtcvs.2022.07.010. Epub 2022 Jul 19.
citation: Fleming IO, Garratt C, Guha R, Desai J, Chaubey S, Wang Y, Leonard S, Kunst G. Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth. 2016 Jun;30(3):665-70. doi: 10.1053/j.jvca.2016.01.017. Epub 2016 Jan 16.
citation: Van Grootven B, Jeuris A, Jonckers M, Devriendt E, Dierckx de Casterle B, Dubois C, Fagard K, Herregods MC, Hornikx M, Meuris B, Rex S, Tournoy J, Milisen K, Flamaing J, Deschodt M. How to implement geriatric co-management in your hospital? Insights from the G-COACH feasibility study. BMC Geriatr. 2022 May 2;22(1):386. doi: 10.1186/s12877-022-03051-1.