Feasibility Study of Early Outpatient Review and Early Cardiac Rehabilitation After Coronary Artery Bypass Grafting: Mixed Methods Research Design

Rationale and Background

Currently following CABG, patients attend their first outpatient review six weeks after hospital discharge, where recovery is assessed and fitness to commence CR is determined. CR is then started from eight weeks. In a survey conducted in May/June 2017 by the investigators, 35 of 42 UK cardiac centres responded, and confirmed this as current practice. The long interval before postoperative review and CR extends the period of vulnerability and inactivity for patients, with patients often seeking medical attention for surgery-related complications during this period. In a prospective observational study (FORCAST6), the investigators found that 44% of patients sought further medical help during this 6 week period, and 41% would like an earlier review. This feasibility study will examine the feasibility of bringing forward outpatient review and CR in order to facilitate recovery.

CABG is usually performed through a cut in the breastbone (median sternotomy) and patients are required to refrain from upper body exercises, lifting of heavy objects and usual strenuous activities for 12 weeks. These restrictions, called "sternal precautions" (SP), are intended to aid healing of the cut breastbone. CR which has significant short- and long-term benefits after CABG is therefore delayed. The delay can mitigate the benefits of CR, contribute to physical deconditioning, and hinder the ability of CR to facilitate timely recovery of fitness and physical activity status. According to the 2013 UK national audit of CR, late CR commencement contributes to a substantial number of heart surgery patients declining to participate in CR. Current time frames for postoperative review and CR are not evidence-based and may prolong recovery after CABG, and be placing unnecessary limitations on patient activity.

The standard access for heart operations is through a median sternotomy. In the UK, heart operations have steadily increased since 2010. Of 36,134 operations performed in 2013, 17,630 were isolated CABG. Following CABG, the recovery pathway after hospital discharge has two important elements, namely; outpatient review and CR.

First postoperative outpatient review: It is routine practice to undertake the first postoperative review six weeks after hospital discharge. However, high rates of hospital readmissions for surgery-related complications within this period have been reported. The investigators conducted a prospective observational study (FORCAST6) to investigate postoperative morbidity during, as well as patient opinion about, the six-week interval between hospital discharge and first review. This study showed that 44% of patients reported surgery-related complications; 17.5% required hospital readmission. Although majority of patients who did not have complication were satisfied with the six weeks interval, 41% felt it was too long. Early contact with patients has been associated with reduction in hospital readmissions. Non-randomised studies have also shown lower 30-day adverse outcomes with early review, for heart and other surgical patients.