Shared care for open heart surgery: 21 years' experience.

Objectives: To determine whether patients undergoing open heart surgery, the majority coronary artery bypass grafting (CABG), can safely be returned early to the smaller nonspecialized hospital that referred them for postoperative care by a cardiological team. Another objective is to determine what benefits might accrue from this practice and to whose credit.

Design: All 1696 patients, 1512 having coronary bypass alone or with ventricular aneurysm repair in 6%, referred from a military hospital with investigative facilities from November 1971 to November 1992 were studied with attention to length of postoperative stay in both hospitals, perioperative mortality and major complications mandating return to the surgical centre (which was almost always for reoperation). Time between initial coronary angiography and CABG was examined to see whether it related to the early return policy.

Results: After the first two years, postoperative care at the surgical hospital following CABG was reduced from a mean of 10.4 to 2.4 days, with an 18% reduction in the combined time spent at both hospitals, an estimated reduction of some 48 patient-years at the surgical hospital. A perceived need for active in-patient-rehabilitation and formal postoperative assessment explains the somewhat higher than average 23-day combined hospital stay after CABG. There have been no cardiovascular problems associated with the process of patient transfer and the three postoperative deaths that occurred in the referring hospital do not appear related to early transfer. Most of the 29 patients (2%) returned to the surgical hospital during the postoperative phase to have reoperations; there were three deaths, inevitable in one, scarcely preventable in two and unrelated to the early transfer in all three. Overall perioperative mortality was 2.7%; it was 1.3% for isolated primary CABG, 7.7% for reoperation. Delay between angiography and CABG was less than one day in 9%, less than four weeks in 69% and less than 12 weeks in 96%. It is believed that rapid access to surgical treatment was facilitated by cardiologists' willingness to undertake postoperative care and by the amicable trusting relationship between staff of the two hospitals.

Conclusions: It is possible to transfer patients safely after open heart surgery to a smaller, nonspecialized hospital for postoperative care; there are no significant ill effects from the practice and obvious benefits accrue to several involved parties. This model of shared care may have lessons for those designing or modifying cardiac surgical care programs.