Immediate Opportunities to Expedite Care

Despite the challenges, Dr. Lamparello and others have identified several opportunities for reducing both the average pre-operative stay (2.6 days) and post-operative stay (7.6 days).

Earlier Evaluation Could Rduce the Pre-Operative Period

More than two-thirds of the non-emergent patients required angiograms and cardiac consultations, which in most cases were not performed until the second hospital day or later. Similarly, echocardiograms and stress tests were typically performed two days after admission. The peripheral vascular surgeons and the physicians who perform these diagnostic procedures are developing a new system to improve the scheduling of these services. This should allow many pre-operative tests and consultations to be conducted prior to hospital admission, sometimes permitting surgery on the day of admission. Where outpatient testing is not appropriate or feasible, it should be possible to schedule the diagnostic procedures for the day of admission.

Restoring Patient Function More Swiftly After Surgery

The analysts have also identified several opportunities to accelerate patients' post-operative recovery:

Enhancing Patient Mobility

A key milestone in recovery from surgery, including leg revascularization, is reached when patients are able to get out of bed and walk. But with an incision that runs from groin to ankle and consequent soreness at the knee, these walks can be quite painful. Almost one-third of the patients had to restrict their initial post-surgical ambulation because of pain from the surgical wound or other causes. Only 56 percent of those who found walking painful had been given medication for pain. Although medical complications sometimes restrict the use of pain medication, Dr. Lamparello is looking into ways to provide pharmacological relief to as many patients as possible so they can exercise soon after surgery and recover quickly.

Rapidly Reinitiating Anticoagulation Therapy

Almost one-third of the patients were taking coumadin (an anticoagulant) prior to surgery but had to be switched to heparin to prevent excess surgical bleeding. Switching back to coumadin is a key step in the early post-operative period, but half of these patients did not return to coumadin for two or more days after surgery. With careful monitoring of blood levels, it should be possible to safely reinitiate anticoagulation therapy for most patients within 24 hours after surgery.

Consultation with Infectious Disease Specialists

Although virtually all patients received prophylactic antibiotics both immediately before and after their surgery, 14 percent of the patients received post-surgical treatment for reddened or infected suture lines. In order to expedite recovery, the peripheral vascular surgeons may consult sooner with infectious disease specialists.

Sub-Acute Care Options

Some patients could return more quickly to independent living if appropriate options (possibly in-house) were identified for those who no longer need acute care but still require physical therapy, wound management, or reinitiation of anticoagulation therapy. The Rusk Institute of Rehabilitation is one existing option, but only 22 percent of the patients in the study were discharged to Rusk. Some patients, although no longer in need of acute care, did not meet Rusk's ambulation criteria. Other patients were eligible for transfer but could not do so promptly because of a scarcity of beds at Rusk and delays in the approval process.

A subcommittee of the Case Management and Clinical Pathways Program is investigating ways to expedite transfer of eligible patients to Rusk. Other options for patients recovering from leg-bypass surgery will be explored as the Medical Center re-evaluates how it provides sub-acute care to a variety of patients.

Dramatic Potential of Minimally Invasive Surgery

Techniques for performing revascularization with minimal incisions are being tested and refined at leading medical centers across the country. Since these procedures involve fewer and much smaller incisions, a significant reduction in patient discomfort and length of stay should occur wherever they are employed. Indeed, patients receiving this treatment may often be ready for ambulation and discharge on the day after surgery.

According to Dr. Lamparello, minimally invasive leg-bypass procedures will be available soon at NYU Medical Center as part of a study. The peripheral vascular surgeons will monitor the findings closely because they hope to take a pioneering role in this field. The benefits could be great. Dr. Lamparello believes that, in addition to providing better and more cost-effective care for patients with chronic ischemia, the less invasive methods may justify surgical intervention earlier in the course of illness.