Discharge Your Patient to Rehab Center or Home Post-Coronary Artery Bypass Surgery
Angina symptoms usually respond to nitroglycerin. But, severe angina symptoms or a high risk of heart attack may necessitate coronary artery bypass surgery in your patients. Hospital discharge after an invasive coronary artery bypass graft (CABG) procedure usually occurs within seven days—but the rehab time frame is typically 6-12 weeks.1 Whether your post-CABG patient should recover at home or in a Skilled Nursing Center (SNF) depends on the patient’s safety in the home environment.
Only 11 percent of CABG patients recover in a SNF (rehab center), but an increased CABG population of age 75 (and older) may precipitate the need to more frequently suggest recovery in a rehab center.2 CABG patients with insufficient home care (i.e., patients who live alone) may also benefit from a recovery period in a SNF, rather than immediate hospital discharge to home. The following describes the pros and cons of transferring your post-CABG patients to a rehabilitation center.
Changing Demographics of CABG Patients – Who are Current CABG Recipients?
Eighty percent of people over age 80 have significant cardiovascular disease, and 25 percent of all CABG recipients are at least 75 years of age.3 A Journal of Geriatric Cardiology article (citing an article in the Annals of Thoracic Surgery) specified that 87 percent of patients over age 80 benefited from CABG in terms of their overall quality of life.4 While the authors’ findings showed a 16.8 percent in-hospital mortality for post-CABG patients aged 80 and older (with a corresponding 8-24 percent overall post-CABG mortality rate), they also noted a three-year survival rate of 83 percent in this age demographic.
However, research findings do show a higher complication rate (and poorer short-term outcomes) in octogenarians as compared to younger post-CABG adults5—although the benefits often still outweigh the risks. As described in an article in Vascular and Health Risk Management, the three most frequent benefits (enabling improved quality of life) are as follows:6
- Relief from angina (since unrelieved angina pain is the most common diagnosis preceding the medical decision to perform a CABG).
- Relief from shortness of breath (with such dyspnea relief a common post-CABG outcome).
- Increased maximal exercise performance (e., increased ability to perform physical exercise).
Which Type of CABG is Preferable for Your Patient?
More than 70 percent of all CABG surgeries involves the temporary stoppage of the heartbeat.7 For this reason, cardiopulmonary bypass (with the use of a heart-lung machine, termed a “pump”) is necessary. In contrast, an “off-pump” CABG surgery developed in the 1990s (termed OPCAB, for Off-Pump Coronary Artery Bypass Surgery) is performed on a beating heart.
According to findings in the New England Journal of Medicine in 2016, no statistical difference was found in terms of occurrences of stroke, MI, renal failure, or death at the end of a five-year trial conducted in 4,752 patients who underwent “pump” versus “off-pump” coronary artery grafting.8 Moreover, better outcomes with OPCAB were noted in high-risk patients (i.e., those with diabetes, kidney disease, or advanced age), per an article in 2016 in the Journal of Thoracic Disease.9
Complications Associated with Coronary Artery Bypass Graft (CABG) Surgery
The spouse of an older patient recuperating from a coronary bypass graft procedure at home may be unable to take the necessary life-saving actions when complications in the post-CABG patient occur—and most likely due to that person’s own health problems. For this reason, recovering in a SNF may be preferable. Some post-CABG risks described by SecondsCount.org include:10
- Cardiac arrhythmias (especially one or more episodes of atrial fibrillation);
- Bleeding from surgical site and/or other sources;
- Blood clots (resulting in a heart attack or stroke);
- Infection at the incision site;
- Adverse reactions to anesthesia (including an allergic reaction);
- Renal failure
Infection Rates in Hospitals versus Rehab Center
The most recent Centers for Disease Control data for hospital-acquired infections (HAIs) showed a 14 percent rate (with a 50 percent decrease in central line-acquired HAIs),11 as compared to around 25 percent of SNF patients per day.12 The gram negative bacteria—Klebsiella—is one of the organisms most commonly found in HAI pneumonia and surgical site infections. Problematically, it has also increasingly been associated with antibiotic-resistant infections.
While methicillin-resistant Staph Aureus (MRSA) has decreased in SNFs due to an intensive national infection control campaign targeting MRSA, the potential for your patient to develop this life-threatening infection in a SNF remains. Therefore, a “pro” of discharging your patient to home (rather than a rehab center) is a reduced likelihood of acquiring a MRSA infection.
Medicare Payments and Coronary Artery Bypass Graft (CABG) Home-Based Care
The Centers for Medicare and Medicaid Services (CMS) authorizes home-health aide services for Medicare beneficiaries only if skilled nursing services are necessary—and these services are limited to no more than eight hours per day and 28 hours weekly (although 35 hours weekly may be covered in unusual circumstances).13 Other home-based services that Medicare typically covers post-CABG are physical therapy, medical social services, and durable medical supplies (e.g., a shower chair or walker). Although Medicare Part B is typically associated with home-based nursing and home-health aide services, Medicare Part A—following a three-day hospital stay (such as occurs in hospitalization for CABG surgery)—is the payer.
Impact of Psychological Factors in Post-CABG Outcomes
Depression is often found in patients with angina,14 and was likewise associated with a higher 10-year mortality rate following CABG surgery.15 Since patients often feel extremely tired and weak for a prolonged period of time following open-heart surgery—and especially if 65 years of age or older—depression can be the mental health result.
However, another reason is that an increase in cognitive impairment is linked to cardiac surgeries where the heart is temporarily stopped. Therefore, it is a good idea to periodically assess whether your post-CABG patient is displaying signs of clinical depression.
Impact of Lifestyle on Post-CABG Outcomes
The coronary artery disease (CAD) that necessitated the CABG surgery is often linked to longstanding high cholesterol and triglyceride levels. Following a coronary artery bypass procedure, encouraging the patient to attend nutritional counseling sessions may be beneficial.
Even in elderly patients who have undergone CABG surgeries, the cessation of smoking, switching to a healthier diet, and maintaining an exercise program can improve overall cardiac health.