A new multidisciplinary approach to caring for patients undergoing a colorectal operation results in shorter hospital stays, fewer complications and lower medical costs, research has found.
Study results were published Jan. 28 online in the Journal of the American College of Surgeons.
Patients undergoing a colorectal operation generally remain in the hospital for five to 10 days and often experience significant pain and complications. To improve these outcomes, researchers at the University of Virginia Health System in Charlottesville developed a standardized approach for colorectal surgical care. The program, based on the principles known as enhanced recovery, incorporates proven practices that lead to faster recovery into the preoperative, intraoperative and postoperative phases of surgical patient care. UVA-Health participates in the American College of Surgeons National Surgical Quality Improvement Program.
This approach enables patients to become engaged in their own care from the start. Nurses provide each surgical patient educational materials, checklists and counseling before an operation.
Also, local anesthesia modalities such as intravenous lidocaine infusion and spinal anesthesia are used during and after an operation instead of opioids such as morphine, which can have harmful side effects. Patients are encouraged to eat and get out of bed and start walking as soon as possible after the operation as part of the recovery plan.
“The key to our success is that we brought everyone who cares for these patients together, including anesthesiologists, nursing staff, pharmacists, nutritionists, and we coordinated every detail of their care,” study co-author Traci Hedrick, MD, FACS, assistant professor of surgery, said in a news release. “This recovery plan was a quality initiative right from the start.”
For the study, Hedrick and colleagues including Kathleen M. Rea, MSN, APRN, and Florence E. Turrentine, PhD, RN, analyzed data from 207 consecutive patients at UVA-Health undergoing elective colorectal operations before and after the enhanced recovery protocol was implemented. They studied 109 patients in the enhanced recovery group and 98 in the conventional group.
The primary outcome was risk-adjusted length of stay, with the investigators using the ACS NSQIP Surgical Risk Calculator to estimate expected length of stay. After implementing the protocol, the surgical team found length of hospital stay decreased by 2.2 days, overall complication rate decreased 17% and patient satisfaction scores with pain control increased 55%.
Study results also showed using the enhanced recovery approach reduced healthcare costs by as much as $7,129 per patient, corresponding to a total cost savings of more than $700,000 in the enhanced recovery group.
With a before-and-after study, there is always the possibility that the patients in the study might not be similar. The researchers did note that a limitation of the study was in the before-and-after study. Well-designed randomized controlled trials, where half the patients are treated with standard care and the other half are treated with the new protocol or treatment, are considered the gold standard.
To stratify risk, the researchers entered all patient information into the NSQIP risk calculator, which then provided a predicted length of stay for each patient. “We were actually able to prove that the predicted length of stay was the same for both groups, indicating that both groups were very similar and that the comparisons were accurate,” Hedrick said.
Further, researchers demonstrated that before their protocol was initiated, patient stays were on average 1.6 days longer than the NSQIP predicted length of stay, but after the new standardized model of care was implemented, patient stays were about a half day below the NSQIP predicted length of stay.
“We are now working to implement a similar protocol for other surgical specialties, as well as looking for additional ways to further improve our outcomes and patient experience,” Hedrick said in the release. “This study shows just how successful small investments can be at raising the quality of care for patients.”
The researchers would like to see this protocol for colorectal surgical care adopted nationwide.
“I think in five years this will be the standard way that we are managing patients, because the results are so dramatic,” Hedrick said in the release. “It provides higher quality at lower cost, which is the ultimate goal.”