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Dome - A Quicker Road to Recovery After Colorectal Surgery

Dome October 2014

A Quicker Road to Recovery After Colorectal Surgery

Date: October 6, 2014

How a new standardized protocol engages patients and gets them home faster.

Elizabeth Wick and Christopher Wu
Elizabeth Wick and Christopher Wu hope to decrease hospital stays and improve patients’ experiences.
Photo by Keith Weller

A Johns Hopkins Hospital team of nurses, surgeons and anesthesiologists has reduced the time that patients spend in the hospital following colorectal operations by implementing a new process that standardizes care and speeds recovery.

Known as enhanced recovery after surgery (ERAS), this pathway changes the paradigm of how patients are treated after colorectal surgery, primarily for cancer. It uses a multidisciplinary approach to improve patient care, decrease infectious complications and make patients feel better sooner.

Surgeon Elizabeth Wick says that a patient typically stays in the hospital between five and 10 days after colorectal surgery. A recent meta-analysis of 13 studies, however, found that using the ERAS pathway decreased length of stay by 50 to 60 percent.

Wick introduced the protocol to Johns Hopkins, along with nurse clinician Deb Hobson, after she found too much variation in colorectal surgery practices at The Johns Hopkins Hospital. This single “best care” plan encompasses the preoperative, intraoperative, postoperative and post-discharge phases of care, as well as a standard perioperative anesthetic plan.

After the protocol was introduced in February, nurses began to work closely with patients before surgery to provide print and electronic educational materials, supplies for surgery preparation, checklists and instructions. “This approach engages patients much more in their own care,” Wick explains.

Now during surgery, physicians often use epidural anesthesia and propofol infusion to limit postoperative nausea and vomiting. Afterward, when patients are ready for oral medications, they receive nonopioid agents, like acetaminophen or NSAIDs, as well as other non-narcotic painkillers. Intravenous fluids are limited in the operating room.

Postoperatively, nurses encourage patients to resume drinking and eating and to get out of bed more quickly to expedite the recovery.

Results from using this protocol at Johns Hopkins for the past six months are encouraging: Length of stay has decreased by two days when compared with the previous six months’ average, and patients seem to feel better. “Their pain is under better control,” says anesthesiologist Christopher Wu. “They are eating sooner and are ready to go home.” Additionally, patient satisfaction scores for patients who have benefitted from this protocol are some of the highest in the hospital, according to Wick.

Through the surgical and anesthesia clinical communities sponsored by the Armstrong Institute for Patient Safety and Quality, collaborative work is underway to tailor ERAS pathways to the four other adult hospitals in the health system. And if clinical data continue to show that the protocol is successful for colorectal surgery, the same techniques could be applied for other surgical procedures in the abdomen.

—Lisa Rademakers

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