A Single-Institution Analysis of Targeted Colorectal Surgery Enhanced Recovery Pathway Strategies That Decrease Readmissions

Feasibility of app-based home monitoring after abdominal surgery: A systematic review

BACKGROUND

Abdominal surgery presents great challenges postoperatively. Considering financial healthcare constraints, the use of mobile applications has received increased interest. This systematic review was conducted to assess and report the feasibility of app-based home monitoring after abdominal surgery.

METHODS

MEDLINE, EMBASE, and The Cochrane Library were searched on the October 17, 2023. This systematic review was conducted in accordance with the PRISMA guidelines.

RESULTS

Thirty-six articles were included, 17 of these originating from USA or Canada. The response rate varied between 11.9 ​% and 100 ​%. Bariatric, upper gastrointestinal, and colorectal surgery reported the highest response rates. All included studies had a degree of bias.

CONCLUSION

This study found varying response rates. The data indicated that the response rates were high within bariatric surgery, with additional factors potentially affecting this. The degree of bias was generally high, and the quality of the included studies limits the conclusions.

Multidisciplinary protocol to reduce surgical readmissions in Australia: American College of Surgeons National Surgical Quality Improvement Program

INTRODUCTION

Unplanned readmissions in general surgery are an important quality indicator of patient care and are associated with increased costs to healthcare services. This study aims to implement a multidisciplinary protocol in a single institution in a tertiary referral hospital to monitor and reduce unplanned readmission rates.

METHODS

A prospective cohort study using an institution-based protocol was conducted over an 18-month period including patients undergoing a general surgical procedure. The protocol included: (i) implementation of a surgical readmissions nurse-patient liaison; (ii) access to a surgical walk-in clinic; and (iii) early post-discharge phone contact. Data included demographic details, index procedure, hospital length of stay (LOS), and whether contact between patient/nurse occurred upon discharge. The primary outcome was the cause and rate of 30-day readmissions. Secondary outcomes were mortality, use of surgical clinic, emergency department presentations, and complications.

RESULTS

After protocol implementation, 874 patients underwent a general surgical procedure, with 354 (49%) being male and an overall median age of 53.0 years (interquartile range: 36.0-67.0). The overall readmission rate was 5.6% (n = 49), with a median LOS after readmission of 4 days. Compared with historical pre-protocol ACS-NSQIP data, this reflects a 30% reduction compared to that of readmission rate of 7.9%, P = 0.03.

CONCLUSION

The multidisciplinary protocol was efficacious in significantly reducing unplanned readmissions. Continued audits and monitoring of factors associated with readmissions are required to help design targeted projects that may lead to improved outcomes, lower costs, increased patient satisfaction, and better efficiency within our healthcare system.

Early discharge after enhanced recovery rectal resection does not increase emergency department visits and readmissions: a single institution analysis

BACKGROUND

Same-day discharge after colectomy in enhanced recovery pathways has been shown to be feasible. It is not clear how early patients with rectal resections may be safely discharged. The study aim was to determine if patients discharged ≤ 3 days after rectal resections are associated with increased rates of emergency department (ED) visits and hospital readmissions.

METHODS

Retrospective analysis of enhanced recovery low anterior resection, abdominoperineal resection, and proctocolectomy patients in a prospectively maintained single institution colorectal surgery database from 01/01/2018 to 07/15/2022. Clinic visits were scheduled within 4-7 days and at 30 days after discharge, and every 1-2 weeks for stoma patients until no longer needed. Logistic regression models were used to analyze the association of discharge on postoperative days (POD)-1-3, POD-4-5, and POD ≥ 6 days with incidence of ED visits and readmissions.

RESULTS

A total of 118 patients met inclusion criteria, 76 with stomas. Median postoperative length of stay was 5 [IQR 6.5] days. Mean age was 58.6 years; 59.3% were ASA-3; and 69.5% had a minimally invasive surgical approach. ED visits were not significantly different between discharge-day groups (p = 0.096). No patients were discharged same-day, one without a stoma was discharged on POD-1, ten patients (2 with stomas) on POD-2, and twenty-four patients (13 with stomas) on POD-3. ED visits were lowest for the POD-1-3 group (14.3%) but not significantly different than later discharge groups (p = 0.166). Readmission rate was also lowest for the POD-1-3 group (11.4%) and also not significantly different than later discharge groups (p = 0.261) and this was confirmed with logistic regression. Complication rate was lowest in the POD-1-3 group (p < 0.001).

CONCLUSION

Early discharge after enhanced recovery partial or complete proctectomy is not associated with increased ED visits and readmissions. Follow up studies should identify post-discharge resources that allow safe early discharge and that may be standardized and generalizable.

Pain and opioid use after colorectal resection for benign versus malignant disease: A single institution analysis

BACKGROUND

Studies comparing opioid needs between benign and malignant colorectal diseases are inconclusive.

METHODS

Single institution analysis of prospectively maintained colorectal surgery database. Multiple regression analyses done on perioperative numeric pain scores (NPS) and opioids prescribed at discharge.

RESULTS

641 patients in Benign and 276 patients in the Malignant group. Unadjusted comparison revealed significantly higher NPS for the Benign than the Malignant group preoperative and postoperative day 0 (after surgery), 1, 2, and 3 (all p ​≤ ​0.001). Opioids prescribed at discharge were significantly higher in the Benign group (60.0% vs 51.1%, p ​= ​0.018). After regression analysis, there was no longer a significant difference in NPS (B ​= ​0.703, p ​= ​0.095) and opioids prescribed between groups [OR ​= ​0.803 (95%CI 0.586, 1.1), p ​= ​0.173].

CONCLUSIONS

Pain and opioids prescribed at discharge are not significantly different between benign and malignant diseases in an enhanced recovery pain management pathway that maximizes non-opioid multimodal analgesic strategies.

Digital Health Interventions and Patient Safety in Abdominal Surgery: A Systematic Review and Meta-Analysis

Importance

Over the past 2 decades, several digital technology applications have been used to improve clinical outcomes after abdominal surgery. The extent to which these telemedicine interventions are associated with improved patient safety outcomes has not been assessed in systematic and meta-analytic reviews.

Objective

To estimate the implications of telemedicine interventions for complication and readmission rates in a population of patients with abdominal surgery.

Data Sources

PubMed, Cochrane Library, and Web of Science databases were queried to identify relevant randomized clinical trials (RCTs) and nonrandomized studies published from inception through February 2023 that compared perioperative telemedicine interventions with conventional care and reported at least 1 patient safety outcome.

Study Selection

Two reviewers independently screened the titles and abstracts to exclude irrelevant studies as well as assessed the full-text articles for eligibility. After exclusions, 11 RCTs and 8 cohort studies were included in the systematic review and meta-analysis and 7 were included in the narrative review.

Data Extraction and Synthesis

Data were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline and assessed for risk of bias by 2 reviewers. Meta-analytic estimates were obtained in random-effects models.

Main Outcomes and Measures

Number of complications, emergency department (ED) visits, and readmissions.

Results

A total of 19 studies (11 RCTs and 8 cohort studies) with 10 536 patients were included. The pooled risk ratio (RR) estimates associated with ED visits (RR, 0.78; 95% CI, 0.65-0.94) and readmissions (RR, 0.67; 95% CI, 0.58-0.78) favored the telemedicine group. There was no significant difference in the risk of complications between patients in the telemedicine and conventional care groups (RR, 1.05; 95% CI, 0.77-1.43).

Conclusions and Relevance

Findings of this systematic review and meta-analysis suggest that perioperative telehealth interventions are associated with reduced risk of readmissions and ED visits after abdominal surgery. However, the mechanisms of action for specific types of abdominal surgery are still largely unknown and warrant further research.

Early Discharge after Enhanced Recovery Colectomy Does Not Increase Emergency Department Visits and Readmissions: A Single Institution Analysis

BACKGROUND

Same-day discharge after colorectal surgery in enhanced recovery pathways is increasing. This study aimed to determine if discharge on postoperative days (POD) one or two is associated with increased rates of emergency department (ED) visits and hospital readmissions after left and right colectomy.

METHODS

Single institution retrospective analysis of prospective institutional colorectal surgery database between 07/01/2018 and 07/15/2022. Primary outcomes were ED visit and readmission rates for enhanced recovery open and minimally invasive right and left colectomy using logistic regressions models.

RESULTS

820 patients met inclusion criteria. There were significant differences in discharge-day by diagnosis-58.5% of patients with Crohn's disease were discharged on POD ≥4 and 21.6% with benign colon neoplasia were discharged on POD-0-1 (P < .001). ED visits occurred in 12.9% of the study population and were not significantly different between discharge-day groups (P = .096). Overall readmission rate was 8.5% and significantly different between discharge-day groups (0% POD-0 vs 8.3% POD-1 vs 5.8% POD-2 vs 6.9% POD-3 vs 12.9% POD ≥4, P = .041). Logistic regression showed that ED visits and readmissions for longer discharge-days (POD-2, POD-3, POD ≥4) were not significantly different than POD-0-1. Readmission diagnoses for the study population were higher for ileus (17.1%) and surgical site infection (SSI) type-III (22.9%) than for acute kidney injury (1.4%) and SSI type-I/II (1.4%).

CONCLUSION

Early discharge after left and right colectomy is not associated with increased rates of ED visits and readmissions. Same-day discharge may be feasible in selected enhanced recovery patients. Standardized post-discharge resources that safely allow same-day discharge require further investigation.

Postoperative Oral Rehydration and Regimented Follow-up Decrease Readmissions After Colorectal Surgery That Includes Ileostomies

BACKGROUND

Ileostomies constitute 15% to 43% of readmissions after colorectal surgery, often due to dehydration and acute kidney injury. Prior institutional interventions decreased readmissions but not among patients who underwent new ileostomies.

OBJECTIVE

To evaluate readmissions among patients who underwent new ileostomies after postoperative oral rehydration solution and standardized clinic visits.

DESIGN

Retrospective analysis of prospective database.

SETTINGS

Enhanced recovery colorectal surgery service.

PATIENTS

Patients who underwent new ileostomy before and after intervention.

INTERVENTIONS

Postoperative oral rehydration solution and postdischarge clinic visits with review of inputs/outputs, antimotility and appliance needs, and trained nurse reeducation 4 to 7 days after discharge, 30 days postoperatively, and every 1 to 2 weeks thereafter as needed.

MAIN OUTCOME MEASURES

Readmission rate due to dehydration/acute kidney injury (primary), emergency department visits, and readmission rates overall and for specific diagnoses. Analysis used univariate and weighted techniques.

RESULTS

A total of 312 patients (199 preintervention; 113 postintervention) were included, with a mean age of 59.0 years. Patients were predominantly White (94.9%) and evenly split between men and women. The most common diagnosis was diverticulitis (43.3%). The most common procedure was high anterior resection (38.8%), followed by low anterior resection (16.35%). Patient and procedure characteristics were well matched between groups. Multivariate analysis demonstrated that readmission rate due to dehydration/acute kidney injury significantly decreased between pre- and postintervention study groups (45.7% vs 16.5%, p = 0.039). Emergency department visits due to dehydration/acute kidney injury (12.0% vs 1.7%, p < 0.001) and readmissions from all causes (24.33% vs 10.6%, p = 0.005) also significantly decreased. Other complications were not significantly different between groups. Average stoma output 24 hours before (776 vs 625 mL, p = 0.005) and after (993 vs 890 mL, p = 0.025) discharge was significantly decreased in the postintervention group.

LIMITATIONS

Retrospective single-center study.

CONCLUSIONS

An oral rehydration solution and frequent standardized postdischarge visits led by trained nursing staff decreased readmissions and emergency department visits among patients who underwent new ileostomies after colorectal surgery. See Video Abstract .

LA REHIDRATACIN ORAL POSOPERATORIA Y EL SEGUIMIENTO REGLAMENTADO REDUCEN LOS REINGRESOS EN PACIENTES DE CIRUGA COLORRECTAL CON ILEOSTOMAS

ANTECEDENTES:Las ileostomías constituyen del 15 al 43% de los reingresos después de la cirugía colorrectal, a menudo debido a la deshidratación y la lesión renal aguda. Las intervenciones institucionales previas redujeron los reingresos, pero no entre los pacientes con nuevas ileostomías.OBJETIVO:Evaluar los reingresos entre pacientes con nuevas ileostomías después del uso de solución de rehidratación oral postoperatoria y visitas clínicas estandarizadas.DISEÑO:Análisis retrospectivo de base de datos prospectiva.AJUSTES:Servicio de cirugía colorrectal de recuperación mejorada.PACIENTES:Pacientes con ileostomía nueva antes y después de la intervención.INTERVENCIÓN(ES):Solución de rehidratación oral posoperatoria y visitas clínicas posteriores al alta con revisión de entradas/salidas, antimotilidad y necesidades de aparatos, y reeducación de enfermeras capacitadas 4-7 días después del alta, 30 días después de la operación y cada 1-2 semanas después, según sea necesario.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de readmisión debido a deshidratación/lesión renal aguda (primaria), tasa de urgencias y de readmisión en general y para diagnósticos específicos. El análisis utilizó técnicas univariadas y ponderadas.RESULTADOS:Se incluyeron un total de 312 pacientes (199 preintervención; 113 postintervención), con una edad media de 59,0 años. Los pacientes eran predominantemente blancos (94,9%) y se dividieron equitativamente entre hombres y mujeres. El diagnóstico más frecuente fue diverticulitis (43,3%). El procedimiento más común fue la resección anterior alta (38,8 %) seguida de la resección anterior baja (16,35 %). Las características del paciente y del procedimiento coincidieron bien entre los grupos. El análisis multivariante demostró que la tasa de reingreso debido a deshidratación/lesión renal aguda disminuyó significativamente entre los grupos de estudio antes y después de la intervención (45,7 % frente a 16,5 %, p = 0,039). Las visitas a urgencias por deshidratación/insuficiencia renal aguda (12,0 % frente a 1,7 %, p < 0,001) y los reingresos por todas las causas (24,33 % frente a 10,6 %, p = 0,005) también disminuyeron significativamente. Otras complicaciones no fueron significativamente diferentes entre los grupos. El gasto medio del estoma 24 horas antes (776 ml frente a 625 ml, p = 0,005) y después (993 ml frente a 890 ml, p = 0,025) del alta disminuyó significativamente en el grupo posterior a la intervención.LIMITACIONES:Estudio retrospectivo de centro único.CONCLUSIONES:Una solución de rehidratación oral y frecuentes visitas estandarizadas posteriores al alta dirigidas por personal de enfermería capacitado redujeron los reingresos y las visitas al servicio de urgencias entre los pacientes con nuevas ileostomías después de la cirugía colorrectal. ( Traducción-Dr. Yolanda Colorado ).

Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study

BACKGROUND

Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery.

METHODS

Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes.

RESULTS

5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001).

CONCLUSIONS

The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.

Alvimopan is associated with favorable outcomes in open and minimally invasive colorectal surgery: a regional database analysis

BACKGROUND

Alvimopan is a µ-opioid receptor antagonist associated with shorter time to gastrointestinal recovery in patients having open colorectal surgery. Data demonstrating the benefit of perioperative alvimopan for the minimally invasive surgical approach are inconsistent. The aim of this study is to determine colorectal surgery groups that benefit from perioperative alvimopan.

METHODS

This is a retrospective cohort analysis of colorectal surgery patients who had, and patients who did not have, perioperative alvimopan in the Michigan Surgical Quality Collaborative regional risk-adjusted database from 2018 through 2021. Main outcome measures were postoperative length of hospital stay, time to return of bowel function, and postoperative ileus.

RESULTS

There were 10,010 patients (30.3% open, 40.5% laparoscopic, 12.7% hand-assist laparoscopic, 43.5% robotic) who met inclusion criteria-4919 received alvimopan in the perioperative period and 5091 did not. When compared to those not receiving alvimopan, unadjusted outcomes showed that the alvimopan group had significantly shorter postoperative length of stay (4.75 days vs 5.5 days, p < 0.001), shorter time to return of bowel function (1.61 days vs 2.01 days, p < 0.001) and less postoperative ileus (5.45% vs 7.94%, p < 0.001). After adjustment, regression models confirmed that alvimopan was associated with an 9.6% reduction in hospital length of stay (p < 0.001), a 14.9% shorter time to return of bowel function (p < 0.001), and a 42.1% reduction in postoperative ileus (p < 0.001). Subgroup analysis showed significant benefit of alvimopan for all three outcomes in patients having the minimally invasive approach.

CONCLUSIONS

Alvimopan is associated with shorter hospital length of stay, shorter time to return of bowel function, and decreased postoperative ileus when administered to patients undergoing colorectal surgery. Benefit is not limited to the open approach and includes minimally invasive laparoscopic and robotic colorectal procedures.