Impact of an enhanced recovery programme in colorectal surgery

Patient experience of health and care when undergoing colorectal surgery within the ERAS program

Background

Several studies show that the enhanced recovery after surgery (ERAS) program reduces complications postoperatively and leads to faster recovery and shorter hospital stays. However, little is known about patients’ self-reported health in an enhanced recovery context. The aim of this study was firstly to describe patient experiences of health within the concept of ERAS after colorectal (CR) surgery during a hospital stay and within 2 weeks of discharge. Secondly, to explore whether the ASA classification/co-morbidity, sex, and surgical method affect the patient’s experience of health.

Methods

Data were collected through the ERAS-HEALTH questionnaire, including two open-ended questions, and through telephone interviews postoperatively. Qualitative and quantitative analysis was used. Patients undergoing CR surgery (n = 80) were included from October 2016 to June 2018.

Results

The patients had mainly positive experiences of their hospital stay as well as most of them felt comfortable coming home. However, experienced state of health is affected by factors like surgical method and co-morbidity. Improvements were desired concerning information, food/food intake, pain management, and environment. At home, the patients experienced a lack of information about food/food intake and ostomy care. Decreased appetite and difficulties with micturition were also described. The most troublesome symptom was postoperative fatigue (POF). Analysis of the ERAS-HEALTH questionnaire showed that patients with higher co-morbidity and those who underwent open surgery have a significantly worse experience of their health compared with patients who underwent laparoscopy. However, it seems that the surgical method affects postoperative health to a greater extent than co-morbidity.

Conclusions

The patients reported many positive aspects and challenges when being cared for within the ERAS program. However, several improvements are needed to satisfy patient wishes regarding their care both in hospital and at home. Laparoscopic surgery affects patient state of health positively in several respects compared with open surgery.

A modified TNM staging system for non-metastatic colorectal cancer based on nomogram analysis of SEER database

Background

To revise the American Joint Committee on Cancer TNM staging system for colorectal cancer (CRC) based on a nomogram analysis of Surveillance, Epidemiology, and End Results (SEER) database, and to prove the rationality of enhancing T stage’s weighting in our previously proposed T-plus staging system.

Methods

Total 115,377 non-metastatic CRC patients from SEER were randomly grouped as training and testing set by ratio 1:1. The Nomo-staging system was established via three nomograms based on 1-year, 2-year and 3-year disease specific survival (DSS) Logistic regression analysis of the training set. The predictive value of Nomo-staging system for the testing set was evaluated by concordance index (c-index), likelihood ratio (L.R.) and Akaike information criteria (AIC) for 1-year, 2-year, 3-year overall survival (OS) and DSS. Kaplan–Meier survival curve was used to valuate discrimination and gradient monotonicity. And an external validation was performed on database from the Second Affiliated Hospital of Zhejiang University (SAHZU).

Results

Patients with T1-2 N1 and T1N2a were classified into stage II while T4 N0 patients were classified into stage III in Nomo-staging system. Kaplan–Meier survival curves of OS and DSS in testing set showed Nomo-staging system performed better in discrimination and gradient monotonicity, and the external validation in SAHZU database also showed distinctly better discrimination. The Nomo-staging system showed higher value in L.R. and c-index, and lower value in AIC when predicting OS and DSS in testing set.

Conclusion

The Nomo-staging system showed better performance in prognosis prediction and the weight of lymph nodes status in prognosis prediction should be cautiously reconsidered.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3796-1) contains supplementary material, which is available to authorized users.

Implementing enhanced recovery pathways: a literature review with realist synthesis

OBJECTIVES

Enhanced Recovery Pathways (ERPs) are an increasingly popular, evidenced-based approach to surgery, designed to improve patient outcomes and reduce costs. Despite evidence demonstrating the benefits of these pathways, implementation and adherence have been inconsistent.

METHODS

Using realist synthesis, this review explored the current literature surrounding the implementation of ERPs in the UK. Knowledge consolidation between authors and consulting with field experts helped to guide the search strategy. Relevant medical and social science databases were searched from 2000 to 2016, as well as a general web search. A total of 17 papers were identified, including original research, reviews, case studies and guideline documents. Full texts were analysed, cross-examined, and data extracted and synthesised.

RESULTS

Several implementation strategies were identified, including the contexts in which these operated, the subsequent mechanisms of action that were triggered, and the outcome patterns they produced. Context-Mechanism-Outcome (CMO) configurations were generated, tested, and refined. These were grouped to develop two programme theories concerning ERP implementation, one related to the strategy of consulting with staff, the other with appointing a change agent to coordinate and drive the implementation process. These theories highlight instances in which implementation could be improved.

CONCLUSION

Current literature in ERP research is primarily focussed on measuring patient outcomes and cost effectiveness, and as a result, important detail regarding the implementation process is often not reported or described robustly. This review not only provides recommendations for future improvements in ERP implementation, but also highlights specific areas of focus for furthering ERP implementation research.

Nursing role on rapid recovery programmes fast-track

Rapid recovery (RR) or fast-track programmes are aimed at reducing surgical stress, leading to a reduction in nurse workload, costs and hospital stay, greater patient empowerment, early post-surgical recovery and reduced morbidity and mortality. These new protocols require the coordinated participation of a multidisciplinary team. Based on an integrative review of the literature, this paper aims to define the concept of a RR or fast track programme and show the existing evidence on the implementation of these programmes in nursing. The benefits and low incidence of damage of RR programmes in nursing justify their implementation. The programmes require greater support and diffusion in order to develop, as well as more research to increase the evidence on the effectiveness and efficiency of the protocols.

Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures

Enhanced Recovery After Surgery programmes were first conceived to optimise perioperative patient care and have been delivered by surgical specialities in the UK for over a decade. Although their safety and acceptability have been ratified in many surgical fields including gynaecology and colorectal surgery, the cost effectiveness of its implementation in benign vaginal surgery remains unclear. In this case-control study, the perioperative expenditure for 45 women undergoing vaginal hysterectomy at a North London teaching hospital after implementation of an enhanced recovery pathway was compared with 45 matched controls prior to implementation. Frequency of catheter use (84.4% vs. 95.6%) and median length of stay (23.5 vs. 42.9 h) were significantly lower following implementation of pathway (both p < 0.05). Although enhanced recovery patients were more likely to attend the accident and emergency department for minor symptoms following discharge (15.6% vs. 0%, p < 0.05), the inpatient readmission rate (6.7% vs. 0.0%, p > 0.05) was similar in both groups. Establishing the programme incurred additional expenditures including delivering a patient-orientated gynaecology 'school' and employing a specialist enhanced recovery nurse, but despite these, we demonstrated a saving of 15.2% (or £164.86) per patient. The cost efficiency savings, coupled with increased satisfaction and no rise in morbidity, offers a very attractive means of managing women undergoing vaginal hysterectomy. We believe that our data can be reproduced in other centres and recommend that the pathway be used routinely in women undergoing these procedures.

Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme

PURPOSE

Stoma formation is a well-known cause for delayed discharge following colorectal surgery. This has been addressed by the enhanced recovery programme (ERP) preoperatively through stoma counselling sessions. These aim to promote independent stoma management post-operatively, thus expediting hospital discharge. We compared the numbers of patients with prolonged hospital stay secondary to delayed independent stoma management prior to and following the introduction of an enhanced recovery programme with preoperative stoma education.

METHODS

Data collection on patients undergoing anterior resection with the formation of a loop ileostomy was carried out retrospectively prior to ERP (January 2006 to August 2008) and prospectively following the introduction of ERP (September 2008 to October 2010). Comparisons were made in patients with prolonged hospital stay (defined as hospital stay of more than 5 days) secondary to stoma management.

RESULTS

Two hundred forty patients underwent elective anterior resection with the formation of a loop ileostomy, 120 prior ERP and 120 post-ERP. Average length of hospital stay was 14 days before ERP introduction, with a range of 7-25 days. The mean length of stay amongst the ERP patients was 8 days (p = 0.17), ranging from 3 to 17 days. Twenty-one patients in the pre-ERP group (17.5%) experienced postponed hospital discharge due to a delay in independent stoma management, compared to one patient experiencing such a delay after the introduction of ERP (0.8%, p < 0.0001).

CONCLUSIONS

Delayed discharge secondary to independent stoma management can be significantly reduced with preoperative stoma management teaching as part of an enhanced recovery programme.

The future of surgical nursing and enhanced recovery programmes

Patients undergoing surgery in the UK are seeing a rise in the development of enhanced recovery programmes as a result of increasing medical advances. Enhanced recovery is concerned with helping patients get better sooner after an operation by following a meticulous regime of care. The practical application of these programmes is undertaken largely by nurses, despite encompassing explicit, medically-driven protocols. However, beyond the professional knowledge and skills required to aid the programmes, nursing knowledge has contributed little to this rapidly developing aspect of surgery to date. Nursing has much to offer through future creation of centrally coordinated, surgical nursing units focusing on patients' holistic experience. This article will briefly describe enhanced recovery, identify aspects of nursing knowledge that can have a positive influence, and outline practical changes to assist the development of such programmes, thereby benefiting all patients undergoing elective surgery.