Promoting enhanced recovery after colorectal surgery

Jennie Burch
benefit from enhanced recovery programmes, compared to traditional care (Wind et al, 2006). Lovely et al (2012) examined enhanced recovery pathways and reported that bowel function returned in 1-2 days in patients on the enhanced recovery pathway, conipared to 23 days in those receiving traditional care. Adamina et al (2011) also reported in their study that 30-day morbidity was halved for patients on the enhanced recovery pathway compared to traditional care. It should also be noted that an early discharge was not associated with an increased burden on relatives, GPs or nurses (Jackobsen et al, 2006). However, there are a large number of factors that can affect post-operative recovery. Fiore et al (2012) undertook an international consensus on hospital discharge criteria for patients undergoing colorectal surgery. This was achieved by inviting experts from a variety of countries to examine what criteria are necessary to determine readiness for discharge from hospital. The experts suggest that to be ready for discharge from hospital patients must meet the criteria listed in Box 2. Discharge should occur when these criteria are met, with consideration for post-discharge support. It could be suggested that, by ensuring that a number of predetermined criteria are achieved before discharge, it is more likely that the patient is ready for discharge and the risk of post-discharge complications and, therefore, readmission is reduced. Post-discharge support can be achieved in a number of ways and will be discussed later in this article.

Abstract
Enhanced recovery after surgery, also known as fast track surgery, involves the use of. evidence-based care to improve the surgical process for patients and reduce the length of their hospital stay. The enhanced recovery elements are pre-operative, peri-operative and post-operative; each element can work alone, but better results are achieved when they are used in combination (Gustafsson et al, 2011). Enhanced recovery after surgery can assist patients undergoing various operations, most commonly colorectal, but also orthopaedic and gynaecological surgery. The government and local trusts are keen to optimise patient care and reduce the length of hospitalisation; however, there have been concerns about the possibility of increased readmission rates. A variety of issues related to enhanced recovery will be examined in this article, including the length of the primary hospital stay and readmission. Key words: Colorectal Enhanced recovery Fast track Surgery

nhanced recovery after surgery involves a number of elements before, during and after an operation. Prehabilitation, also termed optimisation, is increasingly being recognised as important to aid post-operative recovery. This is essentially improving the condition of the patient before his/her operation through cessation of smoking and alcohol consumption, and in addition improving nutritional intake and exercise tolerance, ideally a month or more before the operation. The elements of enhanced recovery (Fearon et al, 2005; Lassen et al, 2009) are shown in Box 1. When used in combination, these elements help to reduce the stress associated with surgery, prevent complications and reduce the length of hospital stays to a median of 4 days (Faiz et al, 2008). The likelihood of complications such as chest infection are low, which may be partially due to early mobihsation. Consequently, each day after their operation, patients are encouraged to undertake four walks of 60 metres (Lassen et al, 2009). Additionally, all patients are eligible for inclusion on the enhanced recovery pathway; in particular, elderly patients and those with significant coniorbidities

Length of stay
With improvements in surgery, it would seem inevitable that the length of time that patients remain in hospital after an operation would decrease. The length of stay following colorectal surgery, i.e. the primary length of stay, was historically several weeks after major surgery such as a right hemicolectomy. Henrik Kehlet from Denmark reported that it was possible to reduce the length of the primary hospital stay to 2 days following open colonie surgery (Andersen et al, 2007). However, this did lead to increased readmissions rates and a 3-day hospital stay (Andersen et al, 2007). Hospital stays of this duration were also achieved by Lovely et al (2012). In the UK, Faiz et al (2008) reported slightly longer stays; for laparoscopic colonie surgery 4 days, and for open colonie surgery and laparoscopic rectal surgery 6 days compared to 9 days following open surgery. Boulind et al (2012) and Ahmed at el (2010) reported a median length of stay of 5 6 days. These results are similar to those reported by Wick et al (2011) in the US who found that the mean length of stay was 6 days for laparoscopic surgery and 10 for open surgery.

Jennie Burch is Enhanced Recovery Nurse, St Marks Hospital, Middlesex

Accepted for publication: February 2013

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Box I. Elements of enhanced recovery

Pre-assessment counselling Pre-operative optimisation No routine use of bowel preparation No prolonged period of fasting Pre-operative carbohydrate ioading No pre-operative sedation Prevention of venous thromboembolism Avoidance of sodium andfluidoverioad Provision of peri-operative antimicrobials Prevention of nausea and vomiting No post-operative nasogastric tube Use of short-acting anaesthetics Use of epidural anaesthesia and analgesia No routine use of drains Warming the patient during surgery Use of short incisions Peri-operative feeding Post-operative mobilisation Post-operative gut stimulation Eariy catheter removal Audit Within the author's workplace, the plan for elective operations is to have a length of stay of 36 days; for example, for a laparoscopic rectopexy (rectal prolapse repair) and an eoanal pouch formation, respectively. An unpublished audit undertaken within the author's workplace shows the length of hospital stay is 4 days for laparoscopic surgery. Thus, it can be seen that the length of the hospital stay in a variety of international settings is now a few days following colorectal surgery, with laparoscopic surgery requiring a shorter stay than open surgery.

the enhanced recovery pathway to be related to pathology and intraoperative complications. It should be noted that in one-third of patients (36%), a prolonged hospital stay was predicted by age, number of procedures and deviation from the enhanced recovery pathway. Using a greater number of enhanced recovery elements resulted in a shorter hospital stay (Gustafsson et al, 2011;Vlug et al, 2012). Another factor that might increase the length of stay after colorectal surgery is having a stoma formation. There has been research to suggest that preoperative stoma training (Chaudhri et al, 2005) can reduce the length of a hospital stay to 5 days for people having a stoma formation (Bryan and Dukes, 2010). The length of a hospital stay can also be extended due to post-operative compHcations. Lovely et al (2012) reported complication rates within 30 days of surgery to be 32% in enhanced recovery patients. However, discharge home can be delayed for non-medical reasons and thus it is essential to plan for discharge as soon as possible. In unpublished data firom the author's workplace, the only pre-operative factors that determined an increased length of stay were open surgery and stoma formation. Thus it can be seen that a variety of factors can affect the time spent in hospital after colorectal surgery.

Readmission
Readmission is rarely considered by nurses, as the focus is on helping the patient to recover following their operation while in hospital. However, readmission wl become a bigger focus; in the US, hospitals are penalised when patients are readmitted to hospital. Martin et al (2011) state that readmission rates 'will become a quality indicator of performance'. Readmission costs US national social insurance program Medicare about $17bn per year (Jencks et al, 2009). Readmission rates are usually recorded (unless stated otherwise) for the first 30 days after surgery. Despite concerns that enhanced recovery after surgery would lead to increased readmission rates, overall this has not been the case. Readmission after laparoscopic colorectal surgery has been documented at about 10% (Adamina et al, 2011; Gustafsson et al, 2011; O'Brien et al, 2007;Wick et al, 201 l).Walter et al (2008) reported fewer readmissions for those patients on the enhanced recovery pathway (0-5%) compared to traditional care (0-25%); however, Adamina et al (2011) and Gouvas et al (2009) state that readmission rates are unchanged. When examining readmission rates in relation to surgical type. Wick et al (2011) reported that readmissions were 8% for laparoscopic surgery and 19% for open operations. Gouvas et al (2009) reported that total hospital stays for patients who were readmitted were shorter in the enhanced recovery group at 18 days compared to 23 days. Furthermore, Wick et al (2011) reported that most patients were only readmitted once, but the maximum number of times was seven, with readmissions most commonly occurring at 13 (Wick et al, 2011) or 14 days (Martin et al, 2011). Lovely et al (2012) and RawHnson et al (2011) suggested that there is no difference between mortality or readmission rates when patients foUow the enhanced recovery pathway.

Factors affecting length of stay

There are a number of factors that can affect the primary length of a hospital stay. BouUnd et al (2012) undertook a study that aimed to predict factors that might delay discharge following laparoscopic colorectal surgery on the enhanced recovery pathway. One-third of their patients (31%) deviated firom the enhanced recovery pathway, generally failing on more than one element. The most common element that was not achieved was mobilisation and the reasons for failure were most often related to a paralytic ueus (prolonged cessation of bowel peristalsis resulting in nausea and vomiting) and inadequate analgesia.The authors attributed failure to follow
Box 2. Discharee criteria

Patient shouid: Be able to tolerate orai intai<e Have a return of bowel function Have adequate pain controi on orai analgesia Be mobiiising Be self-caring Have no evidence of complications or untreated medical problems Be proficient in their stoma care (if necessary) Be wiiling to be discharged home

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Box 3. Factors that might contribute to patient readmission after surgery I Lack of caregiver (i.e. family member to help) I I I I Reduced oral intake just before discharge home More than six discharge medications Post-operative complications Older than 69 years

Box 4. Reasons for readmission Dehydration Ileus-obstruction Abdominal abscess I Urinary infection Ancistomotic leak Pulmonary embolism Wound infections (O'Brien et al, 2007; Ozturk et al, 2009; Martin et al, 2011; Wick et ai, 2011)

I Primary hospitalisation longer than 7 days I Inflammatory bowel disease I Pre-operative pulmonary comorbidities I Decreised performance status I Pre-operative anticoagulation problems I Steroid use I Not being discharged to home I Wound infection during primary hospitalisation I Stoma 1 Living alone 1 Major complication during surgical procedure (O'Brien et at, 2007; Martin et al, 201; Wick et al, 2011)

However, it is noted that often not all, and in some studies as few as four, of the elements of enhanced recovery \vere used. Results from the author's prospective workplace data collection found a similar readmission rate of 8%. Factors related to readmission It is essential to increase awareness of any potential predicting factors for readmission in order to be able to address them and possibly prevent them and a number of studies discuss this (see Box 3). Fauci et al (2011) reported that the patients who were readmitted had a higher number of pre-existing comorbidities, with reasons for readmission being most commonly a small bowel obstruction or ileus but also wound complications and thromboembolic events; however, this study did not include patients on the enhanced recovery pathway. Martin et al (2011) suggest that requiring health professionals to provide support in the patient's home was associated with a higher readmission rate. This may be because patients were generally less independent on discharge and needed more help with daily living activities. In fact, Adamina et al (2011) state that early discharge was associated with fewer readmissions than longer primary stays. This suggests that, if there were no post-operative complications in hospital, there were unlikely to be any problems post-discharge either. However, when readmissions occurred, the reasons included preoperatively having a low functional capacity and nonadherence to the enhanced recovery pathway. Wick et al (2011) reported that 18% of ostomates were readmitted to hospital within 30 days of discharge home. KEY POINTS
I Enhanced recovery after surgery (ERAS) is also known as fast track surgery I ERAS reduces stress related to the operation I ERAS reduces the length of hospital stay lERAS does not increase readmission rates

However, they also suggested that readmission rates in the under-65 age group were similar to those in older patients. Ozturk et al (2009) suggested that pre-operative comorbidities result in readmissions, although this is refuted by Wick et al (2011). White et al (2012) reported that patients with Crohn's disease who were on immunosuppressive therapy before their surgery appeared to show an increased incidence of readmission. The possible reasons for readmission are listed in Box 4.

Prevention of readmission
It would, of course, be ideal to prevent readmissions. Wind et al (2006) suggested that this can be achieved by the facilitation of a safe discharge home through the use of a discharge criteria checklist. The discharge criteria include a variety of components as described in Box 2. Fauci et al (2011) suggest that readmissions may be prevented through the use of a nurse telephone follow-up. Martin et al (2011) suggests that early outpatient appointments, even immediately after discharge could prevent some radmissions. However, Wick et al (2011) found that half of patients who were readmitted had already had an outpatient appointment, which suggests that their clinic review may have led to the readmission. Within the author's workplace, a list of discharge criteria needs to be attained, nurse telephone follow-up is provided and most patients are seen in a surgical follow-up clinic within about 2 ^veeks of discharge home.

Conclusion
It can be seen that one benefit of the enhanced recovery pathway is a shorter hospital stay. It has been shown in various studies that the length of stay has been successfiiUy reduced to a few days after major colorectal surgery without any increase in adverse events; in fact, complications such as infections are reduced. It has been reported that there are a number of factors that can affect the length of stay. Gustafsson et al (2011) reported that adverse post-operative outcomes were significantly reduced with a better adherence to the enhanced recovery protocol. They report that one-third (34%) of patients who complied with 70% of the enhanced recovery pathway compared to almost half of patients (44%) who only had 50% adherence to protocol had one or more complications respectfully. Thus non-compliance with the enhanced recovery pathway can be seen as adversely affecting the primary length of stay and may also affect readmission rates. It is not easy to predict which patients are at risk of

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CLINICAL MANAGEMENT
readmission. However, it appears that patients that did not progress well in the imniediate post-operative period are more likely to have a prolonged primary hospital stay and are at a greater risk of readmission. Although it can be seen that readmission to hospital is not increased in patients on the enhanced recovery pathway, remaining stable at about 10%. If readmissions do occur, it is likely that this will be within about 2 weeks of discharge home and will only be a single readmission. Furthermore patients on the enhanced recovery pathway who are readmitted will still have a reduced length of stay compared to those having traditional care. It is suggested that the reasons for readmission to hospital are related to post-operative complications, although it is uncertain if pre-operative comorbidities are also a confounding factor. Thus it is difficult to plan to reduce readmission rates; however ensuring that a list of discharge criteria is met and early follow-up are likely to be beneficial. QS
Conflict of interest: none
Adamina M, Kehlet H,Tonilinson GA, Senagore AJ, Delaney CP (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a metaanalysis of randomized controlled trials in colorectaJ surgery. Snidery 149(6): 830-40 Ahmed J, Lim M, Khan S, McNaught, MacFie J (2010) Predictors of length of stay in patients having elective colorectal surgery within an enhanced recovery protocol. /(J SMK 8(8): 628-32 Andersen J, Hjort-Jakohsen D, Christiansen PS, Kehlet H (2007) Readmission rates after a planned hospital stay of 2 verses 3 days in fast-track colonie surgery. BrJ SUIS 94(7): 890-3 Boulind CE,Yeo M, Burkill C et al (2012) Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery. Colorectal Dis 14(3): 1462-3 Bryan S, Dukes S (2010) The enhanced recovery programme for stoma patients: an audit. BrJ Nurs 19(13): 831-4 Chaudhri S, Brown L, Hassan 1, Horgan AF (2005) Preoperadve intensive, community-based vs.tradidonal stoma education: a randomiszed, controlled trial. Dis Colon Rectum 48(3): 504-9 Fauci JM, Schneider KE, Frederick PJ et al (2011) Assessment of risk factors for 30-Day hospital readmission after surgical cytoreducdon in epidielial ovarian carcinoma. Inl] Cynecol Cancer 21(5): 806-10 Faiz O, Brown XColucci G.Kennedy R H (2008) A cohort study of results following elecdve colonie and rectal resection widiin an enhanced recovery programme. Colorectal Dis 11(4): 366-72 Fearon KCH, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: A consensus review of clinical care for padents undergoing colonie resecdon. Clin Nutr 24(3): 466-77 Fiore JF Jr, Bialocerkowslci A, Browning L, Faragher lG, Denehy L (2012) Criteria to determine readiness for hospital discharge following colorectal surgery: an internadonal consensus using the Delphi technique. Dis Colon Rectum 55(4): 416-23 Gouvas N,Tan E, Windsor A, Xynos E,Tekkis PP (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. IntJ Colorectal Dis 24(10): 1119-31 Gustafeson UO, Hausel J,Thorell A et a] (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Sutg 146(5): 571-7 Jackohsen DH, Sonne E, Andersen J, Kehlet H (2006) Convalescence after colonie surgery with fast-track vs convendonal care. Colorectal Dis 8(8): 683-7 Jencks SF, Williams MV, Coleman EA (2009) Rehospitalizadons among padents in the Medicare fee-for-service program. N EnglJ Med 360(14): 1418-28 Lassen K, Soop M, Nygren J et al (2009) Consensus review of opdmal perioperadve care in colorectal surgery. Arch Suig 144(10): 961-69 Lovely JK, Maxson PM, Jacob AK et al (2012) Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. BrJ Swig 99(1): 1323-5 Mardn RCG, Brown R, Puffer L et al (2011) Readmission rates after abdominal surgerythe role of the surgeon, primary caregiver, home health and suhacute rehab./imiSii 254(4): 591-7 O'Brien DP (2007) Predictors and outcome of readmission after laparoscopic intesdnal surgery. World J Suig 31(11): 2138-43 Ozturk E, Kiran RP, Remzi F Fazio VW (2009) Early readmission after Ueoanal pouch surgery. Dis Colon Rectum 52(11): 1848-53 Rawlinson A, Kang P, Evans J, Khanna A (2011) A systemadc review of enhanced recovery protocols in colorectal surgery. Ann R Coll Surg Engl 93(8): 583-8 . Vlug MS, Bartels SAL, Wind J et al (2012) Which fast track elements predict early recovery after colon cancer surgery? Colorectal Dis 14(8): 1001-8 Walter CJ, CoUin J, Dumville JC, Drew PJ, Monson J R (2008) Enhanced recovery in colorectal resecdons: a systemadc review and meta-analysis. Colorectal Dis 11(4): 344-53 White E, Melmed GY, Vasiliauskas EA et al (2012) Does preoperadve immunosuppression influence unplanned hospital readmission after surgery in padents with Crohn's disease? Dis Colon Rectum 55(5): 563-8 Wick EC, Shore AD, Hirose K et al (2011) Readmission rates and cost following colorectal surgery. Dis Colon Rectum 54(12): 1475-9 Wind J, PoUe SW, Fung Kon Jin PHP et al (2006) Systemadc review of enhanced recovery ptogramnies in colonie surgery. BrJ Siirg 93(7): 800-9

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