Practice Matters

What works: Enhancing bowel recovery after colorectal surgery

The average length of stay (LOS) for patients undergoing colorectal surgery is 5 to 10 days, depending on the type of surgical procedure. Key factors affecting LOS following an uncomplicated colorectal surgery are diet advancement, pain control, return of bowel function, and mobility level. Fatigue, nausea/vomiting, and ileus formation can occur postoperatively, delaying full recovery and increasing LOS. Use of tubes and drains also may slow recovery.

In the past decade, fast-track, also referred to as enhanced recovery, bowel protocols have been implemented to reduce LOS to 2 to 3 days. Several components make up these protocols, including preoperative education, early ambulation, early return of diet, surgical techniques to reduce discomfort, and decreasing the use of drains or early removal of drains and catheters. Multidisciplinary teams who use the protocols as part of clinical pathways drive this enhanced recovery.

Here is our experience with an enhanced recovery protocol for patients undergoing colorectal surgery and how it benefitted our patients.

Enhanced bowel recovery protocol

To provide more cost-effective care and reduce hospital LOS for our colorectal patients within our 35-bed surgical stepdown unit, our unit-based medical director suggested we research fast-track programs for these patients. We formed a team that included bedside nurses, unit managers, research nurses, and our medical director, who is a colorectal surgeon. The bedside nurses conducted an extensive literature review, under the expert guidance of the research nurses. Using this information, we created a postoperative fast-track order set and algorithm that specifically addressed the removal of drainage tubes and diet progression.

Discharge criteria with fast-track protocols are similar to those of conventional care, but the fast-track program’s purpose is to meet the discharge criteria sooner. The team decided to name the protocol the “Enhanced Bowel Recovery Protocol” rather than using words like “Fast Track” to avoid the perception that our chief concern was rushing the patient out of the hospital. We were instead investigating if we could safely move patients through their recovery more efficiently by eliminating delays in obtaining and carrying out orders.

With conventional postoperative care of the colorectal patient, the physician is responsible for determining when it is appropriate to discontinue the nasogastric tube that was inserted in the operating room, usually after the patient has passed flatus. The physician then decides when it is appropriate to start and advance the patient’s diet, and will typically advance it slowly. The patient is not discharged unless he or she has had a bowel movement. By contrast, the Enhanced Bowel Recovery Protocol order set allows the nurse to discontinue the nasogastric tube and advance the postoperative diet based on his or her physical assessment of the patient’s progress. On Postoperative Day One, the algorithm directs the nurse to discontinue the nasogastric tube if the patient has fewer than 200 mL of nasogastric tube output per shift and doesn’t have nausea, vomiting, or abdominal distention. A clear liquid diet is started as soon as the patient passes flatus, and the diet is advanced to a low residue diet on Postoperative Day Two, based on nurse assessment. (See Enhanced bowel recovery protocol algorithm.)


Because enhanced recovery protocols are well documented in the literature as safe and acceptable practice, we implemented the protocol as a performance improvement pilot, rather than a research study. The population chosen for the pilot study was colorectal surgical patients between the ages of 18 and 70 whose surgeries were nonemergent, not a reoperation, and without unanticipated intraoperative findings.

The surgical patients had the same attending surgeon in the initial phase of the pilot study; expansion of the program to include the patients of other colorectal surgeons occurred about 3 months into the pilot study.

A physician order was required to initiate the Enhanced Bowel Recovery Protocol, and a copy of the algorithm was kept on the chart for reference. A data collection tool was created to record times of first ambulation, nasogastric tube removal, flatus, start of clear liquid diet, advancement of diet to low residue diet, and time of discharge.

Our goal was to have a minimum of 30 patients complete the protocol, as recommended by our research nurses. Our other goals were to reduce LOS by 0.5 days in 6 months’ time, without increasing patient harm. Consistent with studies in the literature, we also chose to monitor our 30-day readmission rate.

Results

Baseline data from January to September 2013 revealed an average LOS of 5.4 days for colorectal surgical patients, and a 30-day readmission rate of 11.1%. In all, 37 patients were enrolled in this pathway from September 2013 to June 2014. LOS was reduced to 5.01 days, a decrease of 0.41 days. Our 30-day readmission rate remained relatively unchanged at 11.8%. Although these results were slightly below the expected decrease of 0.50 days and a statistical analysis showed that the results were not statistically significant (P = 0.081), there was a definite downward trend in the length of stay, which indicated that our interventions were taking us in the right direction. (See Effects of enhanced bowel recovery program.)

Keys to success

Our keys to success with implementing this program were an interdisciplinary approach and nurse autonomy in practice. An interdisciplinary approach to postoperative care has been shown to be an essential component to a successful enhanced recovery program. As bedside caregivers, nurses play a significant role in the success of these programs, from reinforcing expectations to implementing interventions.

We continue to use the Enhanced Bowel Recovery Protocol with our colorectal patients with no complications. We no longer measure outcomes from this specific protocol, but the overall LOS on our surgical unit continues to trend down

Selected references

Baird G, Maxson P, Wrobleski D, et al. Fast-track colorectal surgery program reduces hospital length of stay. Clin Nurse Spec. 2010;24(4):202-8.

Ehrlich A, Wagner B, Kairaluoma M, et al. Evaluation of a fast-track protocol for patients undergoing colorectal surgery. Scand J Surg. 2014;103(3):182-8.

Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014;118(5):1052-61.

Ricciardi R, MacKay G, Weiser M, et al. Fast-track protocols in colorectal surgery. March 2015; updated August 2015. www.uptodate.com/contents/fast-track-protocols-in-colorectal-surgery .

Wang Q, Suo J, Jiang J, et al. Effectiveness of fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis. 2012;14:1009-13.

The authors work at Christiana Care Health System in Newark, Delaware. Kristen Foulk is nurse manager of a transitional care unit, and Karen McCloud is nurse manager of a surgical unit.

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