For colorectal surgery patients at Vanderbilt University Medical Center, the introduction last summer of a new patient care protocol, which includes intensive follow-up by anesthesiologists in the hospital, has led to an average 25 percent reduction in hospital length of stay after surgery — from four days to three — and 90 percent reduction in the use of opioids to treat post-operative pain.
The cost of hospital care for these patients has decreased in step with the reduction in length of stay.
Rates of unexpected readmission to Vanderbilt University Hospital within 30 days of discharge and rates of patients unexpectedly needing a second Vanderbilt operation within 30 days have both remained unchanged as length of stay has decreased.
“The collaboration between our colorectal surgeons and anesthesiologists to achieve these impressive outcomes is an important step that will hopefully be emulated across other teams in the Medical Center. Not only are these patients as a whole faring much better, the ability to reduce patient’s length of stay represents the significant improvement of a key hospital performance metric,” said C. Wright Pinson, MBA, M.D., deputy vice chancellor for Health Affairs and CEO of the Vanderbilt Health System.
The so-called enhanced recovery pathway is based on an approach that originated in Denmark in the early 1990s, pioneered by Henrik Kehlet, M.D., Ph.D. The approach has since been adopted internationally, particularly in the United Kingdom.
“We’ve sought to take the published evidence and see how we could iteratively improve care at Vanderbilt through a collaborative, multidisciplinary effort between anesthesiologists, colorectal surgeons, nurses, pharmacists and others,” said Matthew McEvoy, M.D., associate professor of Anesthesiology, who helped lead development and implementation of the pathway.
As outlined by McEvoy, the pathway avoids use of opioids in favor of multi-modal analgesia — that is, acetaminophen (Tylenol), ibuprofen and gabapentin — and makes far more use of pain suppressing nerve blocks.
This approach to pain management in turn supports the pathway’s other chief components: earlier feeding and oral hydration after surgery, and earlier ambulation.
According to McEvoy, troublesome side-effects of opioids can include nausea and vomiting, slowing down the bowel, itching and at times dangerously slowed respiration. Compared to analgesics, opioids lead to somewhat slower functional recovery.
McEvoy said average pain scores reported by patients were unaffected by the switch to analgesics, but that scores for satisfaction with pain levels have improved.
“The reasons these patients tend to stay in the hospital are pain control and return of bowel function. The traditional postoperative care model included medicines that controlled pain but increased nausea and decreased bowel function. The pathway squarely addresses these issues. We’re starting earlier with a liquid diet after surgery, and as soon as it appears that the bowel is waking up we move to a full diet,” said project co-leader Timothy Geiger, M.D., assistant professor of Surgery.
McEvoy and Geiger met with nurses in the hospital prior to implementation.
“We asked them to partner with us not only to do these things differently but to monitor what we’re doing and give us feedback. And there have been a number of things that we’ve tweaked along the way because of that feedback from the nurses,” Geiger said.
Attending physicians and residents from the Department of Anesthesia now follow these patients throughout hospitalization to guide pain management and monitor recovery.
According to McEvoy, Vanderbilt teams are now adapting this approach for surgical weight loss, surgical oncology and abdominal wall reconstruction patients. Work on additional Vanderbilt pathways will begin soon for gynecological surgery, major spine surgery, certain liver procedures, major breast reconstructive surgery, bladder removal (cystectomy), kidney removal (nephrectomy) and head and neck cancer reconstructive surgery.
“It only works as a partnership where the key stakeholders get together, decide upon the components of the pathway and how they can be delivered in a high reliability fashion, then agree who owns which steps of the process — and nursing, pharmacy and the rest of the care team all have very important parts in that,” McEvoy said.
A research paper based on the project is now under review.