Fast Tracking After Ivor Lewis Esophagogastrectomy

Fast Tracking After Ivor Lewis Esophagogastrectomy* Robert James Cerfolio, MD, FCCP; Ayesha S. Bryant, MSPH; Cynthia S. Bass, MSN, CRNP; Jeana R. Alexander, RN, BSN; and Alfred A. Bartolucci, PhD

Objectives: We streamlined our care using an algorithm for the postoperative care of patients who undergo Ivor Lewis esophagogastrectomy to try to reduce hospital stay to 7 days and maintain safety and patient satisfaction. Methods: A consecutive series of 90 patients who underwent elective esophageal resection by one general thoracic surgeon were studied. An algorithm to guide postoperative care was used, featuring avoidance of the ICU, early ambulation, jejunal tube feeds starting on postoperative day (POD) 1, removal of nasogastric tube and epidural on POD 3, a gastrograffin swallow on PODs 4 or 5, and discharge on POD 7. Results: There were 90 patients (70 men). Fifty-two patients (58%) underwent preoperative radiation and chemotherapy. Esophagectomies were done for cancer or high-grade dysplasia. Forty-two of the last 55 patients (77%) went directly to the floor. Sixteen patients (17.7%) had major complications, which included pneumonia in 5 patients and aspiration pneumonia in 4 patients. There were no anastomotic leaks, and there were four operative deaths (4.4%). There was a greater incidence of failure to fast track, and to have a major complication in patients who underwent neoadjuvant treatment (p ⴝ 0.025 and p ⴝ 0.048, respectively). Median hospital stay was 7 days (range, 6 to 74 days). Complications or mortality could not be definitively attributed to fast tracking. Ninety-seven percent reported excellent satisfaction with their hospital stay, and four patients were readmitted within 1 month of discharge. Conclusions: Fast tracking patients using an algorithm after esophageal resection is safe and delivers minimal morbidity and mortality, and a high patient satisfaction rate. A median hospital stay of 7 days is possible, and the ICU can be avoided in most patients. (CHEST 2004; 126:1187–1194) Key words: chemotherapy; hospital stay; ICU; Ivor Lewis esophagogastrectomy; postoperative; radiotherapy Abbreviation: POD ⫽ postoperative day

n the past several years, several articles have I evaluated fast-tracking protocols and standard1–7

ized, computer-based clinical pathways. These pathways or algorithms aid less-experienced physicians, physician assistants, or rotating residents or fellows to provide consistent and efficient postoperative care. These reports have shown that these pathways *From the Division of Cardiothoracic Surgery (Dr. Cerfolio, Ms. Bass, and Ms. Alexander), University of Alabama at Birmingham; and Departments of Epidemiology (Ms. Bryant) and Biostatistics (Dr. Bartolucci), University of Alabama School of Public Health, Birmingham, AL. Manuscript received January 8, 2004; revision accepted May 26, 2004. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Robert J. Cerfolio, MD, FCCP, Associate Professor of Surgery, Chief of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294; e-mail: [email protected] www.chestjournal.org

can help provide a general framework or guideline for patients with a certain diagnosis, or for postoperative care after a specific operation. We reported our experience with an algorithm for fast tracking after pulmonary resection in 2001, and showed that it could be applied safely and feature discharge on postoperative days (PODs) 3 or 4.8 A fast-tracking pathway has not been reported for esophagectomy. In this study, we evaluated our algorithm for patients who underwent Ivor Lewis esophagogastrectomy. The primary objective of our study was to determine if our fast-tracking pathway, which planned discharge on POD 7, could be applied with high patient satisfaction without increasing morbidity or mortality as compared to other reports. Patients and Methods The records of 90 consecutive patients who underwent elective Ivor Lewis esophagogastrectomy over a 4-year period performed CHEST / 126 / 4 / OCTOBER, 2004

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by one general thoracic surgeon (R.J.C.) were studied. This was a retrospective cohort study of a prospective database. A computerized clinical care pathway (algorithm) was designed to help guide the planned care of these patients (Table 1). Patients were excluded if their esophagogastrectomy was performed at the Veterans Administrative Hospital at the University of Alabama at Birmingham, or who had any other type of esophagectomy aside from Ivor Lewis, and/or who had an emergency esophagogastrec-

Table 1—Daily Guideline of the Postoperative Care of the Typical Patient Who Undergoes an Ivor Lewis Esophagectomy Day of surgery Patient sent to floor Nasogastric tube placed to suction Monitor chest tube output and urinary outputs q4h Continuous monitoring of heart rhythm and pulse oximeter Laboratory tests: hemoglobin levels q4h ⫻ 3 POD 1 Jejunal tube feedings at full concentration, starting at 20 mL/h Ambulate patient four times per day; physical therapy every day Chest tube to suction Laboratory tests: CBC and electrolytes in the morning Strict aspiration precautions; head of bed at 30°; nasogastric tube suction POD 2 Remove anterior chest tube Continue to ambulate patient a minimum of four times per day until discharge Increase rate of jejunal tube feedings, 10 mL/4 h Consult nutritional therapist Continue aspiration precautions; physical therapy POD 3 Increase rate of jejunal tube feedings until achieving goal rate Remove last chest tube if drainage ⬍ 450 mL/d Remove epidural Remove nasogastric tube Consult speech pathologist Remove Foley catheter Continue aspiration precautions; physical therapy; telemetry POD 4 Gastrograffin swallow (or on POD 5 if POD 4 is a Sunday) Continue jejunal tube feeds If swallow shows no leak, advance patient to a full liquid diet and skip clear liquids Continue aspiration precautions; patient warned not to eat while drowsy or to lie recumbent within 3 h of eating. Continue physical therapy Education on chewing and swallowing POD 5 Advance to soft diet as tolerated Start compressing jejunal feedings by increasing rate and turning off for 4 h/d Remove central line Continue aspiration precautions; physical therapy POD 6 Nutrition education provided by dietician Set up home jejunal tube feedings Start to compress jejunal tube feedings 7 pm to 7 am Continue aspiration precautions; physical therapy POD 7 Discharge home on soft diet with continued aspiration precautions and compressed tube feedings at night only

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tomy. The Institutional Review Board at the University of Alabama at Birmingham approved this study. Patients were seen preoperatively in our university clinic. All patients were staged with chest and abdominal CT, esophageal ultrasound with fine-needle aspiration, and positron emission tomography. In general, patients that were T2 or greater or who had nodal disease received neoadjuvant chemo/radiotherapy, and then were restaged with all four staging modalities listed above. If surgery was indicated and if the patients agreed, they were informed of the planned postoperative algorithm. The patients received an outline of the protocol, which listed the planned activities for each POD. The patient and family were asked to review the algorithm and to also bring a copy of it to the hospital. Patients were admitted to the same-day surgical unit on the morning of the operation, and were asked to consume only clear liquids the day before surgery. Epidural catheters were placed in the holding area prior to the resection, and standard preoperative evaluation and intraoperative techniques were used.9 The abdomen was explored through a midline incision above the umbilicus, and if there was no metastatic disease the stomach was completely mobilized and its blood supply was based on the right gastroepiploic artery. The celiac lymph nodes were removed. A pyloroplasty or pyloromyotomy was performed, and toward the later half of this series we favored the latter. A feeding jejunostomy was placed using a Witzel technique. The abdomen was closed, a double lumen endotracheal tube was placed, and a right, posterior, lateral thoracotomy was performed preserving the serratus anterior muscle and without breaking or removing or cutting the fifth rib. A standard Ivor Lewis esophagogastrectomy was performed,9 and thoracic lymphadenectomy was also performed. An anastomosis was performed between the end of the esophagus and the side of the stomach above the divided azygous vein. The anastomosis was hand sewn using a two-layered technique with a back row of interrupted 3– 0 silk and an inner layer of running 3– 0 polydioxanone (PDS; Ethicon; Cornelia, GA). During the first 20 months of this series, the initial 35 patients enrolled in this study were all sent to the ICU for a planned 1-day stay. After this period, all patients were sent directly to the floor unless they had a history of a coronary artery disease, a diffusion capacity of the lung for carbon monoxide ⬍ 40% of predicted, and/or a Paco2 on the arterial blood gas ⱖ 47 mm Hg. The rest of the patients went to the recovery room and then to a floor bed that featured continuous centralized telemetry and bedside pulse oximetry (Table 1). Patients who could not follow the algorithm had their care changed as needed, and these deviations were recorded and labeled as failure to fast track. Major complications were defined as any complication excluding transient atrial arrhythmias, urinary retention, nonoperatively managed chylothorax, or air leak. Mortality was defined as any death occurring during the hospital stay or within 30 days postoperatively Satisfaction surveys were done at time of hospital discharge (Appendix). Patients were seen 2 weeks postoperative. Strict aspiration cautions were stressed at home and over the first 6 weeks postoperatively. Patients received metoclopromide for 6 weeks after surgery. Enteral feedings via the jejunostomy tube were continued at home and compressed over a 12-h period from 7 pm to 7 am. Patients were discharge on a soft postgastrectomy diet. The number of patients who were dilated after resection was recorded. The indication for dilation was variable, and was often at the discretion of the home physicians. Outcome data were collected from a prospective surgical database and subsequently analyzed using ␹2 or Fisher Exact Tests. Clinical Investigations

Results There were 90 patients (70 men; median age, 63 years; age range, 38 to 85 years). Patient characteristics and the incidence of complications are described in Table 2. The median dose of neoadjuvant radiotherapy was 5,040 cGy (range, 3,500 to 6,600 cGy). Median operative time was 4 h and 15 min, and only one patient received blood (2 U) in the operating room. All patients had a preoperative epidural catheter placed; however, in three patients, it did not function and was removed on POD 1. As shown in Table 1, 21 patients (22%) could not be fast tracked. All 16 patients who had a major complication could not be fast tracked; in addition, 5 others also failed fast tracking. These patients included two patients who had chylothoraces from the lymph node

dissection. Both were managed with a medium chained triglyceride diet with resolution, and were discharged on PODs 13 and 9, respectively. The other three patients could not or did not want to go home on the planned discharge day despite the fact they were medically ready, and they went home on day PODs 10, 11, and 14, respectively. Postoperative morbidities are outlined in Table 3. The four operative deaths are shown in Table 4, and all underwent neoadjuvant therapy. The median length of hospital stay was 7 days (Table 5). Four patients were readmitted to other hospitals within 1 month of discharge, for the following reasons: abdominal distention and pain (n ⫽ 1), weakness and fatigue (n ⫽ 1), and nausea and/or vomiting (n ⫽ 2). All cases were self-limiting, and the patients were dis-

Table 2—Patient Characteristics* Characteristics Overall Age, yr ⬍ 70 ⱖ 70 Gender Male Female Radiation/chemotherapy Positive history Negative history Pathology Adenocarcinoma Squamous cell carcinoma Barretts Other Stage of cancer at time of surgery Barretts (0) Complete response (0) 1a 1b 2a 2b 3a 3b 4 Other Location of lesion Upper esophagus Mid-esophagus Distal esophagus Gastroesophageal junction Other Tolerated fast track Yes No

All Patients (n ⫽ 90)

Major Complications†

Failed Fast Track‡

p Value for Tolerating Fast Track

90 (100)

16 (18)

21 (23)

70 (78) 20 (22)

11 (16) 5 (25)

6 (9) 15 (75)

⬍ 0.001

70 (78) 20 (22)

12 (17) 4 (20)

16 (23) 5 (25)

NS

52 (58) 38 (42)

13 (25) 3 (8)

17 (33) 4 (11)

0.025

56 (62) 26 (73) 6 (7) 2 (3)

10 (18) 5 (19) 1 (17) 0

14 (25) 6 (23) 1 (17) 0

10 (11) 12 (13) 19 (21) 17 (19) 6 (7) 10 (11) 9 (10) 2 (2) 3 (3) 2 (2)

1 (10) 3 (25) 5 (5.3) 2 (11) 1 (17) 3 (30) 0 1 (50) 0 0

1 (10) 5 (42) 5 (26) 4 (24) 1 (17) 4 (40) 0 1 (50) 0 0

NS

1 (1) 22 (24) 51 (57) 15 (17) 1 (1)

0 4 (18) 9 (18) 3 (20) 0

0 5 (23) 13 (25) 3 (20) 0

NS

68 (76) 22 (24)

2 (3) 14 (64)

NS

⬍ 0.001§

*Data are presented as No. (%). NS ⫽ not significant. †There were a total of 19 major complications in 16 patients. Three patients had two major complications. ‡Five of the 21 patients that failed fast tracking did not have a major complication. §Corresponds to major complications. www.chestjournal.org

CHEST / 126 / 4 / OCTOBER, 2004

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Table 3—Postoperative Morbidity*

Table 5—Outcomes*

Variables

Data

Outcomes

Data

Morbidity (includes deaths)† Pulmonary‡ Pneumonia Aspiration pneumonia Mucous plug Prolonged intubation Anastomotic Leak Postoperative dilation required Abdominal complications‡ Cryptogenic liver failure Superior mesenteric artery embolus and dead gut Ischemic cecum Clostridium difficile Renal, acute renal failure‡ Neurologic, transient ischemic attack‡ Cardiac Atrial fibrillation Atrial flutter Other Hoarseness Chylothorax (nonoperatively managed) Bilateral subclavian and axillary vein clot‡ Gout flare-up

24 (26.6) 12 (13) 6 4 1 1

Mortality Median length of stay, d Median ICU stay, d† Excellent to very good satisfaction‡ 30-day readmission rate

4 (4.4) 7 1 79 (96) 4 (4.4)

0 16 (18) 4 (4.4) 1 1 1 1 1 (1.1) 1 (1.1) 7 (8) 6 1 5 (5.5) 1 2 1 1

*Data are presented as No. of patients (%) or No. †Three patients had two major complications each. ‡Major complications.

charged within 6 days. Eighty-two of the 86 operative survivors completed a patient satisfaction survey at the time of discharge, and 79 survivors (96%) reported excellent to very good satisfaction with their overall hospital care and experience. Seventy-five percent of patients ⱖ 70 years old failed the fast-tracking protocol (p ⬍ 0.001). A higher percentage of patients with a history of preoperative radiation and chemotherapy (33%, compared to 11%) also failed the fast-tracking protocol (p ⫽ 0.025) and had major complications (25%, compared to 8%, p ⫽ 0.048) [Table 2]. No signifi-

*Data are presented as No. (%) or No. †This reflects only the 48 patients who went to the ICU postoperatively. ‡Based on survey administered at time of patient discharge, completed by 82 patients (91%).

cant differences in rate of complications were attributed to differences in stage of tumor, location of lesion, pathology, type of tumor, or gender. Discussion Over the past several decades, health maintenance organizations and third-party payers have dictated how physicians should practice medicine in the United States. Despite this changing environment, the physician’s job remains the same. We must continue to provide a safe product with a high success rate, good outcomes, and high patient satisfaction. A secondary goal is to try to control costs. For these reasons, we decided to evaluate a fasttracking protocol for esophageal resection designed by surgeons instead of by third-party payers. As shown in our previous article, we designed, implemented, and reported a successful algorithm that was applied to 500 patients after pulmonary resection that featured a 4-day hospital stay. Several third-party payers have used this as a template for standard postoperative care. This experience showed us the advantages of postoperative algorithms, especially with the continuous flow of new fellows,

Table 4 —Data for Mortalities* Preoperative Chemotherapy and/or Radiation

Death on POD No.

1

Yes

6

2

Yes

7

3

Yes

15

4

Yes

42

Patient No.

Stage of Cancer

Can Fast Tracking Be Blamed?

T3N1M0 downstaged to T1N0M0 T2N1M0 downstaged to T1N0M0 T4N0M0 nonresponder T4N0M0

Unknown

T3N1M0 complete responder

No

Unknown No

Complications/Cause of Death Aspirated on POD 4 prior to gastrograffin swallow. Died of MOSF. Coded on floor (POD 6) probably from silent aspiration. Died of ventricular arrhythmia. Pneumonia (POD 6), atrial fibrillation (POD 7), SMA embolism, dead gut (POD 14). Died of MOSF. Pneumonia (POD 4), cryptogenic liver failure. Died of MOSF, made DNR status.

*MOSF ⫽ multiorgan system failure; DNR ⫽ do not resuscitate. 1190

Clinical Investigations

residents, and medical students that join our “thoracic team” on a weekly basis. The average length of stay in most reports after Ivor Lewis esophagogastrectomy is 12 days (Table 6). We have shown it can be significantly shortened and still achieve high patient satisfaction. However, one of the major sources of morbidity and mortality in this series is aspiration. Four patients had a major aspiration event, which led to death in two patients; these events occurred at 4 days and 6 days postoperatively, respectively. The first patient was still receiving nothing by mouth, and the other patient was only taking sips of clear liquids. This vexing complication occurred despite our strict aspiration precautions stressed throughout the hospitalization and after discharge, the use of a nasogastric tube for 72 h after surgery, elevation of the head of the bed, evaluation by a speech pathologist, and prokinetic agents. The real question is, is the fast-tracking algorithm responsible for these complications? If we have had feed the patients later, would we have been able to lower the incidence of aspiration or pneumonia in this series? Pulmonary complications continue to be the number one cause of morbidity after esophageal resection.20 There is no evidence that feeding patients later can decrease or eliminate this problem. The gastric conduit is essential a gravity conduit after Ivor Lewis or transhiatal esophagectomy; therefore, patients can aspirate months to years after resection. Thus, we believe it is safe to feed patients on PODs 4 or 5 if they are educated to the problem of aspiration, have limited intake for the first few weeks, and are awake and alert and aware of the risks of aspiration. We have no data that PODs 6, 7, or 8 are any safer than PODs 4 or 5. Yet, despite our heightened awareness and our practice of head elevation at all times, the early and continued use of prokinetic agents from POD 1 until POD 30, the avoidance of liquids, and instructing patients to wait 3 h after eating prior to sleeping, etc., pulmonary complications remain the number one problem after esophagectomy. This article and Table 1 demonstrate one way to accomplish discharge by POD 7 with extremely high patient satisfaction and safety. We were able to reduce the length of stay by almost 50% when compared to other large series, and yet maintain similar mortality and morbidity rates. We believe that the keys to this pathway are aggressive physical therapy, removal of epidurals by POD 3, and the gastrograffin swallow on PODs 4 or 5. One cannot fast track patients without careful operative technique that avoids postoperative bleeding or anastomotic leaks. An anastomosis that joins well-perfused gastric mucosa to esophageal mucosa in a tensionwww.chestjournal.org

free manner is critical. Our concern that a running inner layer might lead to a high dilation rate was not found. After the first year and a half of this series, we started to avoid the ICU in most patients. We noted no difference in the outcomes between these 55 patients and the first 35 patients. Although patients are sent directly to the floor from the recovery room, their heart rhythm and arterial saturations are continuously monitored. In the last 55 patients, 42 patients (77%) were selected to go the floor, and none had to be sent to the ICU. By avoiding the ICU, family members are not restricted in their visiting hours. Another advantage of avoiding the ICU, besides the cost savings, is that the family members are able to stay and even sleep in the same room with the patient on the floor. This improves the experience and satisfaction of the families and patients. It may also help the patient from becoming confused. Patient satisfaction is also maintained by daily review on rounds of the planned activity for each day with the patient and family. Daily communication is absolutely critical to maintain expectations and high patient satisfaction. In any teaching hospital, there is a constant turnover of the general thoracic team. This includes the cardiothoracic fellow, general surgical residents, medical students, and often the floor nurses as well. Similarly, in nonteaching hospitals, the postoperative care may be delivered by physician assistants or by a covering partner who has less experience with postesophagectomy patients then the operating surgeon. A study by Sutton et al10 showed the need for continuing supervision of even the “fully trained” surgeon with regard to esophageal resections given the recent trend toward shorter training periods. The type of pathway outlined in our article helps minimize these problems. There are several advantages to our series when compared to others. Ours has a reduced variance by having one surgeon who performed all procedures, utilized the same protocol (except avoidance of the ICU in the second half of this study) over the entire duration of the study, and had a relatively short duration. In this series, we found that patients who underwent neoadjuvant treatment had a higher incidence of postoperative complications. All four operative deaths occurred in patients who underwent neoadjuvant chemotherapy and radiotherapy. Bosset et al11 also observed an increased morbidity and mortality in this patient population. However, several other larger series12–14 have shown little difference. The failure rate for fast tracking patients who underwent neoadjuvant therapy was 33%, compared to 11% in the other patients in this report. Perhaps, fast-tracking algorithms should only be carefully or CHEST / 126 / 4 / OCTOBER, 2004

1191

1192

Clinical Investigations

54 NA 228 220

6

NA

10

3

Headrick et al16 (1991–1997) Linden and Sugerbaker17 (review) Griffin et al18 (1990–2000) Visbal et al19 (1992–1995)

18

*NA ⫽ data not available in article.

McLarty et al23 (1972–1990)

33

10

107

63

1,085

20

Orringer et al21 (1978–1998) Gluch et al22 (1999)

143

10

Karl et al20 (1989–1999)

120

9

Doty et al15 (1989–1998)

90

Patients, No.

4

Study Span, yr

Current study (1999–2003)

Source

6–7

Multiple

1

2

Multiple

1

NA

Multiple

Multiple

1

Surgeons, No.

4.6

(n ⫽ 44) NA 69.8%

12

9.1

(n ⫽ 20) NA 60.6%

40%

13

0.9 3.6 contained leaks 3.5

2

NA

13

0.8

0

Anastamotic Leak, %

NA

29%

45% overall 10% major 37.7%

50%

57%

(n ⫽ 28) 26.6% overall (n ⫽ 16) 17.7% major 40.3% history of radiation/chemotherapy 7.8% no radiation/chemotherapy 37%

Postoperative Morbidity

NA

4.6%

6.1%

4.0%

2.1%

1.4%

10% nationally, 3% large institution 2–4%

1.8%

0.8%

4.4% overall

Mortality

Table 6 —Recently Published Esophagectomy Outcomes*

3.3 ICU, 13.5 overall 10–52%, 14–28%, 21–11% 2.9 ICU, 26 overall 1.7 ICU, 23 overall 72% Ivor Lewis, 13% transhiatal, 15% other

ICU NA, 11 overall

1 ICU, 13 overall

ICU NA, 13 overall NA

ICU NA, 15 overall

0 ICU, 7 overall

Median or Mean Length of Stay, d

Transhiatal

Ivor Lewis only

Transhiatal

Ivor Lewis only

Ivor Lewis only

Ivor Lewis only

All esophagectomies

All types esophagectomies in patient status post chemotherapy/radiation only (Ivor Lewis in four patients)

Ivor Lewis only

Type of Esophagectomy

selectively applied to these patients, especially if they are ⬎ 70 years old. Few studies have compared complication rates using the same protocol and only one surgeon, between a group of patients who underwent neoadjuvant therapy compared to those who did not. In conclusion, we have shown that the majority of patients who undergo elective Ivor Lewis esophagogastrectomy can go directly to the floor and avoid the ICU. Seventy-seven percent can be fast tracked and follow a postoperative algorithm, and be discharged home by POD 7 without compromising morbidity, mortality, or patient or family satisfaction. Aspiration and pneumonia remain one of the biggest risks after esophageal resection despite careful patient education. Patients who are ⱖ 70 years old or who have undergone neoadjuvant therapy are more likely to have postoperative complications, and thus are less likely to tolerate a fast-tracking protocol. Further studies are needed to analyze the results of standardized postoperative pathways after esophagectomy so we can control our practice, as opposed to others dictating to us how to practice. Further prospective multi-institutional studies that feature a large number of surgeons may also help identify the ideal pathway and which patients can and cannot be fast tracked.

Appendix The pertinent parts of the patient satisfaction survey administered at hospital discharge for patients who underwent Ivor Lewis esophagogastrectomy are as follows. In order to improve the care provided to his patients, Dr. Cerfolio and the Division of Thoracic Surgery at the University of Alabama at Birmingham appreciate you taking a few minutes to complete this questionnaire. Your response is completely confidential. Thank you. Please circle your answer where appropriate (1 ⫽ very favorable, 2 ⫽ favorable, 3 ⫽ neutral, 4 ⫽ unfavorable, 5 ⫽ very unfavorable). Were you provided with an adequate understanding of the goals of surgery and the procedure to be performed by Dr. Cerfolio? What was your overall impression of your operating room experience? What was your overall impression of your care on the floor? What was your overall experience with the nurses on the floor? What floor were you on? How was your pain control? Did you experience abdominal pain from the tube feeds? If so, was it managed well? Did you experience any choking when you first started to re-swallow? Did Dr. Cerfolio and the surgical service spend an acceptable amount of time answering your questions and informing you about your daily progress each day on rounds? Did you receive adequate discharge and follow-up instructions from the nursing staff? www.chestjournal.org

Did you feel like you were forced out of the hospital before you were ready? Did you feel that you could have left the hospital sooner? Your overall surgical experience at University of Alabama Medical Center was? Would you come back, or would you recommend Dr. Cerfolio to other family or friends? Would you recommend the University of Alabama at Birmingham to other family or friends? In the space provided below, please feel free to make additional comments. Please feel free to mention specific individuals as necessary (spelling does not matter). All comments are strictly confidential.

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Clinical Investigations