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Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection
Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection Antonia E. Stephen, MD, and David L. Berger, MD, Boston, Mass
Background. Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway. Methods. One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups. Results. Mean total length of stay (± standard deviation [SD]) was less in the postclinical pathway patients (3.7 ± 1.5 days) compared to preclinical pathway patients (6.6 ± 3.3 days) ( P < .001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant ( P < .001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 ± 2.8 days and in the prepathway patients was 6.9 ± 4.1 days ( P < .001). The average cost per patient (± standard error of the mean), with readmission costs added, was $9310 ± $5170 in the prepathway group and $7070 ± $3670 in the postpathway group ( P = .002). Conclusions. The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay. (Surgery 2003;133:277-82.) From the Department of Surgery, Massachusetts General Hospital, Boston, Mass
COLON CANCER AND DIVERTICULAR DISEASE of the large bowel are extremely common afflictions of the elderly in the western hemisphere. Elective colon resections for these and other diseases of the large bowel are performed on a regular basis in large and small health care institutions around the country. The average length of stay after an open colon resection is 5 to 10 days,1,2 with advancement of oral intake and return of bowel function significant factors limiting early discharge. The introduction of laparoscopically assisted large bowel resections led to a close examination of the length of stay after colonic surgery and motivated those involved in these procedures to improve care with regard to cost and patient outcome. Several recent Accepted for publication September 27, 2002. Reprint requests: David L. Berger, MD, Department of Surgery, ACC 465, Massachusetts General Hospital, 15 Parkman St, Boston, MA 02114. © 2003, Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10.1067/msy.2003.19
studies compared length of stay and overall postoperative recovery in patients undergoing open versus laparoscopic colon resection.3-6 In addition, recent data demonstrate that with the introduction of patient care guidelines including epidural anesthesia, early mobilization and diet advancement, and preoperative and postoperative teaching, the length of stay after either open or laparoscopic colon resection can be markedly reduced.4,7 A clinical pathway was designed for patients undergoing elective, open, large bowel resections with the intent to standardize the perioperative management of these patients. This study compared cost, length of stay, and morbidity in patients operated on before and after institution of the pathway. PATIENTS AND METHODS The study period began in August 1997, when the senior author started his clinical practice at the hospital, and included all of his patients who underwent elective colon resections for cancer or diverticular disease from August 1997 through December 2000. The patients were studied by retSURGERY 277
278 Stephen and Berger
rospective chart review, and data collected on each patient included age, sex, indication for operation, type of operation, length of stay in the hospital, and major postoperative complications. Also recorded were readmissions within 30 days of surgery and whether the patient underwent a colostomy or splenic flexure takedown at the time of operation. The total hospital cost per patient, including the operative costs and hospital stay and excluding surgeon’s fee, was calculated. In addition, the cost and length of stay were recorded for all readmissions of study patients. All patients entered the hospital the morning of surgery; patients who were admitted to the hospital on days before surgery or through the emergency department were excluded. Before initiation of the clinical care pathway, patients who underwent elective bowel resections had their nasogastric tube removed when they passed flatus and were discharged when they had a bowel movement. The clinical pathway was instituted in March 1999. The pathway was designed with the aim of providing optimal care in a cost-effective manner and consisted of the following. Each patient underwent preoperative teaching in the doctor’s office. They were informed of their expected length of stay (2 to 3 days) and when they might anticipate advancement of diet, ambulation, and return of bowel function. A complete blood count and electrocardiogram were ordered and reviewed for each patient unless otherwise indicated. No additional preoperative laboratory values were checked routinely. The preoperative bowel preparation, which took place at home on the day before surgery, consisted of Go-lytely (Braintree Labs, Braintree, Mass) and oral neomycin and erythromycin. On the day of surgery, if the patient accepted it, an epidural catheter was placed by a member of the anesthesiology department in the lower thoracic or lumbar region. Intraoperatively the epidural was dosed with a local anesthetic (2% lidocaine or 0.5% bupivacaine, 10 to 20 mL) and postoperatively infused with a mixture of hydromorphone and 0.1% bupivacaine for pain control. Each patient received 1 dose of intravenous cefazolin and metronidazole before surgery. All operations were performed through a judicious incision (infraumbilical vertical incision for left colon resections and abdominoperineal resections and transverse incision for right colectomies). In patients undergoing a left colon resection, the anastomosis was performed in either a 2-layer hand-sewn (3-0 silk and 3-0 polyglactin 910) fashion or with a stapler (EEA, AutoSuture; US Surgical Corporation, Norwalk, Conn). After a right colectomy the anas-
Surgery March 2003
tomosis was hand-sewn (3-0 silk and 3-0 polyglactin 910) in an end-to-side fashion. Operations were grouped for data analysis into right colectomies (including cecectomies and right colectomies), left colectomies (including left colectomies, sigmoid resections, and low anterior resections), and abdominoperineal resections. Postoperatively the patient was admitted to a regular surgical unit and mobilized on the evening after surgery. The extent of mobilization depended on the individual patient. The majority of patients were mobilized to a chair on the evening of surgery and ambulated 3 times during the course of the first postoperative day. On the morning of postoperative day 1, the nasogastric tube was removed and the patient was started on sips of clear liquids, excluding carbonated beverages. On postoperative day 2 the epidural and Foley catheters were removed, and the patient was allowed an unrestricted clear liquid diet. Patients were then discharged on the evening of postoperative day 2 or on the morning of postoperative day 3, provided they were tolerating a liquid diet and were able to take adequate doses of pain medication by mouth. Before discharge, patients received postoperative teaching regarding diet, activity, and return of bowel function. From March 1999 when the clinical pathway was instituted until December 1999 the patients were discharged on an unrestricted diet; in January 2000 the pathway was amended and the patients were instructed to maintain a diet excluding meat and leafy green vegetables until postoperative day 7, after which time they could resume a regular diet. Statistical analysis to determine level of significance of differences in characteristics and length of stay between the 2 groups of patients was calculated by using a 2-sample t test and Fischer exact test. Statistical analysis of the difference in cost between the 2 groups was calculated by using a 1-tailed t test. Data on length of stay are expressed as mean ± SD, and cost data are expressed as mean ± standard error. RESULTS There were 138 patients in the study; 52 patients were operated on before the institution of the clinical pathway in March 1999 (preclinical pathway patients) and 86 patients were operated on after March 1999 (postclinical pathway patients). Patient characteristics are detailed in Table I. The average age of the preclinical and postclinical pathway patients was 69 and 62 years, respectively (P = .004). Of the patients who underwent left colectomies, the bowel anastomosis was hand-sewn in 67 patients and stapled in 25 patients. One patient did not have an anastomosis constructed; he had
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Table I. Patient characteristics, including length of stay, complication, and readmission rates Preclinical pathway patients (n = 52)
Postclinical pathway patients (n = 86)
P value comparing groups
69 ± 13 30 (58)
62 ± 14 35 (41)
.004 .056 .073
43 (83) 9 (17)
58 (67) 28 (33)
15 (29) 34 (65) 3 (6) 4 (7) 7 (13) 6.6 ± 3.3 6.9 ± 4.1 13 (25) 1 (2)
21 (24) 59 (69) 6 (7) 7 (8) 11 (13) 3.7 ± 1.5 4.2 ± 2.8 10 (12) 8 (10)
Age, y (mean ± SD) No. of female sex (%) Diagnosis, no. (%) Cancer Diverticular disease Operation, no. (%) Right colectomy Left colectomy Abdominoperineal resection Colostomy, no. (%) Splenic flexure takedown, no. (%) Length of stay, days (mean ± SD) Length of stay with readmissions, days (mean ± SD) Complications, no. (%) Readmissions, no. (%)
undergone an abdominoperineal resection 20 years previously and presented with a tumor at the splenic flexure. Total length of stay was less in the postclinical pathway patients (3.7 ± 1.5 days) compared with preclinical pathway patients (6.6 ± 3.3 days) (P < .001) (Table I). When adjusted for age, sex, diagnosis, and type of operation by using multiple regression analysis, the difference in length of stay remained statistically significant (P < .001). The average cost per patient in the prepathway group was $8790 ± $3680 and in the postpathway group was $6490 ± $2290 (P < .001) (Table II). The complication rate in the preclinical pathway patients was 25% (13 of 52 patients) and in the postclinical pathway patients was 12% (10 of 86 patients) (P = .058) (Table I). Postoperative complications in the prepathway and postpathway patients are detailed in Table III. Included in the complications are only those that occurred during the initial admission; complications requiring readmission were considered separately and detailed in the following paragraph. There were no perioperative deaths. Only 1 preclinical pathway patient was readmitted within 30 days of surgery for an anastomotic breakdown on postoperative day 9. This patient had been discharged on postoperative day 6 after a low anterior resection for cancer. There were 8 readmissions in the postclinical pathway group, 1 for an anastomotic breakdown on postoperative day 7 and 7 for abdominal pain/ileus. All 7 patients in the postpathway group who were readmitted with abdominal pain/ileus were treated conservatively with bowel rest and hydration; 5 were admitted for 1 to 2 days, 1 stayed for 4 days, and 1 patient had a readmission stay of 19 days with a prolonged
>.05
<.001 <.001 .058 .089
postoperative ileus; this patient required total parenteral nutrition during his readmission. Of the 86 postpathway patients, 46 were operated on before January 2000 and were sent home on an unrestricted diet, and 40 were operated on after January 2000 and were sent home on a diet excluding meat and leafy green vegetables. Five of the 7 patients in the postpathway group readmitted with abdominal pain/ileus were operated on before January 2000 and therefore were discharged home on an unrestricted diet; 2 of the 7 readmitted patients were operated on after January 2000 and were sent home on the amended diet. The readmission rate for postoperative ileus was therefore 11% in the group sent home on an unrestricted diet and 5% in the group sent home on the amended diet. The total readmission rate in the prepathway group was 2% (1 of 52) and in the postpathway group was 9% (8 of 86) (P = .153). When the readmission length of stay for both groups was added to the length of stay of the original admission, the mean length of stay in the postpathway patients (4.2 ± 2.8 days) was still shorter than that of the prepathway patients (6.9 ± 4.1 days) (P < .001). With the cost of readmissions added to the cost of the original admission, the average cost per patient in the prepathway group was $9310 ± $5170 and in the postpathway group was $7070 ± $3670 (P = .002). There were a total of 3 anastomotic breakdowns, 2 in the prepathway group and 1 in the postpathway group for an overall rate of 2% (3 of 138). All 3 anastomotic breakdowns occurred in patients who underwent a low anterior resection, and all 3 patients had a stapled anastomosis. After adjusting for age, sex, and diagnosis by using multiple regression analysis, the difference in complication and
280 Stephen and Berger
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Table II. Patient cost* before and after institution of the pathway
Cost per patient for surgical admission Cost per patient for surgical admission with readmission cost added
Preclinical pathway patients (n = 52)
Postclinical pathway patients (n = 86)
P value comparing groups
$8790 ± $3680 $9310 ± $5170
$6490 ± $2290 $7070 ± $3670
<.001 .002
*Mean ± standard error of mean.
Table III. Postoperative complications Preclinical pathway patients (n = 13)
Postclinical pathway patients (n = 10)
Fever/atelectasis (3) Wound infection (2) Urinary retention (2) Low hematocrit requiring transfusion (1) Prolonged ileus (1) Pancreatitis (1) Respiratory failure (1) Congestive heart failure (1) Anastomotic breakdown (1)
Atrial fibrillation (2) Wound infection (2) Chest pain with evaluation for myocardial infarction (1) Intra-abdominal abscess (1) Prolonged ileus (2) Intra-abdominal bleed with re-exploration (1) Spinal headache treated with a blood patch (1)
readmission rates between the 2 groups was still not statistically significant. DISCUSSION In the current environment of managed care and the increasing involvement of governmental agencies in the economics of medicine, it is crucial that health care practitioners, including surgeons, participate in the development of clinical pathways. The goal of these practice guidelines is to provide high quality care in a cost-effective manner. Clinical pathways were initially developed to streamline the nursing care of postoperative patients8 and in recent years have come to include the participation of physicians and other nonphysician health care workers, in addition to nurses. In general, clinical pathways are designed for commonly performed procedures and have been instituted for cardiothoracic,9,10 vascular,11-13 urologic,14 and gastrointestinal operations.7,15-18 They encompass not only the postoperative plan but also preoperative and intraoperative patient care. This study represents an analysis of patients who underwent elective large bowel resections before and after the prospective introduction of a clinical pathway. All patients who had elective colon resections, regardless of age or medical condition, were included in the pathway. Notably, the length of stay, including readmissions, decreased from a mean of 6.9 to 4.2 days, a difference that remains statistically significant after adjusting for differences between the 2 groups in age, sex, operation, and diagnosis. The average age of the postpathway
patients was 62 years, 7 years younger than the average age of 69 years in the prepathway patients; this difference was statistically significant and potentially could contribute to the decreased length of stay in the postpathway group. However, the difference in length of stay between the 2 groups remains significant when corrected for age and other factors by using multiple regression analysis. There was no increase in the postoperative complication rate between the 2 groups; in fact, the complication rate was lower in the postpathway patients compared with the prepathway patients. It is important to note that 1 surgeon operated on all the patients included in this study, and it is possible that an increase in surgical experience contributed to the decrease in complication rate over time. Furthermore, the study periods were not contemporaneous and patients were not randomized. It would be difficult to conduct such a study because the institution of a clinical pathway influences the care of patients not on the pathway. In a recent report, institution of a clinical pathway after bowel surgery led to a decreased length of stay in patients not included on the pathway, as well as for those on the pathway.18 There was 1 readmission in the prepathway group, which was for an anastomotic breakdown. There were no readmissions for postoperative ileus in the prepathway group. This is in contrast to the postpathway group, in which 7 patients were readmitted with an ileus. Patients readmitted with ileus in the postpathway group were managed conservatively until resolution of their discomfort and
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return of bowel function. The majority of them had a readmission stay of only 1 to 2 days. Despite the fact that the overall difference in readmission rates was not statistically significant, it is worth noting for its potential clinical importance, and it is possible that the relatively small number of patients in the study did not demonstrate this difference (type II error). In the postpathway group after January 2000, when patients were discharged from the hospital they were carefully instructed to maintain a diet without meat or leafy green vegetables and to anticipate return of bowel function on postoperative day 4 to 6. Specifics of the postoperative diet may contribute to ileus and readmission. Five of the 7 patients readmitted with an ileus were discharged home after their operation on an unrestricted diet; the readmission rate decreased by more than half after the pathway was changed to send the patients home on a more restricted diet excluding meat and leafy green vegetables. Although the numbers are too small for a statistical comparison, this would suggest that modifications in diet may decrease readmissions for ileus. The elimination of meat and leafy green vegetables from the diet postoperatively decreases the amount of dietary fat and fiber, both of which increase stool bulk and could potentially cause gastrointestinal distress in the early postoperative period. To successfully implement clinical pathways, it is imperative that we make an effort to recognize which patients may not tolerate an early discharge and provide all patients with specific instructions that will expedite their recovery at home and decrease the likelihood of complications and readmissions. Clinical pathways require a coordinated effort from physicians, nurses, and ancillary hospital staff. Each step in the care of these patients is crucial to maintain a safe and expeditious operation and recovery. A key element of the clinical pathway is patient education. This begins in the surgeon’s office with extensive preoperative teaching detailing projected length of stay and return of bowel function. The patients included in the pathway therefore expect a shorter length of stay, compared with patients not prepared in this manner. The use of epidural anesthesia has been shown to reduce the incidence of postoperative morbidity when used for patients undergoing several different types of procedures, including abdominal surgery.19 During the postoperative recovery period, the surgical residents, nurses, and aides need to follow the pathway to ensure timely removal of tubes and drains, appropriate diet advancement, and early
mobilization. Prompt removal of the nasogastric tube after laparotomy is a practice supported by recently published studies20,21 and greatly contributes to patient mobilization and diet advancement. After removal of the nasogastric tube, the patients are permitted to begin oral feeding immediately. Recent studies of early postoperative feeding after open bowel resection have shown no increase in the complication rate22,23 and have demonstrated improvements in the length of stay.24-26 In the postpathway group, despite nasogastric tube removal and discharge not being dependent on passage of flatus or stool, the outcome was not adversely affected to a great extent, indicating that patients can be safely managed in this manner. The introduction of clinical pathways streamlines the postoperative care of surgical patients and reduces cost and length of stay for patients undergoing general surgical procedures.18 In this study, the mean length of stay in the postclinical pathway patients was 4.2 days, including readmissions, which was shorter than most reported in the literature1,2 and comparable to the length of stay reported for laparoscopic colon resections.3-6 In addition, the average cost per patient for the patients on the clinical pathway was $2240 less than the average cost per patient for the patients not on the pathway. These statistics are clearly of interest to hospital administration, insurance companies, and others outside the health care profession who often impose financial restrictions on patient care. It is, of course, important to be frugal, but first and foremost, the ultimate goal is to provide the highest standard of care for each and every patient. Clinical pathways may represent an ideal solution by standardizing preoperative, postoperative, and intraoperative care to reduce costs while improving patient care. REFERENCES 1. Bokey EL, Chapuis PH, Fung C, Hughes WJ, Koorey SG, Brewer D, et al. Post-operative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon Rectum 1995;38:480-7. 2. Schoetz DJ Jr, Bockler M, Rosenblatt MS, Malhotra S, Roberts PL, Murray JJ, et al. ‘Ideal’ length of stay after colectomy: whose ideal? Dis Colon Rectum 1997;40:806-10. 3. Faynsod M, Stamos MJ, Arnell T, Borden C, Udani S, Vargas H. A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg 2000;66:841-3. 4. Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995;345:763-4. 5. Vargas HD, Ramirez RT, Hoffman GC, Hubbard GW, Gould RJ, Wohlgemuth SD, et al. Defining the role of laparoscop-
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6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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ic-assisted sigmoid colectomy for diverticulitis. Dis Colon Rectum 2000;43:1726-31. Franklin ME, Kazantsev GB, Abrego D, Diaz-E JA, Balli J, Glass JL. Laparoscopic surgery for stage III colon cancer: long term follow-up. Surg Endosc 2000;14:612-6. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 1999;86:227-30. Campion FX, Rosenblatt MS. Quality assurance and medical outcomes in the era of cost containment. Surg Clin North Am 1996;76:139-59. Wright CD, Wain JC, Grillo HC, Moncure AC, Macaluso SM, Mathisen DJ. Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality. Ann Thorac Surg 1997;64:299-302. Cohn LH, Rosborough D, Fernandez J. Reducing costs and length of stay and improving efficiency and quality of care in cardiac surgery. Ann Thoracic Surg 1997;64:S58-60. Muluk SC, Painter L, Sile S, et al. Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital. J Vasc Surg 1997;25:84-93. Barker SG, Sachs R, Louden C, Linnard D, Abu-Own A, Buckland J, et al. Integrated care pathways for vascular surgery. Eur J Vasc Endovasc Surg 1999;18:207-15. Su LT, Carpenter JP. Decreasing carotid endarterectomy length of stay at a university hospital. Cardiovasc Surg 1999;7:292-7. Chang PL, Wang TM, Huang ST, Hsieh ML, Chuang YC, Chang CH. Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy. World J Urol 2000;18:417-21. Basse L, Jakobsen DH, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000;232:51-7. Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
decreasing length of hospitalization. Arch Surg 2001;136:391-8. Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S, et al. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 2001;233:704-15. Pritts TA, Nussbaum MS, Flesch LV, Fegelman EJ, Parikh AA, Fischer JE. Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 1999;230:728-33. Rodgers A, Walker N, Schug S, McGee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from overview of randomised trials. Br Med J 2000;321:1-12. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A metaanalysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469-76. Pearl ML, Valea FA, Fischer M, Chalas E. A randomized controlled trial of postoperative nasogastric tube decompression in gynecologic oncology patients undergoing intra-abdominal surgery. Obstet Gynecol 1996;88:399. Ortiz H, Armendariz P, Yarnoz C. Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures. Int J Colorectal Dis 1996;11:246-9. Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras JJ, Wexner SD. Is early oral feeding safe after elective colorectal surgery: a prospective randomized trial. Ann Surg 1995;222:73-7. DiFronzo LA, Cymerman J, O’Connell TX. Factors affecting early postoperative feeding following elective open colon resection. Arch Surg 1999;134:941-6. Hawalsi A, Schroder DM, Lloyd LR, Featherstone R. Elective conventional colectomy in the era of laparoscopic surgery. Am Surg 1996;62:589-93. Binderow SR, Cohen SM, Wexner SD, Nogueras JJ. Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum 1994;37:584-9.
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Background. Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway. Methods. One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups. Results. Mean total length of stay (± standard deviation [SD]) was less in the postclinical pathway patients (3.7 ± 1.5 days) compared to preclinical pathway patients (6.6 ± 3.3 days) ( P < .001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant ( P < .001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 ± 2.8 days and in the prepathway patients was 6.9 ± 4.1 days ( P < .001). The average cost per patient (± standard error of the mean), with readmission costs added, was $9310 ± $5170 in the prepathway group and $7070 ± $3670 in the postpathway group ( P = .002). Conclusions. The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay. (Surgery 2003;133:277-82.) From the Department of Surgery, Massachusetts General Hospital, Boston, Mass
COLON CANCER AND DIVERTICULAR DISEASE of the large bowel are extremely common afflictions of the elderly in the western hemisphere. Elective colon resections for these and other diseases of the large bowel are performed on a regular basis in large and small health care institutions around the country. The average length of stay after an open colon resection is 5 to 10 days,1,2 with advancement of oral intake and return of bowel function significant factors limiting early discharge. The introduction of laparoscopically assisted large bowel resections led to a close examination of the length of stay after colonic surgery and motivated those involved in these procedures to improve care with regard to cost and patient outcome. Several recent Accepted for publication September 27, 2002. Reprint requests: David L. Berger, MD, Department of Surgery, ACC 465, Massachusetts General Hospital, 15 Parkman St, Boston, MA 02114. © 2003, Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10.1067/msy.2003.19
studies compared length of stay and overall postoperative recovery in patients undergoing open versus laparoscopic colon resection.3-6 In addition, recent data demonstrate that with the introduction of patient care guidelines including epidural anesthesia, early mobilization and diet advancement, and preoperative and postoperative teaching, the length of stay after either open or laparoscopic colon resection can be markedly reduced.4,7 A clinical pathway was designed for patients undergoing elective, open, large bowel resections with the intent to standardize the perioperative management of these patients. This study compared cost, length of stay, and morbidity in patients operated on before and after institution of the pathway. PATIENTS AND METHODS The study period began in August 1997, when the senior author started his clinical practice at the hospital, and included all of his patients who underwent elective colon resections for cancer or diverticular disease from August 1997 through December 2000. The patients were studied by retSURGERY 277
278 Stephen and Berger
rospective chart review, and data collected on each patient included age, sex, indication for operation, type of operation, length of stay in the hospital, and major postoperative complications. Also recorded were readmissions within 30 days of surgery and whether the patient underwent a colostomy or splenic flexure takedown at the time of operation. The total hospital cost per patient, including the operative costs and hospital stay and excluding surgeon’s fee, was calculated. In addition, the cost and length of stay were recorded for all readmissions of study patients. All patients entered the hospital the morning of surgery; patients who were admitted to the hospital on days before surgery or through the emergency department were excluded. Before initiation of the clinical care pathway, patients who underwent elective bowel resections had their nasogastric tube removed when they passed flatus and were discharged when they had a bowel movement. The clinical pathway was instituted in March 1999. The pathway was designed with the aim of providing optimal care in a cost-effective manner and consisted of the following. Each patient underwent preoperative teaching in the doctor’s office. They were informed of their expected length of stay (2 to 3 days) and when they might anticipate advancement of diet, ambulation, and return of bowel function. A complete blood count and electrocardiogram were ordered and reviewed for each patient unless otherwise indicated. No additional preoperative laboratory values were checked routinely. The preoperative bowel preparation, which took place at home on the day before surgery, consisted of Go-lytely (Braintree Labs, Braintree, Mass) and oral neomycin and erythromycin. On the day of surgery, if the patient accepted it, an epidural catheter was placed by a member of the anesthesiology department in the lower thoracic or lumbar region. Intraoperatively the epidural was dosed with a local anesthetic (2% lidocaine or 0.5% bupivacaine, 10 to 20 mL) and postoperatively infused with a mixture of hydromorphone and 0.1% bupivacaine for pain control. Each patient received 1 dose of intravenous cefazolin and metronidazole before surgery. All operations were performed through a judicious incision (infraumbilical vertical incision for left colon resections and abdominoperineal resections and transverse incision for right colectomies). In patients undergoing a left colon resection, the anastomosis was performed in either a 2-layer hand-sewn (3-0 silk and 3-0 polyglactin 910) fashion or with a stapler (EEA, AutoSuture; US Surgical Corporation, Norwalk, Conn). After a right colectomy the anas-
Surgery March 2003
tomosis was hand-sewn (3-0 silk and 3-0 polyglactin 910) in an end-to-side fashion. Operations were grouped for data analysis into right colectomies (including cecectomies and right colectomies), left colectomies (including left colectomies, sigmoid resections, and low anterior resections), and abdominoperineal resections. Postoperatively the patient was admitted to a regular surgical unit and mobilized on the evening after surgery. The extent of mobilization depended on the individual patient. The majority of patients were mobilized to a chair on the evening of surgery and ambulated 3 times during the course of the first postoperative day. On the morning of postoperative day 1, the nasogastric tube was removed and the patient was started on sips of clear liquids, excluding carbonated beverages. On postoperative day 2 the epidural and Foley catheters were removed, and the patient was allowed an unrestricted clear liquid diet. Patients were then discharged on the evening of postoperative day 2 or on the morning of postoperative day 3, provided they were tolerating a liquid diet and were able to take adequate doses of pain medication by mouth. Before discharge, patients received postoperative teaching regarding diet, activity, and return of bowel function. From March 1999 when the clinical pathway was instituted until December 1999 the patients were discharged on an unrestricted diet; in January 2000 the pathway was amended and the patients were instructed to maintain a diet excluding meat and leafy green vegetables until postoperative day 7, after which time they could resume a regular diet. Statistical analysis to determine level of significance of differences in characteristics and length of stay between the 2 groups of patients was calculated by using a 2-sample t test and Fischer exact test. Statistical analysis of the difference in cost between the 2 groups was calculated by using a 1-tailed t test. Data on length of stay are expressed as mean ± SD, and cost data are expressed as mean ± standard error. RESULTS There were 138 patients in the study; 52 patients were operated on before the institution of the clinical pathway in March 1999 (preclinical pathway patients) and 86 patients were operated on after March 1999 (postclinical pathway patients). Patient characteristics are detailed in Table I. The average age of the preclinical and postclinical pathway patients was 69 and 62 years, respectively (P = .004). Of the patients who underwent left colectomies, the bowel anastomosis was hand-sewn in 67 patients and stapled in 25 patients. One patient did not have an anastomosis constructed; he had
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Table I. Patient characteristics, including length of stay, complication, and readmission rates Preclinical pathway patients (n = 52)
Postclinical pathway patients (n = 86)
P value comparing groups
69 ± 13 30 (58)
62 ± 14 35 (41)
.004 .056 .073
43 (83) 9 (17)
58 (67) 28 (33)
15 (29) 34 (65) 3 (6) 4 (7) 7 (13) 6.6 ± 3.3 6.9 ± 4.1 13 (25) 1 (2)
21 (24) 59 (69) 6 (7) 7 (8) 11 (13) 3.7 ± 1.5 4.2 ± 2.8 10 (12) 8 (10)
Age, y (mean ± SD) No. of female sex (%) Diagnosis, no. (%) Cancer Diverticular disease Operation, no. (%) Right colectomy Left colectomy Abdominoperineal resection Colostomy, no. (%) Splenic flexure takedown, no. (%) Length of stay, days (mean ± SD) Length of stay with readmissions, days (mean ± SD) Complications, no. (%) Readmissions, no. (%)
undergone an abdominoperineal resection 20 years previously and presented with a tumor at the splenic flexure. Total length of stay was less in the postclinical pathway patients (3.7 ± 1.5 days) compared with preclinical pathway patients (6.6 ± 3.3 days) (P < .001) (Table I). When adjusted for age, sex, diagnosis, and type of operation by using multiple regression analysis, the difference in length of stay remained statistically significant (P < .001). The average cost per patient in the prepathway group was $8790 ± $3680 and in the postpathway group was $6490 ± $2290 (P < .001) (Table II). The complication rate in the preclinical pathway patients was 25% (13 of 52 patients) and in the postclinical pathway patients was 12% (10 of 86 patients) (P = .058) (Table I). Postoperative complications in the prepathway and postpathway patients are detailed in Table III. Included in the complications are only those that occurred during the initial admission; complications requiring readmission were considered separately and detailed in the following paragraph. There were no perioperative deaths. Only 1 preclinical pathway patient was readmitted within 30 days of surgery for an anastomotic breakdown on postoperative day 9. This patient had been discharged on postoperative day 6 after a low anterior resection for cancer. There were 8 readmissions in the postclinical pathway group, 1 for an anastomotic breakdown on postoperative day 7 and 7 for abdominal pain/ileus. All 7 patients in the postpathway group who were readmitted with abdominal pain/ileus were treated conservatively with bowel rest and hydration; 5 were admitted for 1 to 2 days, 1 stayed for 4 days, and 1 patient had a readmission stay of 19 days with a prolonged
>.05
<.001 <.001 .058 .089
postoperative ileus; this patient required total parenteral nutrition during his readmission. Of the 86 postpathway patients, 46 were operated on before January 2000 and were sent home on an unrestricted diet, and 40 were operated on after January 2000 and were sent home on a diet excluding meat and leafy green vegetables. Five of the 7 patients in the postpathway group readmitted with abdominal pain/ileus were operated on before January 2000 and therefore were discharged home on an unrestricted diet; 2 of the 7 readmitted patients were operated on after January 2000 and were sent home on the amended diet. The readmission rate for postoperative ileus was therefore 11% in the group sent home on an unrestricted diet and 5% in the group sent home on the amended diet. The total readmission rate in the prepathway group was 2% (1 of 52) and in the postpathway group was 9% (8 of 86) (P = .153). When the readmission length of stay for both groups was added to the length of stay of the original admission, the mean length of stay in the postpathway patients (4.2 ± 2.8 days) was still shorter than that of the prepathway patients (6.9 ± 4.1 days) (P < .001). With the cost of readmissions added to the cost of the original admission, the average cost per patient in the prepathway group was $9310 ± $5170 and in the postpathway group was $7070 ± $3670 (P = .002). There were a total of 3 anastomotic breakdowns, 2 in the prepathway group and 1 in the postpathway group for an overall rate of 2% (3 of 138). All 3 anastomotic breakdowns occurred in patients who underwent a low anterior resection, and all 3 patients had a stapled anastomosis. After adjusting for age, sex, and diagnosis by using multiple regression analysis, the difference in complication and
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Table II. Patient cost* before and after institution of the pathway
Cost per patient for surgical admission Cost per patient for surgical admission with readmission cost added
Preclinical pathway patients (n = 52)
Postclinical pathway patients (n = 86)
P value comparing groups
$8790 ± $3680 $9310 ± $5170
$6490 ± $2290 $7070 ± $3670
<.001 .002
*Mean ± standard error of mean.
Table III. Postoperative complications Preclinical pathway patients (n = 13)
Postclinical pathway patients (n = 10)
Fever/atelectasis (3) Wound infection (2) Urinary retention (2) Low hematocrit requiring transfusion (1) Prolonged ileus (1) Pancreatitis (1) Respiratory failure (1) Congestive heart failure (1) Anastomotic breakdown (1)
Atrial fibrillation (2) Wound infection (2) Chest pain with evaluation for myocardial infarction (1) Intra-abdominal abscess (1) Prolonged ileus (2) Intra-abdominal bleed with re-exploration (1) Spinal headache treated with a blood patch (1)
readmission rates between the 2 groups was still not statistically significant. DISCUSSION In the current environment of managed care and the increasing involvement of governmental agencies in the economics of medicine, it is crucial that health care practitioners, including surgeons, participate in the development of clinical pathways. The goal of these practice guidelines is to provide high quality care in a cost-effective manner. Clinical pathways were initially developed to streamline the nursing care of postoperative patients8 and in recent years have come to include the participation of physicians and other nonphysician health care workers, in addition to nurses. In general, clinical pathways are designed for commonly performed procedures and have been instituted for cardiothoracic,9,10 vascular,11-13 urologic,14 and gastrointestinal operations.7,15-18 They encompass not only the postoperative plan but also preoperative and intraoperative patient care. This study represents an analysis of patients who underwent elective large bowel resections before and after the prospective introduction of a clinical pathway. All patients who had elective colon resections, regardless of age or medical condition, were included in the pathway. Notably, the length of stay, including readmissions, decreased from a mean of 6.9 to 4.2 days, a difference that remains statistically significant after adjusting for differences between the 2 groups in age, sex, operation, and diagnosis. The average age of the postpathway
patients was 62 years, 7 years younger than the average age of 69 years in the prepathway patients; this difference was statistically significant and potentially could contribute to the decreased length of stay in the postpathway group. However, the difference in length of stay between the 2 groups remains significant when corrected for age and other factors by using multiple regression analysis. There was no increase in the postoperative complication rate between the 2 groups; in fact, the complication rate was lower in the postpathway patients compared with the prepathway patients. It is important to note that 1 surgeon operated on all the patients included in this study, and it is possible that an increase in surgical experience contributed to the decrease in complication rate over time. Furthermore, the study periods were not contemporaneous and patients were not randomized. It would be difficult to conduct such a study because the institution of a clinical pathway influences the care of patients not on the pathway. In a recent report, institution of a clinical pathway after bowel surgery led to a decreased length of stay in patients not included on the pathway, as well as for those on the pathway.18 There was 1 readmission in the prepathway group, which was for an anastomotic breakdown. There were no readmissions for postoperative ileus in the prepathway group. This is in contrast to the postpathway group, in which 7 patients were readmitted with an ileus. Patients readmitted with ileus in the postpathway group were managed conservatively until resolution of their discomfort and
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return of bowel function. The majority of them had a readmission stay of only 1 to 2 days. Despite the fact that the overall difference in readmission rates was not statistically significant, it is worth noting for its potential clinical importance, and it is possible that the relatively small number of patients in the study did not demonstrate this difference (type II error). In the postpathway group after January 2000, when patients were discharged from the hospital they were carefully instructed to maintain a diet without meat or leafy green vegetables and to anticipate return of bowel function on postoperative day 4 to 6. Specifics of the postoperative diet may contribute to ileus and readmission. Five of the 7 patients readmitted with an ileus were discharged home after their operation on an unrestricted diet; the readmission rate decreased by more than half after the pathway was changed to send the patients home on a more restricted diet excluding meat and leafy green vegetables. Although the numbers are too small for a statistical comparison, this would suggest that modifications in diet may decrease readmissions for ileus. The elimination of meat and leafy green vegetables from the diet postoperatively decreases the amount of dietary fat and fiber, both of which increase stool bulk and could potentially cause gastrointestinal distress in the early postoperative period. To successfully implement clinical pathways, it is imperative that we make an effort to recognize which patients may not tolerate an early discharge and provide all patients with specific instructions that will expedite their recovery at home and decrease the likelihood of complications and readmissions. Clinical pathways require a coordinated effort from physicians, nurses, and ancillary hospital staff. Each step in the care of these patients is crucial to maintain a safe and expeditious operation and recovery. A key element of the clinical pathway is patient education. This begins in the surgeon’s office with extensive preoperative teaching detailing projected length of stay and return of bowel function. The patients included in the pathway therefore expect a shorter length of stay, compared with patients not prepared in this manner. The use of epidural anesthesia has been shown to reduce the incidence of postoperative morbidity when used for patients undergoing several different types of procedures, including abdominal surgery.19 During the postoperative recovery period, the surgical residents, nurses, and aides need to follow the pathway to ensure timely removal of tubes and drains, appropriate diet advancement, and early
mobilization. Prompt removal of the nasogastric tube after laparotomy is a practice supported by recently published studies20,21 and greatly contributes to patient mobilization and diet advancement. After removal of the nasogastric tube, the patients are permitted to begin oral feeding immediately. Recent studies of early postoperative feeding after open bowel resection have shown no increase in the complication rate22,23 and have demonstrated improvements in the length of stay.24-26 In the postpathway group, despite nasogastric tube removal and discharge not being dependent on passage of flatus or stool, the outcome was not adversely affected to a great extent, indicating that patients can be safely managed in this manner. The introduction of clinical pathways streamlines the postoperative care of surgical patients and reduces cost and length of stay for patients undergoing general surgical procedures.18 In this study, the mean length of stay in the postclinical pathway patients was 4.2 days, including readmissions, which was shorter than most reported in the literature1,2 and comparable to the length of stay reported for laparoscopic colon resections.3-6 In addition, the average cost per patient for the patients on the clinical pathway was $2240 less than the average cost per patient for the patients not on the pathway. These statistics are clearly of interest to hospital administration, insurance companies, and others outside the health care profession who often impose financial restrictions on patient care. It is, of course, important to be frugal, but first and foremost, the ultimate goal is to provide the highest standard of care for each and every patient. Clinical pathways may represent an ideal solution by standardizing preoperative, postoperative, and intraoperative care to reduce costs while improving patient care. REFERENCES 1. Bokey EL, Chapuis PH, Fung C, Hughes WJ, Koorey SG, Brewer D, et al. Post-operative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon Rectum 1995;38:480-7. 2. Schoetz DJ Jr, Bockler M, Rosenblatt MS, Malhotra S, Roberts PL, Murray JJ, et al. ‘Ideal’ length of stay after colectomy: whose ideal? Dis Colon Rectum 1997;40:806-10. 3. Faynsod M, Stamos MJ, Arnell T, Borden C, Udani S, Vargas H. A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg 2000;66:841-3. 4. Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995;345:763-4. 5. Vargas HD, Ramirez RT, Hoffman GC, Hubbard GW, Gould RJ, Wohlgemuth SD, et al. Defining the role of laparoscop-
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6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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ic-assisted sigmoid colectomy for diverticulitis. Dis Colon Rectum 2000;43:1726-31. Franklin ME, Kazantsev GB, Abrego D, Diaz-E JA, Balli J, Glass JL. Laparoscopic surgery for stage III colon cancer: long term follow-up. Surg Endosc 2000;14:612-6. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 1999;86:227-30. Campion FX, Rosenblatt MS. Quality assurance and medical outcomes in the era of cost containment. Surg Clin North Am 1996;76:139-59. Wright CD, Wain JC, Grillo HC, Moncure AC, Macaluso SM, Mathisen DJ. Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality. Ann Thorac Surg 1997;64:299-302. Cohn LH, Rosborough D, Fernandez J. Reducing costs and length of stay and improving efficiency and quality of care in cardiac surgery. Ann Thoracic Surg 1997;64:S58-60. Muluk SC, Painter L, Sile S, et al. Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital. J Vasc Surg 1997;25:84-93. Barker SG, Sachs R, Louden C, Linnard D, Abu-Own A, Buckland J, et al. Integrated care pathways for vascular surgery. Eur J Vasc Endovasc Surg 1999;18:207-15. Su LT, Carpenter JP. Decreasing carotid endarterectomy length of stay at a university hospital. Cardiovasc Surg 1999;7:292-7. Chang PL, Wang TM, Huang ST, Hsieh ML, Chuang YC, Chang CH. Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy. World J Urol 2000;18:417-21. Basse L, Jakobsen DH, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000;232:51-7. Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
decreasing length of hospitalization. Arch Surg 2001;136:391-8. Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S, et al. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 2001;233:704-15. Pritts TA, Nussbaum MS, Flesch LV, Fegelman EJ, Parikh AA, Fischer JE. Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 1999;230:728-33. Rodgers A, Walker N, Schug S, McGee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from overview of randomised trials. Br Med J 2000;321:1-12. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A metaanalysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469-76. Pearl ML, Valea FA, Fischer M, Chalas E. A randomized controlled trial of postoperative nasogastric tube decompression in gynecologic oncology patients undergoing intra-abdominal surgery. Obstet Gynecol 1996;88:399. Ortiz H, Armendariz P, Yarnoz C. Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures. Int J Colorectal Dis 1996;11:246-9. Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras JJ, Wexner SD. Is early oral feeding safe after elective colorectal surgery: a prospective randomized trial. Ann Surg 1995;222:73-7. DiFronzo LA, Cymerman J, O’Connell TX. Factors affecting early postoperative feeding following elective open colon resection. Arch Surg 1999;134:941-6. Hawalsi A, Schroder DM, Lloyd LR, Featherstone R. Elective conventional colectomy in the era of laparoscopic surgery. Am Surg 1996;62:589-93. Binderow SR, Cohen SM, Wexner SD, Nogueras JJ. Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum 1994;37:584-9.
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