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498
12 mg if the procedure is planned as open or has a high risk of conversion. In lapa-
roscopic colectomy using our ERP, the typical LOS is the same or better than the
published median for laparoscopic colectomy with alvimopan, so we have not
appreciated a benefit in these patients [59, 64]. We avoid thoracic epidurals for pain
control, having found no benefit to their use in randomized trials of laparoscopic
and open colectomy [65, 66]. Intraoperatively patients are actively warmed and IV
fluids are given judiciously as determined by our anesthesiologists familiarized with
ERP principles. We routinely perform transversus abdominus plane (TAP) blocks at
the conclusion of laparoscopic and open procedures [67–71]; we do not use NG
tubes or drains after colectomy. Post-operatively patients are ordered IV patient
controlled analgesia (PCA) plus 650 mg of oral acetaminophen every 4 h beginning
immediately after surgery. Gabapentin 300 mg every 8 h and ketorolac 15 mg IV
every 6 h are given for up to 72 h unless there is preexisting renal dysfunction or
high risk of bleeding. Bisacodyl 10 mg daily is given beginning the following day.
Patients are given noncarbonated liquids and chewing gum on the evening of sur-
gery and are walked with the assistance of their nurse.
On post-op day 1, the PCA and Foley catheter are removed. Laparoscopic colec-
tomy patients who have tolerated liquids are given a soft diet on post-op day 1 and
their IV fluids are hep-locked. We continue liquid diets until day 2 after open proce-
dures. Oral narcotics are offered in addition to the other analgesic modalities if
needed. Patients are instructed to walk the halls (roughly 60 m) up to 5 times per
day, sit in a chair between walks, and use an incentive spirometer at regular inter-
vals. Before discharge patients must be passing flatus, tolerating solid food, com-
fortable on oral analgesia, and have adequate home support as assessed by the
discharge planner on the hospital floor. Adherence to our protocol has been greatly
facilitated by trying to keep our patients on a single hospital ward and the hiring of
dedicated nurse practitioners who provide consistency in the face of frequently
changing housestaff and fellows.
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going elective open colorectal resection: a meta-analysis update. Appl Nurs Res ANR.
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38. Raue W, Haase O, Junghans T, Scharfenberg M, Muller JM, Schwenk W. “Fast-track” multi-
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39. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus
conventional postoperative care in colorectal surgery. J Gastrointest Surg. 2010;14(1):88–95.
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bilitation in elective colorectal surgery patients: a prospective clinical and immunological
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tional recovery strategies for colorectal surgery. Cochrane Database Syst Rev.
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enhanced recovery protocols. Colorectal Dis. 2010;12(12):1175–82.
43. Henriksen MG, Jensen MB, Hansen HV, Jespersen TW, Hessov I. Enforced mobilization,
early oral feeding, and balanced analgesia improve convalescence after colorectal surgery.
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44. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-
track vs conventional care. Colorectal Dis. 2006;8(8):683–7.
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a fast-track program on postoperative fatigue and functional recovery after major colonic sur-
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46. Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN. The enhanced
recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal
surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010;29(4):434–40.
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surgery: a meta-analysis update. Int J Colorectal Dis. 2009;24(10):1119–31.
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length of stay after colon surgery. J Am Coll Surg. 1998;186(5):501–6.
50. Walter CJ, Collin J, Dumville JC, Drew PJ, Monson JR. Enhanced recovery in colorectal
resections: a systematic review and meta-analysis. Colorectal Dis. 2009;11(4):344–53.
51. Wind J, Polle SW, Jin H, et al. Systematic review of enhanced recovery programmes in colonic
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2009;47(7 Suppl 1):S28–32.
53. Thiele RH, Rea KM, Turrentine FE, et al. Standardization of care: impact of an enhanced
recovery protocol on length of stay, complications, and direct costs after colorectal surgery.
J Am Coll Surg. 2015;220(4):430–43.
54. Ehrlich A, Kellokumpu S, Wagner B, Kautiainen H, Kellokumpu I. Comparison of laparo-
scopic and open colonic resection within fast-track and traditional perioperative care path-
ways: clinical outcomes and in-hospital costs. Scand J Surg. 2015;104(4):211–8.
55. Wang H, Zhu DX, Liang L, et al. Short-term quality of life in patients undergoing colonic
surgery using enhanced recovery after surgery program versus conventional perioperative
management. Qual Life Res. 2015;24(11):2663–70.
56. Reurings JC, Spanjersberg WR, Oostvogel HJ, et al. A prospective cohort study to investigate
cost-minimisation, of traditional open, open fAst track recovery and laParoscopic fASt track
multimodal management, for surgical patients with colon carcinomas (TAPAS study). BMC
Surg. 2010;10:18.
57. Brozek JL, Akl EA, Compalati E, et al. Grading quality of evidence and strength of recom-
mendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing
recommendations. Allergy. 2011;66(5):588–95.
58. Delaney CP. Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery.
Dis Colon Rectum. 2008;51(2):181–5.
59. Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ. Towards optimizing periop-
erative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using
enhanced recovery pathways. Am J Surg. 2012;203(3):353–5; discussion 355–6.
60. Lawrence JK, Keller DS, Samia H, et al. Discharge within 24 to 72 hours of colorectal surgery
is associated with low readmission rates when using enhanced recovery pathways. J Am Coll
Surg. 2013;216(3):390–4.
61. Brady KM, Keller DS, Delaney CP. Successful implementation of an enhanced recovery path-
way: the Nurse’s role. AORN J. 2015;102(5):469–81.
62. Keller DS, Stulberg JJ, Lawrence JK, Delaney CP. Process control to measure process improve-
ment in colorectal surgery: modifications to an established enhanced recovery pathway. Dis
Colon Rectum. 2014;57(2):194–200.
63. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic
surgery: Enhanced Recovery After Surgery (ERAS((R))) Society recommendations. World
J Surg. 2013;37(2):285–305.
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64. Delaney CP, Craver C, Gibbons MM, et al. Evaluation of clinical outcomes with alvimopan in
clinical practice: a national matched-cohort study in patients undergoing bowel resection. Ann
Surg. 2012;255(4):731–8.
65. Zutshi M, Delaney CP, Senagore AJ, et al. Randomized controlled trial comparing the con-
trolled rehabilitation with early ambulation and diet pathway versus the controlled rehabilita-
tion with early ambulation and diet with preemptive epidural anesthesia/analgesia after
laparotomy and intestinal resection. Am J Surg. 2005;189(3):268–72.
66. Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomized clinical trial compar-
ing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colec-
tomy. Br J Surg. 2003;90(10):1195–9.
67. Keller DS, Ermlich BO, Delaney CP. Demonstrating the benefits of transversus abdominis
plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecu-
tive cases. J Am Coll Surg. 2014;219(6):1143–8.
68. Keller DS, Ermlich BO, Schiltz N, et al. The effect of transversus abdominis plane blocks on
postoperative pain in laparoscopic colorectal surgery: a prospective, randomized, double-blind
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69. Favuzza J, Delaney CP. Outcomes of discharge after elective laparoscopic colorectal surgery
with transversus abdominis plane blocks and enhanced recovery pathway. J Am Coll Surg.
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W.C. Mustain and C.P. Delaney
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503© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_44
Chapter 44
Quality Improvement: Preventing
Readmission After Ileostomy Formation
Najjia N. Mahmoud and Emily Carter Paulson
Introduction
Readmission after surgery is a problem that is increasingly recognized by surgeons,
patients, insurers, and hospitals. It exposes patients to additional risk and increases
expense in a variety of predictable ways. Readmission can occur for a number of
reasons but in colorectal surgery it falls into a few broad categories: complications
related to the operative procedure, functional complications as a result of the proce-
dure, and medical complications unrelated to the procedure but related to hospital-
ization, anesthesia, or patient comorbidities. Relatively common reasons for
readmission following discharge after elective colorectal operation include surgical
site infection (wound infection and anastomotic leak or intra-abdominal abscess),
high ileostomy output and dehydration, and symptomatic venous thrombosis events.
In recent years, a focus on quality metrics has highlighted deficiencies that are pos-
sible to target by planned interventions resulting in improvement in patient clinical
outcomes as well as health system resource allocation. Surgical site infection and
venous thrombosis prevention have been the subject of numerous studies. There are
evidence-based guidelines and recommendations focused on creating pathways and
specific interventions for these issues already and a chapter on evidence and recom-
mendations could easily be written on each of these problems. Acceptable interven-
tions for ileostomy dehydration are not as well studied and therefore consensus is
more difficult.
Readmission following diverting ileostomy in colorectal surgery is a frequent occur-
rence and could serve as a target for future quality improvement programs. A recent
retrospective review of over 75,000 patients undergoing colectomy with either primary
N.N. Mahmoud (*) • E.C. Paulson
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
e-mail: Najjia.Mahmoud@uphs.upenn.edu
504
anastomosis, colostomy, or ileostomy revealed that ileostomy patients return to the
hospital at a much more frequent rate than those patients who do not have an ileostomy
[1]. In this group, almost 40 % of the ileostomy patients had a hospital-based acute care
encounter within 30 days of their initial discharge. Over 17 % of these encounters were
secondary to either renal failure and/or fluid and electrolyte disorders from dehydra-
tion. This result is consistent with many other studies published in the past 5 years
regarding readmission following ileostomy [1–6]. In these studies, the overall readmis-
sion rate for patients with new ileostomies ranged from 17 % to over 40 %. Dehydration
and/or renal failure accounted for up to 40 % of these readmissions.
Pre-operative stoma education with involvement of enterostomy nurses, includ-
ing preoperative marking of the planned stoma site, have been advocated as a
means to reduce stomal complications. Much of this discussion, however, has
focused on prevention of mechanical stomal problems, such as leakage due to mal-
position, and on the psychosocial preparation required for adapting to life with an
ostomy [7, 8]. There has been little published regarding interventions targeted at
reducing the high rate of readmission following ileostomy, especially readmission
due to the dehydration and electrolyte imbalances that can accompany high ileos-
tomy output. The aim of this chapter is to identify and review the published litera-
ture regarding interventions aimed at reducing readmission following ileostomy
formation.
Search Strategy
We searched the PubMed database from January 1, 2005-January 1, 2016 to identify
studies (including meta-analyses, randomized controlled trials, and retrospective
cohort studies) relevant to readmission following ileostomy formation. The search
terms were: “ostomy” or “ileostomy” or “stoma” and “readmission” or “dehydra-
tion” or “renal failure”. The articles were screened by title and abstract by both
authors. English-only articles were included if they evaluated a specific ostomy-
focused intervention at the time of stoma creation (pre- or post- creation) and
reported on the outcome of interest--readmission.
Patient population Intervention Comparator Outcomes studied
Patients undergoing
ileostomy
Patient education; stoma
teaching
Traditional
management
Readmission
Results
Only three articles were identified that specifically discussed stoma-related inter-
ventions and readmission (Table 44.1) [9–11]. The quality of evidence of these stud-
ies is rated as low.
N.N. Mahmoud and E.C. Paulson
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505
In 2012, Nagel et al. published the results of a non-randomized before-and-
after trial examining the impact of a well-defined ileostomy pathway on readmis-
sion following formation of a new ileostomy [9]. Their pathway included
preoperative education, standardized ileostomy teaching materials, in-hospital
teaching including direct patient engagement with their ileostomy, and strict post-
discharge tracking of fluid input and output.. The authors compared readmission
rate for new ileostomy patients over the 7 months after implementation of the
pathway (n = 42) to the rate for new ileostomy patients for the 4 years prior
(n = 161). The overall readmission rate dropped from 35.4 to 21.4 % after the
pathway was initiated, but this was not statistically significant (p = 0.28). The
readmission rate for dehydration, however, dropped from 15.5 to 0.0 % with
adoption of the ileostomy pathway (p = 0.02). These authors conclude that their
overall decrease in readmissions was almost exclusively “due to preemptive man-
agement of potential diarrhea and dehydration by patient’s self-management of
their input and output.”
In 2012, Younis et al. published the results of a non-randomized trial evaluating
the impact of focused preoperative patient stoma education on post-ileostomy out-
comes [10]. In this study, the stoma intervention was included as part of a larger
enhanced recovery program (ERP) being evaluated. Patients in their ERP received
a stoma instructional DVD and a “practice pack” to allow them to practice ileos-
tomy care preoperatively. Prior to ERP, the patients at their institution had only
received routine information and counselling at their surgical preoperative visit. The
authors compared 120 patients who underwent ileostomy after institution of the
ERP to 120 patients who underwent ileostomy in the 2 years prior to ERP. They
found that delay in hospital discharge caused by delay in independent stoma man-
agement was reduced from 17.5 % in the pre-ERP group to 0.8 % in the ERP group
(p < 0.001). Their readmission rate was very low compared to almost all other pub-
lished studies. Only 2.5 % of the pre-ERP patients were readmitted, compared to
0 % of the ERP group, although this was not a statistically significant difference
(p = 0.001)
Table 44.1 Studies of Ileostomies and Readmission Rates
Study Study design Patients
Outcome of
interest
Traditional
management
Enhanced
education
Quality
of
evidence
Nagle
[9]
(2012)
Uncontrolled
before and
after
203
Loop or
end
ileostomy
Readmission
rates
35.4 % 21.4 % Low
Younis
[10]
(2012)
Uncontrolled
before and
after
240
Loop or
end
ileostomy
Readmission
rates
2.5 % 0 % Low
Phatak
[11]
(2014)
Systematic
Review
NA Readmission
rates
NA NA Low
44 Quality Improvement: Preventing Readmission After Ileostomy Formation
506
Finally, in 2014, Phatak et al. published a systematic review of educational inter-
ventions for ostomates [11].This group only identified 3 articles, two of which are
discussed above, that reported rates of readmission following new ostomy from a
total of 7 articles that evaluated any stoma education intervention. They conclude
that the quality of evidence regarding educational interventions and readmission
following ostomy surgery is low. Of note, the third article identified in this review
was a randomized-trial published by Delaney et al. in 2003 evaluating the impact of
a postoperative care pathway using controlled rehabilitation with early ambulation
and diet (CREAD) on outcome after intestinal resection. Upon review of this article,
there is no clear description of specific stoma-related interventions. The authors do
mention that CREAD patients received “supporting written information document-
ing the expected post-operative milestones.” As such, it is hard to draw any conclu-
sions related to stoma-specific interventions and readmission from this trial, which
is why it is not included in our review.
Recommendations Based on the Data
It should be quite obvious that the data related to specific ileostomy pathways for
prevention of readmission, and specifically readmission for dehydration, is quite
sparse. Furthermore, the data that is available is low quality. Even so, there are many
institutions that have implemented ad hoc ileostomy counseling and have encour-
aged pathway development in an effort to prevent the well-known complication of
post-discharge dehydration and readmission.
There is good reason to believe from the study by Nagle et al., that an appro-
priately powered, prospective study would likely show that a programmatic
approach to providing specific counselling to prevent dehydration results in a
reduction of readmissions. But there are also compelling reason to believe that
the additional benefits of counselling new ostomates obviates the need for level
1 data In reality, stoma interventions including pre- and post-operative counsel-
ling and education and patient-driven pathways to track and balance post-dis-
charge fluid management pose minimal risk to new ostomates. The benefits,
however, can improve quality of life and decrease readmission and cost of care.
Our practice includes, when possible, preoperative stoma site marking and coun-
selling with an enterostomal therapist, in-hospital counselling and education,
and post-discharge visiting nursing.
Preoperative ileostomy marking can ensure that the planned ileostomy is in a
position that enables the avoidance of leakage, skin excoriation, and facilitates pat-
ent self-care. It is also an opportunity to counsel, educate, and reassure. New osto-
mates desire and require preoperative education to set expectations and alleviate
anxiety. They need to know what to expect both in the hospital and afterwards. Data
in the field of education supports the fact that repetitive exposure to the same set of
educational objectives reinforces desirable behaviors and, in this case, helps com-
pliance. The patient should be reassured that they will receive stoma education
N.N. Mahmoud and E.C. Paulson
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507
again prior to discharge and be helped and supervised in the care of their own
ostomy prior to discharge.
Personal Recommendations Based on the Data
While published data is scarce, the basics of post-discharge ileostomy management
is actually quite simple. In our practice, prior to hospital discharge, patients should
be able to:
1. Change their own appliance.
2. Make daily measurements of output and record 24 h totals until the first office
visit.
3. Be aware of dietary restrictions.
4. Be familiar with 2–3 interventions for reducing output.
5. Have recourse to contact help if confused or ill.
Specific interventions include:
1. An ileostomy checklist reviewed, point-by-point, with a caregiver prior to dis-
charge. Review with both patient and family members can help reinforce
compliance.
2. A 24 h chart for documenting output.
3. Ensuring that the patient can participate in his or her own care by viewing a
change of appliance in the hospital.
4. A list of foods to avoid in the post-operative period.
5. A graduated measuring vessel and a specific 24 h total ileostomy output to
target.
6. A list of interventions and medications to try if output exceeds the target.
7. A reliable call-in number for the patient to reach out to the office in the event of
questions or concerns that will be answered within several hours.
Other interventions that may be offered that are quite valuable and improve
patient satisfaction include routine and automatic referral to visiting nurse services
for new ostomates, calls from the office in the early discharge period to reinforce
checklist, measurement, and dietary compliance, and reminder texts and emails via
secure medical portals to ensure that directions are followed.
Although it seems logical that program like this should reduce readmissions, it is
also likely that overall institutional and practitioner compliance is poor. Improvement
in our ability to administer complex pathways is dependent upon diffusion of
knowledge of goals of care to all members of the team including floor nurses and
social workers and home nurses, and empowerment of ancillary providers to pro-
vide counselling and materials for ileostomy care postoperatively. A pathway such
as the one outlined is not difficult to organize, it is simply hard to routinely admin-
ister. Providing alternative means (data pushed out via electronic medical records
and secure portals) and empowering personnel (floor nurses, advanced practitioners,
44 Quality Improvement: Preventing Readmission After Ileostomy Formation