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'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and
C P Delaney1, V W Fazio, A J Senagore
1Department of Colorectal Surgery/A-111, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA. delanec@ccf.org
Background:
A combination of factors has emphasized the need to reduce postoperative stay after surgery. Multimodal care plans may shorten hospital stay, but have been associated with high readmission rates and are generally reserved for straightforward, non-complicated colonic (not rectal) resections. This study evaluated a 'fast track' protocol in patients undergoing major colonic and rectal surgery.
Methods:
Sixty consecutive patients (median age 44.5 (range 13-70) years) underwent major procedures over a 6-week period on one colorectal service. Nasogastric tubes and epidural anaesthesia were not used. Patients participated in a protocol of early diet and early ambulation, and were discharged after meeting defined criteria.
Results:
Fifty-eight patients (97 per cent) were deemed suitable for the 'fast track' approach at the time of surgery and stayed for a mean(s.d.) of 4.3(1.6) days after operation. Patients in diagnosis-related group (DRG) 148 (colorectal resection with co-morbidity; n = 40) stayed for 4.6(1.7) days, which was longer than those in DRG 149 (without co-morbidity; n = 18) who stayed 3.5(0.8) days (P = 0.01). Three patients (5 per cent) required a nasogastric tube for vomiting. There were no readmissions directly attributable to 'fast track' failure, although four patients (7 per cent) were readmitted within 30 days of operation for other reasons. Eight poorly compliant patients stayed for 5.1(1.1) days (P = 0.02 versus compliant patients). 'Fast track' patients had a shorter length of stay than patients receiving traditional care on other colorectal services during the same time period (compared by DRG 148, DRG 149 and for all patients) (P < 0.0001).
Conclusion:
The 'fast track' protocol allows patients with high levels of co-morbidity undergoing complex colorectal and reoperative pelvic surgery to benefit from a rapid recovery and early discharge from hospital. The approach is safe and has low readmission rates.