Patients undergoing colon and rectal operations who participated in an innovative quality improvement (QI) program to speed their recovery and enhance results experienced shorter hospitalizations, reduced infection rates, and lower hospital costs, according to new study results.  The study, published as an “article in press” on the Journal of the American College of Surgeons website in advance of print publication later this year, also demonstrated improved patient satisfaction.

The QI project, which took place at The Johns Hopkins Hospital in Baltimore, made multiple changes to surgical care processes, or clinical interventions, based on evidence-based best clinical practices. Only 11 months after implementing the new standardized care plan, called an Integrated Recovery Pathway, the researchers found these patients’ hospital stays were two days shorter, on average, than before implementation.  Also, the rate of surgical site infection (SSI)—a common postoperative complication—decreased by more than half, said principal investigator Elizabeth C. Wick, MD, FACS, associate professor of surgery and oncology at Johns Hopkins University School of Medicine, Baltimore.

A key to the program’s success, according to Dr. Wick, was that it changed the organizational culture (values and behaviors) to be more patient-centered.  The researchers used a trust-based accountability model that reportedly defined the actions needed from not only the care providers but also the hospital’s senior leadership, which ensured sufficient resources and monitored results. “We had executive support coupled with participation from the frontline health care staff, so this QI effort was a priority for everyone,” Dr. Wick said. “We consistently kept the patient at the center of care.”

To help build trust and accountability among staff members, the same teams of providers worked together in the operating rooms, and all colorectal surgical patients stayed in a single inpatient unit after their operations.  Dr. Wick said these were changes to past processes. Dr. Wick also considers it important that the hospital first put into place the infrastructure needed to improve surgical teamwork and patient safety.  Specifically, a Comprehensive Unit-based Safety Program (CUSP), started in 2010, helped reduce colorectal SSI rates after one year.* 

Beginning in February 2014, the new integrated recovery pathway expanded on the existing safety program, with the aim of improving patient outcomes, value, and experience (satisfaction), Dr. Wick reported.First, project leaders educated the staff about the pathway and the need to engage patients and their families as partners in their care.  Ongoing staff education included an electronic “dashboard,” an interactive performance review tool, which showed progress on the main outcomes being evaluated: length of stay, SSI rate, and patient satisfaction. Other pathway components, with examples of steps taken, included:

Prevention of SSIs: before the operation, preventive administration of oral antibiotics and antiseptic skin cleansing

Enhanced recovery techniques, designed to help the patient more quickly recover physical function and self-care ability:

• Allowing the patient to drink clear fluids until two hours before the operation, to prevent dehydration
• Avoiding general anesthesia by gas inhalation when possible
• Encouraging the patient to get up from bed and resume oral intake on the day of the operation

Over the 11 months of the study (through December 2014), the investigators compared results of 310 patients who underwent colorectal operations before the integrated recovery pathway began with those of 330 patients whose colorectal surgical care involved the pathway.  Both groups had similar demographic characteristics and procedures. The average hospital stay after a colorectal operation was seven days without the pathway and five days with it according to the study authors.

On average, the SSI rate decreased from 18.8 percent before the pathway to 7.3 percent after the intervention. Average direct costs of a hospital stay fell by more than 17 percent, from $10,933 to $9,036, the investigators reported. Results of patient satisfaction surveys, obtained randomly from some patients, showed improved satisfaction from before the pathway intervention to after it.  The greatest improvements were with staff communication about medications (from 52 to 71 percent), staff responsiveness to patients’ requests (24 versus 34 percent), and pain management (68 versus 77 percent).

“We believe this is one of the few published QI studies showing that a clinical intervention to improve care also improved patient experience scores,” Dr. Wick commented.

Secondary outcomes also improved according to the article.  Rates of urinary tract infections dropped from 4.1 to 1.6 percent.  Fewer blood clots occurred in deep veins (deep venous thrombosis), such as in the legs; the postintervention rate of these blood clots was 1.6 percent versus a preintervention rate of 3.5 percent.

     Data for the secondary outcomes and SSIs were tracked with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP®).  NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals.

The study authors wrote they could not conclude that the integrated recovery pathway led to, or was the sole reason for, the improved outcomes.  However, Dr. Wick said the surgical staff has received extensive positive feedback from patients about the changes. “Patients feel we are delivering better care,” she commented.  “We are more geared to getting patients home faster, where they are happier.”

Dr. Wick’s coauthors include Daniel J. Galante, DO; Deborah B. Hobson, BSN; Andrew R. Benson, CRNA; K.H. Ken Lee, DrPH, MHS; Sean M. Berenholtz, MD, MHS; Jonathan E. Efron, MD, FACS; Peter J. Pronovost, MD, PhD; and Christopher L. Wu, MD.