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St. Michael’s paradigm shift in colorectal surgery

Toronto, January 29, 2013

By Emily Holton

The Enhanced Recovery after Surgery guideline focuses on getting patients moving earlier.
The Enhanced Recovery after Surgery guideline focuses on getting patients moving earlier.

The Gastro-intestinal/General Surgery team has an ambitious New Year’s resolution: a paradigm shift in their approach to colorectal surgery.

Starting in January, the team is implementing a bundle of best practices that have been shown to dramatically improve patients’ outcomes and enhance recovery after surgery.

St. Michael’s is one of 15 hospitals across the province implementing the University of Toronto’s Best Practice in General Surgery’s (BPIGS) Enhanced Recovery after Surgery guideline. The U of T group has reexamined all steps in the patient’s journey through the surgical process, and recommended new, evidence-based best practices when necessary.

“We’re very excited to start rolling out these best practices,” said Joan Park, case manager in gastro/general surgery and local champion for the initiative. “And we’re excited about the focus on teamwork: working together as an interprofessional team towards a safe and effective discharge for patients. It’s a big undertaking, but it’s worth it. There is the potential for significant benefits to the patient and the hospital.”

There are approximately 14,000 colon resections performed in Ontario each year, with an average hospital stay of seven days. Where it’s been implemented internationally, the new guideline has been shown to enhance recovery by reducing care time for colorectal surgery patients by more than 30 per cent, and reducing postoperative complications by up to 50 per cent. Patients also tend to experience less postoperative pain, fatigue and gut dysfunction.

Implementing the guideline demands coordination and collaboration among the entire preoperative, perioperative and postoperative multidisciplinary team (surgeons, anaesthetists, nurses, health disciplines) and has a strong focus on patient engagement.

For example, the guideline focuses on the importance of getting patients moving earlier. Nurse champions from the BPIGS group have developed a booklet, based on the guideline, for bowel surgery patients to receive prior to admission. With clinical staff support, patients can use the booklet to track their own progress related to eating and moving around. Other interventions include:

  • Preoperative: education, exercise programs, omission of oral bowel preparation, carbohydrate loading, shortened pre-operative fasting.
  • Intraoperative: fluid restriction or goal-directed fluid management, maintenance of normothermia, Surgical Site Infection and Venous Thromboembolic prophylaxis, use of epidurals.
  • Postoperative: multi-modal approach to pain management, intravenous fluid restriction, early oral intake, gum chewing, no nasogastric tubes, early ambulation.

“Our staff has already embraced the philosophy behind the protocols,” said Park. “The guideline will help us make sure we have a standardized approach to applying the philosophy.”