Up to 70% of patients with Crohn’s disease and some 30% of patients with ulcerative colitis require abdominal surgery during their lifetime. Perioperative adverse events such as anastomotic leaks, intra-abdominal abscess and unplanned stoma formation are associated with potentially modifiable risk factors. Impaired recovery and complications cause considerable loss of quality of life in this population, who are often in a formative stage of life with considerable educational, professional and family commitments. In order to improve outcomes in elective or expedited IBD surgery, identification of these modifiable risk factors and their pre-operative optimisation in each individual patient is important, but preoperative management remains heterogeneous. We therefore aimed to implement a care bundle to systematically identify and optimise preoperative modifiable risk factors in IBD surgery.Method
A literature review identified five important modifiable pre-operative factors in IBD surgery: smoking, anaemia, malnutrition, steroid and immunosuppressant therapy, and intra-abdominal sepsis. From May 2017, a pre-operative patient optimisation bundle was developed to improve these risk factors. It was implemented using a continuous quality improvement (QI) methodology utilising the model for improvement, sequential plan–do–study–act cycles, tests of change and trust wide upscaling. The main outcome measure was days between failure, where failure was defined as non-compliance with one or more of the five components of the pathway. The care pathway was fully implemented from 1 September 2017, with a continuous QI approach.Results
18 consecutive patients operated prior to the implementation date, were retrospectively assessed and 14 patients operated with the care bundle were prospectively studied. Mean days between compliance failure increased approximately 2-fold, from 11.7 to 26.1 days. From the first month of implementation, 100% compliance with the anaemia and smoking interventions were achieved, while full compliance with nutritional assessment and steroid weaning elements took longer time to achieve. Length of stay and incidence of Clavien-Dindo grade ≥II morbidity remain unchanged in this prelimnary data.Conclusion
Quality improvement methodologies including PDSA cycles, tests of change and trust-wide up-scaling are effective in implement a complex multidisciplinary pre-operative optimisation care pathway for patients undergoing major IBD surgery.