Enhanced Recovery After Surgery and Fecal Diversions: Development of a Best Practice Guideline

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Excerpt

Enhanced Recovery After Surgery (ERAS) program, also referred to as Fast Track Surgery, continues to gain increased interest and implementation for colorectal surgeries. Initially pioneered in 2000 by Professor Kehlet and his surgical team in Copenhagen, the ERAS program combines an evidence-based, multimodal, standardized approach to reduce the stress response after surgery, decrease postoperative complications, and enhance recovery to promote early discharge.1 Traditional colonic surgery has been associated with a 15% to 20% complication rate and an average length of stay of 6 to 10 days.1 Remarkably, with the multifaceted, multidisciplinary approach of ERAS, current hospital length of stay has been dramatically reduced. Examples of the innovative patient care management provided with the ERAS program include an emphasis on preoperative education, minimally invasive surgical techniques, newer anesthetics, and aggressive postoperative rehabilitation with early enteral nutrition and ambulation.1–3
In 2006, the Best Practices in General Surgery (BPIGS) group was established with the purpose to standardize general surgical care across the University of Toronto–affiliated hospitals. To date, 6 clinical practice guidelines have been developed including ERAS, Surgical Site Infection, Mechanical Bowel Preparation, Thromboprophylaxis, Intra-Abdominal Infection and Peri-Operative Pain Management (http://www.bpigs.ca).
The ERAS evidence-based guideline for patients undergoing elective colorectal surgery was first implemented in February 2012 at 8 academic teaching hospitals in Toronto. In March 2013, the implementation was extended to 7 additional academic teaching hospitals in the province of Ontario after receiving an Adopting Research to Improve Care (ARTIC) grant from the Council of Academic Hospitals in Ontario (CAHO). All elective colorectal surgery patients with or without an ostomy were included in the ERAS program targeting a length of stay of 3 days for colon surgery and 4 days for rectal surgery.
Early within the implementation phase of the ERAS program, it was identified that the individual needs of a patient requiring an ostomy needed to be met with this new health care delivery model. Gaps were noted in nursing care in terms of efficient preoperative and postoperative ostomy education provided to patients and families within the revised, condensed length of stay as well as nursing resources available to successfully transition the care of patients into the community setting.
This new health care delivery model prompted the development of a Provincial ERAS Enterostomal Therapy Nurse (ETN) Network, led by an ETN Steering Committee. The goal of the committee was to develop best practice guidelines (BPGs) to standardize nursing care for patients requiring a fecal diversion. In November 2013, the ETN Steering Committee surveyed all 15 ERAS organizations to determine the type and level of nursing support available and the preoperative, postoperative and discharge follow-up care provided by each center (Table 1).
Results of the survey indicated provincial variation for access to experienced nursing support and consistent care for this vulnerable patient population within the acute care setting and following discharge into the community setting. Therefore, a standardized approach to ostomy education and care was needed to enhance the immediate postoperative recovery and discharge experience and promote positive patient outcomes.
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