Rethinking postoperative care: same-day ileostomy closure discharge improves patient outcomes.

Background: The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews.

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts.

Acute social isolation and postoperative surgical outcomes. Lessons learned from COVID-19 pandemic.

Background: During COVID-19 pandemic, hospitals changed visitation policy to limit the infection spread. We aimed to evaluate the impact of evolving visitation policy on short-term surgical outcomes.

Methods: All adult patients who underwent colorectal surgery between January 1, 2020, and May 12, 2020, at our institution were included.

Intraoperative Fluid Management a Modifiable Risk Factor for Surgical Quality - Improving Standardized Practice.

Objective: We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKi) risk for elective colorectal surgery patients.

Background: To date, standard practice within institutions, let alone national expectations related to fluid administration, are limited. This fact has perpetuated a quality gap.

Optimizing Clinical Monitoring Tools to Enhance Patient Review by Pharmacists.

Background: The Clinical Monitoring List (CML) is a real-time scoring system and intervention tool used by Mayo Clinic pharmacists caring for hospitalized patients.

Objective: The study aimed to describe the iterative development and implementation of pharmacist clinical monitoring tools within the electronic health record at a multicampus health system enterprise.

Methods: Between October 2018 and January 2019, pharmacists across the enterprise were surveyed to determine opportunities and gaps in CML functionality.

Enhanced Recovery: A Decade of Experience and Future Prospects at the Mayo Clinic.

This work aims to describe the implementation and subsequent learnings from the first decade after the full implementation of enhanced recovery pathway for colorectal surgery at a single institution. This paper will describe the diffusion efforts and plans through the Define, Measure, Analyze, Improve, Control (DMAIC) process of ongoing quality improvement and through research efforts. The information applies to all readers that provide surgical care within their organization as the fundamental principles of enhanced recovery for surgery are applicable regardless of the setting.

Patient colon and rectal operative outcomes when treated with immune checkpoint inhibitors.

There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery.

Preoperative predictive risk to cancer quality in robotic rectal cancer surgery.

Background: Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery.

Methods: This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019.

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements.

Background: Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs.

Objective: This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge.

Design: This is a retrospective cohort study.

Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis.

Objective: To study the impact of multiphase quality improvement efforts to enhance appropriate use of chemical and mechanical venous thromboembolism (VTE) prophylaxis (VTEP) on the rate of hospital-acquired VTE and determine whether efforts have been associated with increased bleeding complications.

Patients And Methods: All adult inpatients discharged between January 1, 2005, and December 31, 2015, were included in the study. Retrospective interrupted time series analysis compared VTEP performance, VTE outcomes, and unintended consequences (derived from linked administrative and clinical data) across 5 improvement phases: baseline (January 1, 2005-December 31, 2006), paper order set phase (January 1, 2007-February 9, 2009), electronic order set phase (February 10, 2009-December 16, 2009), active reminder phase (December 17, 2009-May 31, 2012), and maintenance phase (June 1, 2012-September 30, 2015).

Temporal patterns of hospital readmissions according to disease category for patients after elective colorectal surgery.

Rationale: The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions.

Methods: Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011-2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30-day readmissions (to index facility) including timing and reasons was utilized.

An Institutional Approach to Managing the Opioid Crisis.

The opioid crisis is a major concern of most health care institutions, including our large academic center. In this article, an organized approach to managing the epidemic institutionally is discussed. An Opioid Stewardship Program was instituted at our tertiary-care center with multiple sites and states of practice, which included diverse membership and expertise.

Potential Association Between Perioperative Fluid Management and Occurrence of Postoperative Ileus.

Background: Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs.

Objective: The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway.

Design: This was a retrospective cohort study of a prospectively maintained institutional database.

The effects of tranexamic acid on blood loss and transfusion rate in colorectal surgery.

Background: The present study aimed to evaluate safety of tranexamic acid (TA) administration and to assess bleeding risk in colorectal surgery (CRS).

Methods: Retrospective cohort study including consecutive patients undergoing elective CRS by a single surgeon between August 2014 and May 2015. All patients received 1 g of TA intravenously at induction and at closure.

Early Acute Kidney Injury Within an Established Enhanced Recovery Pathway: Uncommon and Transitory.

Background: The present study aimed to assess the impact of perioperative fluid management on early acute kidney injury (AKI) rate and long-term sequelae in patients undergoing elective colorectal procedures within an enhanced recovery pathway (ERP).

Methods: Retrospective analysis of consecutive patients from a prospectively maintained ERP database (2011-2015) is performed. Pre- and postoperative creatinine levels (within 24 h) were compared according to risk (preoperative creatinine rise ×1.

Clinical pharmacist perspectives for optimizing pharmacotherapy within Enhanced Recovery After Surgery (ERAS) programs.

One of the most durable approaches to perioperative enhanced recovery programming has culminated in the formation of perioperative organizations devoted to improvements in the quality of the surgical patient experience, such as the Enhanced Recovery After Surgery (ERAS) Society. Members of the American College of Clinical Pharmacy (ACCP) Perioperative Care Practice and Research Network (PRN) and officials from the ERAS Society present an opinion that: (1) identifies therapeutic options within each pharmacotherapy-intensive area of ERAS; (2) generates applied research questions that would allow for comparative analyses of pharmacotherapy options within ERAS programs; (3) proposes collaborative practice opportunities between key stakeholders in the surgical journey and clinical pharmacists to manage drug therapy problems and research questions; and (4) highlights examples of pharmacist-led cost savings attributed to ERAS implementation. Clinical pharmacists, working in this manner with the perioperative team across the care continuum, have optimized pharmacotherapy towards measurable outcomes improvements, and stand ready to partner with inter-professional stakeholders and organizations to advance the care of our mutual patients.

Post-surgical opioid prescribing patterns and risk factors for additional opioid prescriptions within one year after non-emergent colorectal surgery.

Background: National opioid concerns resulted in review of prescribing patterns following colorectal surgery.

Methods: This retrospective cohort study examined prescribing patterns in elective colorectal surgery at a tertiary academic medical center from January 2012 through December 2014.

Results: Forty percent of 4286 patients received additional opioid prescriptions within the year following colorectal surgery.

Ordering a Normal Diet at the End of Surgery-Justified or Overhasty?

Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011⁻2016) were retrieved from a prospectively maintained institutional ERP database.

Post-Discharge Opioid Prescribing Patterns and Risk Factors in Patients Undergoing Elective Colon and Rectal Surgery Without Complications.

Background: Few studies have examined opioid usage in the post-discharge period. The primary aim of this study was to evaluate the need for post-discharge opioids in a unique set of patients: those undergoing colorectal operations and experiencing no surgical complications. The secondary aim was to examine the accuracy of the Opioid Risk Tool (ORT) to predict the need for additional opioid prescriptions.

Utilizing Administrative Data to Focus Quality Improvement Efforts for Opioid Prescribing in an Integrated Health System.

This case study describes the use of multiple administrative data sources within a large, integrated health care delivery system to understand opioid prescribing patterns across practice settings. We describe the information needed to understand prescribing patterns and target interventions, the process for identifying relevant institutional data sources that could be linked to provide information on the settings for prescriptions, and the lessons learned in developing, testing, and implementing an algorithm to link the data sources in a useful manner.

Efficacy and Outcomes of Intrathecal Analgesia as Part of an Enhanced Recovery Pathway in Colon and Rectal Surgical Patients.

Purpose: Multimodal analgesia is an essential component of an enhanced recovery pathway (ERP). An ERP that includes the use of single-injection intrathecal analgesia (IA) has been shown to decrease morbidity and cost and shorten length of stay (LOS). Limited data exist on safety, feasibility, and the optimal IA regimen.

A Collaborative for Implementation of an Evidence-Based Clinical Pathway for Enhanced Recovery in Colon and Rectal Surgery in an Affiliated Network of Healthcare Organizations.

Background: In 2015 the Mayo Clinic Care Network (MCCN), in an effort to extend medical knowledge and share these best practices, embarked on an education mission to diffuse the clinical practice redesign involving the practice of colon and rectal surgery at Mayo Clinic (Rochester, Minnesota) to members of the MCCN. They elected to use a collaborative framework in an attempt to transfer knowledge to multiple teams in an efficient and supportive manner.

Methods: Eight MCCN members assembled a multidisciplinary team, which participated in both a didactic learning session delivered by frontline experts, as well as follow-up remote sessions regarding Mayo Clinic's enhanced recovery pathway for colon and rectal surgery.

Attitudes, Beliefs, Practices, and Concerns Among Clinicians Prescribing Opioids in a Large Academic Institution.

Objectives: Opioid treatment of chronic noncancer pain (CNCP) adds complexity and uncertainty to patient interactions. We sought to assess clinician attitudes, beliefs, practice styles, and concerns around opioid prescribing following the release of the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain.

Methods: E-mailed electronic survey to clinicians at a large academic medical institution.

Surgical Site Infection in Colorectal Surgery: A Study in Antibiotic Duration.

Background: Despite distant historical studies that demonstrated the adequacy of preoperative antibiotic prophylaxis, current surgical practice continues to use antibiotics for postoperative coverage up to 24 hours.

Objective: The aim of this study was to evaluate a change in antibiotic prophylaxis duration and its effect on surgical site infection in a high-volume modern colorectal practice.

Design: A case-controlled series retrospectively reviewed outcomes through a prospective validated data base.