Enhanced Recovery for Colorectal Cancer Surgery: Improving Post-Discharge Support

M.A. Ole, J.E.F. Fitzgerald, J. Stewart, A.G. Acheson

Medical Education Unit & Dept of Surgery, Queens Medical Centre, Nottingham University Hospital, UK

Introduction
Enhanced Recovery protocols are increasingly facilitating early hospital discharge. Enhanced Recovery takes several measures (see Figure 1) to allow for prompt discharge and recovery following a major operation. A recent meta-analysis of clinical trials indicates higher readmission rates postop than traditional care. This study investigated community practitioners experiences of enhanced recovery following colorectal cancer surgery.

Median ASA score was 2, ranging from 1 to 4 187 patients underwent enhanced recovery CRC surgery during this study period. 128 unique GPs were contacted with response rate = 69 (53.9%). 91.3% were not aware of the enhanced recovery protocols. Major post-operative problems encountered in the community: infection (13.0%), inadequate communication from hospital (36.2%), inadequate nursing resources (15.9%). 27.5% of respondents felt they had inadequate facilities to deal with enhanced recovery patients. 44.9% of the practitioners stated requirement for increased numbers of community nurses. 40.6% of respondents stated communication issues as main factor hindering patient care. Key themes from questionnaire responses: need for detailed / prompt discharge plan and contacts for surgical team

Major problems and concerns that GPs encounter in community

Difficulties managing wound and other post-op infections Lack of or incomplete communication from hospital on discharge Inadequate pain medication with the patient on discharge
Figure 1. Components of ERAS protocol

13.0% 36.2% 8.7% 15.9%

Inadequate resources regarding District Nurses for patient review

Methods
Patients were identified from a prospectively maintained cancer registry at a regional teaching hospital from January 2007 - September 2008. General Practitioners of surviving patients were contacted retrospectively with an 8-item questionnaire (Figure 2) assessing their knowledge and experience of caring for enhanced recovery patients. The questionnaire was anonymous and a free text area was provided for practitioners to add their own comments regarding their experiences at managing these patients.

Table 1. Major problems and concerns encountered by GPS in the community

Conclusions
The overwhelming majority of community practitioners have not heard of ERAS The nursing resources in the community are inadequate to cater for increasing needs of ERAS patients There is insufficient communication between secondary and primary care regarding hospitalised patients Insufficient communication hinders patients care in the community

Take home messages

There is little knowledge of enhanced recovery after discharge amongst community practitioners. Surgical teams should educate and improve communication with community practitioners. Surgical teams should provide better post-discharge support to minimize readmissions.

References
Kehlet H, Wimore DW Fast-track surgery British Journal of Surgery 2005;92 3-4

Results

Figure 2 Questionnaire sent to GPs

Fearon KCH et al Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection; Clinical Nutrition 2005 Kehlet H, Fast-track colorectal surgery The Lancet 2008;371:791-3 Fearon KCH et al Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection; Clinical Nutrition 2005 Walter JC et al. Enhanced recovery in colorectal resections: a systematic review and metaanalysis Colorectal Disease 2009;11 344-353

Median age was 72, ranging from 28 to 96

Contact Mr Edward Fitzgerald: edwardfitzgerald@doctors.org.uk Presented at the ESCP - Prague, September 2009