Discharge instructions for patients who undergo colon surgery are so poor, that researchers from Baylor College of Medicine, the Houston Veteran's Affairs and Health Services Research Center, and Rice University have produced a consensus suggesting which post-surgical events should provoke patients to either call their doctors, or urgently call 911.
The need is critical, they say, noting that 16.6% of Medicare patients who undergo colon surgery each year require a readmission within 30 days, and those readmitted have higher mortality rates.
The need for better discharge instructions is especially great since colon surgery patients are now "fast-track" discharged about 3.4 days sooner than they were in 1986. And some 600,000 surgical procedures involve the colon or bowel in the United States each year.
Infections from colorectal surgery are the first or second most common type of surgical site infection, according to the American College of Surgeons. And hospital discharge planners now implement discharge interventions for medically ill patients, such as those with chronic obstructive pulmonary disease, congestive heart failure, or diabetes.
"To date, there has been no analogous study in the surgical literature describing enhanced discharge processes to prevent surgical readmissions," wrote lead author Linda Li, research fellow at the Houston VA Health Services Research Center of Excellence.
Li and colleagues published their report in the February issue of the Journal of the American College of Surgeons.
Currently, "indicators of deteriorating condition provided to patients at the time of discharge are based on conventional wisdom, are highly subjective, and lack a systematic implementation methodology," she and coauthors added. "Further, these indicators are often overly generic, with the same indicators provided to medical and postsurgical patients."
Li and colleagues convened an 11-expert panel to amass "collective intelligence" about what possible postsurgical events should cause concern.
Over the course of months, they came up with 37 unique warning symptoms, such as wound disruption, wound drainage, or redness indicating possible surgical site infection, fever or temperature greater than 101.5, or intestinal obstruction, or lack of gas or stool for more than 24 hours. That list was further refined to a set of 12 that most of the panelists could agree on.
"Although some may assume that the elements included in a discharge warning set would be intuitive, we found surprising variation among experts regarding which items should be included," Li and colleagues wrote.
These days, the researchers wrote, typical colorectal surgery patients are increasingly older, with multiple co-morbidities and most will be discharged home.
But "discharge home, even with home health care services, does not guarantee an effective care transition because multimorbid older adults often have cognitive and functional impairments, complex medication regimens, multiple follow-up appointments and greater reliance on social support for basic activities of daily living.
But evidence-based interventions using patient-centered triggers can reduce medication adverse events "and alert patients and families to warning symptoms of disease exacerbations" that prevent readmissions, they wrote.
The final agreement, after five rounds of discussions among panel experts, was as follows:
Patients should call their physician if they experience:
- Wound drainage
- Wound opening
- Wound redness or changes in the appearance of the surrounding skin or around the ostomy
- No bowel movement or lack of gas/stool from the rectum for more than 24 hours
- Increased abdominal pain
- Vomiting
- Abdominal swelling
- High ostomy output and or dark urine or no urine
- Fever greater than 101.5
- Patient is not able to take anything by mouth for more than 24 hours.
Patients should go to the emergency room if they
- Have shortness of breath or are unable to breathe
- Have chest pain
The authors said they see this list as "a starting point in the process of developing a more sophisticated decision-making tool, ultimately to be included in the patient-centered discharge plan."