title: Understanding how colorectal units achieve short length of stay: an interview survey among representative hospitals in England.
abstract: BACKGROUND
  Wide variation in the outcomes of colorectal surgery persists, despite a well-established evidence-base to inform clinical practice. This variation may be attributed to differences in quality of care, but we do not know what this means in practical terms of care delivery. This telephone interview study aimed to identify distinguishing characteristics in the organisation of care among colorectal units with the best length of stay results in England.
  
  
  METHODS
  Ten English National Health Service hospitals were identified with the shortest length of stay after elective colonic surgery between January 2011 and December 2012. Semi-structured telephone interviews were conducted with a senior colorectal surgeon and ward nurse, who were not informed of their performance, at each site. Audio recordings were professionally transcribed and thematically analysed for similarities and differences in practice between units.
  
  
  RESULTS
  All ten short length of stay units approached agreed to participate, and 19 of 20 interviews were recorded. These units standardised clinical care based upon an Enhanced Recovery Program. Beyond this, they organised the clinical team to efficiently and reliably deliver this package of care, with the majority of day-to-day care delivered by consultants and nurses. Patients were closely monitored for postoperative deterioration, using a combination of early warning scores, nurses' clinical judgement and regular senior medical review. Of note, operative volume and laparoscopy rates in these units were not statistically significantly different from the national average (p = 0.509 and p = 0.131, respectively). The postoperative analgesic strategy varied widely between units, from routine epidural use to local anaesthetic infiltration or patient-controlled analgesia.
  
  
  CONCLUSIONS
  The Enhanced Recovery Program may be seen as necessary but not sufficient to achieve the best length of stay results. In the study units, consultants and nurses led and delivered the majority of patient care on the ward. High quality teamwork helped detect and resolve clinical issues promptly, with nurses empowered to contact consultants directly if needed. Other units may learn from these teams by adopting protocol-based, consultant- or nurse-delivered care, and by improving coordination and communication between consultants and ward nurses.
authors.affiliation: Imperial Patient Safety Translational Research Centre, Imperial College London, Office 5.03, 5th Floor, Medical School Building, St Mary's Campus, Norfolk Place, London, W2 1PG UK.
authors.forename: Ben E
authors.initials: BE
authors.lastname: Byrne
authors.affiliation: Imperial Patient Safety Translational Research Centre, Imperial College London, Office 5.03, 5th Floor, Medical School Building, St Mary's Campus, Norfolk Place, London, W2 1PG UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Pinto
authors.affiliation: Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Aylin
authors.affiliation: Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK.
authors.forename: Alex
authors.initials: A
authors.lastname: Bottle
authors.affiliation: Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, Harrow, Middlesex UK.
authors.forename: Omar D
authors.initials: OD
authors.lastname: Faiz
authors.affiliation: Department of Experimental Psychology, University of Oxford, Oxford, UK.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Vincent
keywords: Colorectal surgery; Enhanced recovery; Interviews; Length of stay; Outcomes; Performance; Quality