title: Reducing Readmissions While Shortening Length of Stay: The Positive Impact of an Enhanced Recovery Protocol in Colorectal Surgery.
abstract: BACKGROUND
  Hospital readmission rates are an increasingly important quality metric since enactment of the 2012 Hospital Readmissions Reduction Program. The proliferation of enhanced recovery protocols and earlier discharge raises concerns for increased readmission rates.
  
  
  OBJECTIVE
  We evaluated the effect of enhanced recovery on readmissions and identified risk factors for readmission.
  
  
  METHODS
  This study involved implementation of a multidisciplinary enhanced recovery protocol.
  
  
  METHODS
  It was conducted at a large academic medical center PATIENTS:: All patients undergoing elective colorectal surgery between 2011 and 2015 at our center were included.
  
  
  METHODS
  This cohort study compared patients before and after enhanced recovery initiation, looking at 30-day readmission as the primary outcome. A multivariable logistic regression model identified predictors of 30-day readmission. Kaplan-Meier analysis identified differences in time to readmission.
  
  
  RESULTS
  A total of 707 patients underwent colorectal procedures between 2011 and 2015, including 383 patients before enhanced recovery protocol was implemented and 324 patients after enhanced protocol was implemented. Length of stay decreased from a median 5 days to a median 4 days before and after enhanced recovery implementation (p < 0.0001). Thirty-day readmission decreased from 19% (72/383) in the pre-enhanced recovery pathway to 12% (38/324) in the enhanced recovery pathway (p = 0.009). Twenty-one percent (21/99) of patients who underwent ileostomy were readmitted before enhanced recovery implementation compared with 19% (18/93) of patients who underwent ileostomy after enhanced recovery implementation (p = 0.16). Multivariable logistic regression identified ileostomy as increasing the risk of readmission (p = 0.04), whereas enhanced recovery protocol decreased the risk of readmission (p = 0.006).
  
  
  CONCLUSIONS
  The study is limited because it was conducted at a single institution and used a before-and-after study design.
  
  
  CONCLUSIONS
  These data suggest that use of a standardized enhanced recovery protocol significantly reduces length of stay and readmission rates in an elective colorectal surgery population. However, the presence of an ileostomy maintains a high association with readmission, serving as a significant burden to patients and providers alike. Ongoing efforts are needed to further improve the management of patients undergoing ileostomy in the outpatient setting after discharge to prevent readmissions.
authors.affiliation: 1 Department of Surgery, University of Virginia, Charlottesville, Virginia 2 Enhanced Recovery Program, University of Virginia, Charlottesville, Virginia 3 Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.
authors.forename: Puja M
authors.initials: PM
authors.lastname: Shah
authors.forename: Lily
authors.initials: L
authors.lastname: Johnston
authors.forename: Bethany
authors.initials: B
authors.lastname: Sarosiek
authors.forename: Amy
authors.initials: A
authors.lastname: Harrigan
authors.forename: Charles M
authors.initials: CM
authors.lastname: Friel
authors.forename: Robert H
authors.initials: RH
authors.lastname: Thiele
authors.forename: Traci L
authors.initials: TL
authors.lastname: Hedrick
mesh_terms: D002985:Clinical Protocols; D015331:Cohort Studies; D003108:Colonic Diseases / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000601:surgery; D003107:Colorectal Surgery; D003125:Colostomy / Q000706:statistics & numerical data; D013505:Digestive System Surgical Procedures / Q000706:statistics & numerical data*; D004240:Diverticulum / Q000601:surgery; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000706:statistics & numerical data; D015212:Inflammatory Bowel Diseases / Q000601:surgery; D053208:Kaplan-Meier Estimate; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D012002:Rectal Diseases / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000453:epidemiology*