ABSTRACT
Purpose/Background: Quality improvement (QI) and enhanced recovery after surgery (ERAS) protocols are effective in reducing length of stay and complications after colorectal surgery. The COVID-19 pandemic's strain on hospital personnel and resources called into question the feasibility of implementation of QI studies. Hypothesis/Aim: We aimed to successfully implement of a novel, structured postoperative ambulation protocol in colorectal surgery patients and determine its effect on patient outcomes in a time of strained personnel. Methods/Interventions: This prospective non-randomized study included all patient who underwent elective inpatient abdominal colorectal procedures at a single quaternary care center. All patients were already undergoing a standard ERAS protocol at baseline. A structured, aggressive postoperative ambulation protocol was developed. An erasable poster (Figure) was placed in patient rooms which allowed the nursing staff and patient to track progress towards specific ambulation goals. The protocol measured specific metrics such as out-of-bed to chair and the number and extent of daily ambulation relative to postoperative day. The protocol was initiated on post-operative day 0, and increased in duration and distance daily. Nursing staff was educated on the protocol prior to initiation and a standard process was created to outline the documentation requirements. The primary outcome measured was hospital length of stay. Secondary outcomes were return of bowel function, 30-day postoperative DVT/PE rate, and 30-day readmission rate. A change in these outcomes metrics over time compared to historical controls was noted. Results/Outcome(s): The protocol was implemented in February 2020, with improvements in outcomes beginning in July 2020 following extensive re-education for nursing staff. Adherence to the post-operative ambulation regimen increased from 36% at baseline to 75%. This was associated with an improvement in postoperative return of bowel function (2.13 days vs 1.44 days), post-operative length of stay (6.36 days vs 3.33 days), postop VTE/PE rates (1.64% vs 0%) and readmission rate (6.56% vs 0%) over a period of 12 months. Limitations: The outcomes of this study may have been influenced by other uncontrolled measures during the COVID crisis but most if not all led to decreased personnel and resources making success of such a project difficult. A standard ERAS protocol was in place with good compliance (>95%) for over 2 years prior to the initiation of this study. Conclusions/Discussion: A novel, structured, aggressive early postoperative ambulation protocol is feasible during times of strained personnel resources such as the COVID-19 pandemic, and leads to improvement in postoperative outcomes such as postoperative length of hospital stay, return of bowel function, VTE/PE rates, and postoperative ambulation without an increase in the readmission rate.