Reducing hospital length of stay is an effective way to address the challenges of productivity and NHS financial efficiency.
Using techniques applicable across other surgical specialties, the Freeman Hospital in Newcastle has halved the NHS national average length of stay for colorectal surgery.
Last month the British Journal of Surgery published our study, which shows that the use of intraoperative oesophageal Doppler monitoring (ODM) reduced hospital stay by two days.
Routine ODM use is now included in our enhanced surgical recovery programme (ESRP). The ESRP involves a variety of practices:
A pre-operative co-morbidity assessment, performed in pre-admission clinics, helps to improve estimation of pre and post-operative patient needs, such as requirement for high-dependency care.
Basic education to prepare patients for how they may feel after surgery. Two days were taken off length of stay simply by educating patients in the home.
Pre-operative carbohydrates are administered to reduce surgical stress in patients and we liaise with colleagues in community and social care to plan home care and reduce delayed discharge.
Perhaps the single most important element of the ESRP is the greater use of laparoscopic surgery - 80 per cent of patients undergoing colorectal surgery at Freeman Hospital, compared to the national average of 5-8 per cent.
Optimal blood volume is very important to patient well-being. It prevents hypovolemia, which can cause serious complications. The oesophageal Doppler facilitates effective optimisation of fluid replacement and drugs to maintain adequate supply of oxygen. The National Institute for Health and Clinical Excellence recommends this as standard clinical practice, but it is not yet widely used in the NHS.
In this study, patients treated without ODM were discharged at nine days. Those receiving targeted fluid management by Doppler monitoring were discharged at seven days. The combination of laparoscopic colorectal surgery and ODM allowed patients to be discharged with a total length of stay of only four days.
Significantly, these further reductions were accompanied by improved quality of care. The ODM patients suffered considerably fewer post-operative complications (2 per cent of patients versus 15 per cent) and required no unplanned admissions into the critical care unit.
There is no reason why the average length of stay for colorectal surgery should be as high as 14 days. These principles replicated across surgical specialties in every trust. And remember that a day in an NHS ward can cost up to£400, it is a good example of how clinical practice can help deliver management priorities.
Alan Horgan is a consultant in colorectal surgery and Dr Chris Snowden is a consultant anaesthetist at Newcastle upon Tyne Hospitals foundation trust's Freeman Hospital.