In the 1970s and 1980s, the average hospital stay for colorectal surgery patients was two to three weeks. Since then, with the advent of minimally invasive surgery and enhanced recovery programs at many institutions, the average length of stay nationally has steadily declined to two to three days.
The Mount Sinai Health System is now advancing a bold new milestone designed to help address the severe shortage of hospital beds: same-day discharge for carefully selected patients undergoing uncomplicated colectomy.
Making this major change possible is a rigorous protocol that Mount Sinai colorectal surgeons have methodically developed. Since December 2023, nearly 60 patients have been enrolled under its guidelines, with highly encouraging results that generally support the feasibility and safety of same-day colorectal surgery discharge in a carefully controlled environment. The team is now gearing up to conduct a comprehensive study to match that data with a cohort of patients to be treated under standard inpatient timelines. They hope this effort can shed valuable light on the still-controversial issue of sending patients home within 24 hours of major abdominal colorectal surgery.
"We’re constantly getting alerts that we’re at full bed capacity, making that crunch the main incentive for getting patients through the system safely and effectively,” says Patricia Sylla, MD, System Chief of Colon and Rectal Surgery and the driving force behind the Same-Day Colectomy Protocol. “But we’re also focused on standardizing postoperative pain management to reduce opioid use and prescribing, and our protocol calls for zero use of narcotics postoperatively.”
The interest in so-called ambulatory colectomy soared during COVID-19 as restrictions on hospital capacity and fear of viral transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. Dr. Sylla elected to push the envelope at Mount Sinai, setting a standard for other institutions by leading a study that summarized the results of same-day discharge programs by early adopters while mapping out a tactical blueprint to allow patients to recover in the comfort of their own homes. That study was published in Surgical Endoscopy.
Under the umbrella of the Same-Day Colectomy Protocol, Mount Sinai is continuing to collect and codify data around the advantages and concerns attached to same-day discharge. Findings to date show that, of the 58 patients enrolled, mostly for ileostomy closures, 98 percent were sent home within 30 hours of surgery (in some cases, this meant discharge the same day, in other cases, discharge the next day); and that the average length of hospital stay was 18 hours. Within this cohort, 8.6 percent required readmission to the hospital, and 5.2 percent developed complications requiring reoperation.
“We can’t eliminate all complications,” points out Dr. Sylla, a leader in the development of minimally invasive approaches to surgical treatment of colon and rectal cancer and Professor of Surgery (Colon and Rectal Surgery) at the Icahn School of Medicine at Mount Sinai. “But what’s encouraging here is that we proved we could bring these patients back quickly to competently manage those complications.”
Dr. Sylla and her team are setting a new standard for same-day discharge programs for colectomy patients. From left, Divina Alorro, MSN, RN; Rashid Logan, MD (surgery resident); Sue Hahn, MD (colorectal surgery attending); nurse manager Janet Thompson, BSN, RN; Dr. Sylla; Rossana Cheng He, MD (surgery resident); Laura Caplan, PA (colorectal surgery); Tianyi Lu, MD (colorectal surgery attending); Erica Fagelman, MD (anesthesia attending).
Indeed, the Same-Day Colectomy Protocol is tightly designed around patient inclusion and exclusion factors to reduce risk and ensure the success of postoperative care management. For example, patients must be ambulatory and functionally independent, have adequate home support, own and be able to use a cell phone, and live within three hours of the hospital. Excluded are patients with cognitive impairment, malnutrition, severe comorbidities, anticoagulation therapy, or chronic opioid use.
Just as important as selection criteria are the education and preparation of staff—including office staff, inpatient nursing personnel, anesthesia and surgical unit employees, and hospital administrators—to remove unanticipated barriers to same-day discharge implementation. That process, Dr. Sylla explains, must also embrace patients by involving them in discussions around activity levels, oral intake, and pain control. And it should include a postoperative remote monitoring plan that currently involves twice-daily phone calls, but would also ideally use digital mobile health technology to transmit medical information from patient to physician without the need for a home visit.
Dr. Sylla acknowledges that any program to accelerate discharge of colorectal patients will have its share of critics: physicians who fret about delays in treating patients who might experience serious complications or other setbacks at home, and patients who are uncomfortable with leaving the hospital promptly after major surgery.
“Our experience is that it takes time to develop a same-day discharge culture within an institution,” Dr. Sylla asserts. “It requires buy-in from all players, especially the surgeons who must opt to practice same-day discharge because they truly believe in it, and because they know it’s in the best interest of their patients.”