Optimizing discharge decision-making in colorectal surgery: a prospective cohort study of discharge practices in a recently implemented enhanced recovery pathway

Aim: The objectives of this project were (1) to compare time to readiness for discharge by set criteria and actual length of stay (LOS) in a newly implemented colorectal enhanced recovery pathway and (2) to identify reasons for delayed hospital discharge.

Method: We conducted a prospective cohort study of 73 adult patients (age 67 ± 14 years, 56% men, 51% laparoscopic, 13% stoma creation) undergoing elective colorectal surgery in a university hospital with a recently implemented recovery pathway (<2 years). Time to readiness for discharge (oral intake, flatus, pain control, ability to walk, and no complications) was compared to actual LOS using a correlation-adjusted log-rank test. The treating team was interviewed, and thematic analysis was used to identify reasons for patients remaining in hospital after discharge criteria (DC) were achieved.

Results: Median LOS was 6 (4-8) days and median time to readiness for discharge was 5 (3-8) days (P < 0.001). Twenty-eight patients (37%) remained in hospital after DC were achieved. Although some delayed discharges were medically justified (e.g., workup [13%] or treatment of complications not captured by DC [2.6%]), unnecessary hospital stays were common (e.g., perceived need for observation [16%], or patients not willing to be discharged [11%]).

Conclusions: Unnecessary hospital stays were common within a recently implemented enhanced recovery pathway and represent a target for quality improvement. Efforts should be directed at optimizing patient education regarding discharge expectations, early consultation of the discharge planning team and improving discharge decision-making using standardized DC.