Fast track (FT) protocols, which include early feeding and ambulation, have been developed to reduce length of stay for ostomy patients. This prospective, case matched study evaluated data for 98 patient pairs matched for procedure type, age, gender, and diagnosis. Surgical procedures included a total proctocolectomy and pouch creation or completion proctectomy and pouch creation. Additional matched features included the presence or absence of a diverting ileostomy. Five additional patients who had a pouch revision were included to evaluate the relationship between success and failure of FT protocols to decrease LOS. Patients were followed up for more than a year and a half. A total of 83 matched pairs were evaluated for cost comparisons.

 

Patient education about FT protocols and milestones were seen as essential features of the program to improve patient adherence. The FT protocols included patient instructions prior to surgery so that they would know what to expect as postoperative milestones and what was expected of them. The summary of FT versus control instructions are shown in the table below.

 

Instructions	Fast Track	Control
Pre-surgery	Oral liquids offered, patient asked to sit in chair and walk; stoma nurse provides pre-operative advice	No supporting information provided
Post surgery	Oro-gastric tubes removed before extubation	Naso-gastric tube removed 1-2 days after surgery
	Day 1 post-surgery: Walking at least 5 times around nursing floor, offered solid food (if tolerated) and liquids with or without indicators of intestinal function Day 2 post-surgery: Teaching visits initiated	Day 1 post-surgery: Sitting out of bed Day 2 post-surgery: Walking Diet withheld until signs of return of intestinal function Oral analgesia started when liquids were tolerated
Discharge from hospital	After passing flatus or stool, able to drink and eat solid foods, and comfortable on oral analgesia
Not discharged from hospital	Not comfortable with discharge plans (added 12-24 hours) or did not meet criteria for discharge

 

Patients discharged within five days were considered successes on FT protocols and patients staying longer than five days were considered FT failure. FT success was achieved in 79 of the 98 FT patients. FT failure for the remaining 24 patients was associated with male gender and FT failure seemed suggestive of a more complicated recovery, with a higher rate of readmissions than patients with FT success. The authors suggested that there may be a set of criteria that could identify patients who would benefit most from FT protocols.

 

The median length of stay (LOS) was not significantly different between FT and control groups. When the LOS was broken down by days in hospital (less than 3 days and less than 4 days), there were more patients discharged in less than 3 days and in less than 4 days in the FT group compared with the control group. It was suggested that because research on fast-track protocols had taken place in their facilities, some of the physicians who were not using strict FT protocols may have incorporated some of the principles into their practice and already lowered LOS for their patients, which may have affected the comparison.

 

Another concern about FT protocols includes the possibility that less direct care after discharge may lead to a delay in the recognition of complications or other problems that may require medical attention. However, the readmission rates were similar between the two groups. The use of FT protocols to reduce length of stay did not increase complications or to other issues that led to readmission and reoperation, particularly in patients who were able to comply with the protocols. The authors suggest that failure with the protocol may predict higher incidence of complications.

 

The FT protocols were associated with a reduction in direct 30-day expenses of approximately $1,000 ($5,692 for 83 FT patients versus $6,672 for matched control group patients). Reduced expenses were primarily associated with reduced nursing care and other issues associated with length of stay.

 

Study limitations include the lack of homogeneity of protocols for the control patients and that different surgeons were involved in the FT versus the control group care. However, the authors note that careful matching of the patients should have been able to overcome the differences between a strict FT protocol and variations in care provided in the control group.