The effect of early ambulation on postoperative length of stay (LOS) has been underemphasized, according to Shannon McChesney, M.D., an assistant professor in the Department of General Surgery at Vanderbilt University Medical Center.
In a study they are calling “Get Up and Walk!” McChesney and Vanderbilt colleagues investigated the effect of early ambulation on LOS following elective colorectal surgery. Additionally, they measured the effects on hospital length of stay made by immunonutrition compliance in the preoperative period.
“We have society guidelines that specify the importance of early ambulation after colorectal surgery, but if you look at the literature, there’s no set protocol,” McChesney said. “From our preliminary data, those who ambulated sooner were significantly more likely to leave the hospital earlier.”
The study emerged from a comprehensive Vanderbilt enhanced recovery after surgery (ERAS) initiative that is evaluating perioperative protocols in multiple specialties.
“We know that getting patients ready for surgery optimizes their recovery,” said McChesney, who is first author on the study. “Moving forward we would like to define a specific protocol, setting goals for each patient, and increasing the number of patients who are compliant.”
Pre- and Post-surgery Metrics
The researchers reviewed a group of 697 patients undergoing elective colorectal surgery and enrolled in a prospective ERAS pathway database between September 2019 and September 2021, with postoperative LOS as the metric of interest.
“From our preliminary data, those who ambulated sooner were significantly more likely to leave the hospital earlier.”
The preliminary study looked at a heterogeneous group: from patients in their 20s undergoing surgery for inflammatory bowel disease (IBD) to geriatric colorectal cancer patients, McChesney said.
Primary metrics were preoperative and postoperative compliance with an ambulation protocol. The protocol was defined as walking three times daily for every postoperative day except the day of discharge, and the patient was considered compliant if 100 percent of the required ambulation was performed.
The team recorded LOS and unplanned readmissions, finding 29-percent compliance with postoperative ambulation. Patients who were noncompliant were more likely to be in the hospital four or more days. The readmission rate was 9 percent.
“We didn’t look at patients’ overall mobility pre-surgery,” McChesney said. “Certainly, frailer patients, especially those having a major abdominal surgery, we would anticipate to be less compliant.”
Metrics were also recorded for anemia and patient compliance with preoperative immunonutrition. The investigators observed a 41-percent preoperative anemia rate and 76 percent compliance with preoperative immunonutrition.
“Many patients needing colorectal surgery are anemic, especially those with debilitating IBD,” McChesney noted.
“We would like to define a specific protocol, setting goals for each patient, and increasing the number of patients who are compliant.”
Refining the Research
In the next phase of the study, patients will be stratified by age and comorbidities, as well as surgical approach – minimally-invasive versus open.
McChesney said further studies should be directed at facilitating postoperative ambulation through increased use of physical therapy and targeted ambulation goals. Considering the financial benefit of decreasing patient LOS, she noted that a cost analysis to justify these measures could also be considered.