Standardized Protocol Improves Patient Recovery

Surgeon Matthew Silviera MD, reviews medical records with clinical nurse manager Angelia McBride, RN. Silviera and colleagues have developed a protocol to reduce surgical complications, hospital length of stay and readmissions.

Washington University colon and rectal surgeons are working with public health sciences researchers to incorporate best practices as they implement an enhanced recovery after surgery (ERAS) protocol at Barnes-Jewish Hospital and Barnes-Jewish West County Hospital.

The surgeons’ past efforts to expand and standardize infection-control procedures at the two hospitals already have reduced the rate of surgical-site infections in colorectal surgery patients. The ERAS protocol is designed to reduce other surgical complications, hospital length of stay and readmissions. It includes: early feeding and walking, nutritional supplements, bathing, avoiding nasogastric tubes, minimizing IV fluids, multi-modal pain management and use of Entereg, the only FDA-approved medicine to address lack of digestive propulsion

ERAS has already reduced length of stay by one day. But colorectal surgeon Matthew Silviera, MD, and Division of Public Health Sciences researcher Rebecca Lobb, ScD, MPH, hope for better results. They have applied for federal funding to help them put in place evidence-based methods for improving care-provider compliance with the protocol. Strategies might include providing staff members with feedback on their performance and assigning an individual to oversee adherence. As part of the effort, other surgical services — including urology, hepatobiliary-pancreatic surgery and thoracic surgery — would also implement strategies best suited for their patients.

“A critical component of implementing an enhanced recovery protocol is education across health-care providers,” says Silviera. “Providers need to understand it, why we are doing it, and how it benefits patients.”

Lobb says education for clinical staff needs to be ongoing and a routine part of orientation for new staff. The approach to education may vary by the size of the surgical section. “A section with smaller patient volume and less turnover might primarily use an interactive approach to staff education with a multidisciplinary team,” he says. “A section with larger patient volume might use web-based or written protocols.

“Our study examines how to put these implementation strategies in place. Although the literature emphasizes these strategies, it doesn’t tell decision-makers how to use them.”


Sean Glasgow, MD, a U.S. Air Force lieutenant colonel, established the Air Force’s C-STARS (Center for Sustainment of Trauma and Readiness Skills) program at Washington University and conducted training courses for three years before recently becoming a full Washington University faculty member. C-STARS training, based at Saint Louis University and two other national centers, prepares U.S. Air Force doctors, nurses and medical technicians to care for traumatic injuries to soldiers during wartime.

Steven Hunt, MD, was appointed as a surgical co-director of the new Center for Advanced Medicine — South County, which opened in April 2016 in south St. Louis County. He will see patients there with colorectal surgery chief Matthew Mutch, MD. Hunt and co-director Todd Rice, MD, an anesthesiologist, serve as liaisons between hospital management and the medical school’s surgical departments.

Colon and rectal surgery fellows presented research results at national meetings:

  • Alexander Hawkins, MD: on preoperative chemotherapy and improved survival for large anorectal gastrointestinal stromal tumors, and on American College of Surgeons National Surgical Quality Improvement Program® data on the role of a diverting loop ileostomy to prevent anastomotic leak rate.
  • Katrina Wells, MD: on the need for chemotherapy in patients with early-stage colorectal cancer who do not have an adequate number of lymph nodes retrieved at the time of surgery.
  • Devi Mukkai Krishnamurty, MD: on radiation therapy before surgery improving survival in locally advanced colon cancer.