Enhanced recovery after surgery pathways in thoracic surgery, do they end at discharge?

Fast track pulmonary resection protocols have shown to be feasible and to improve hospital related costs, shortening length of stay and maintaining quality of care (1-4).

Despite the increasing number of scientific literature addressing the benefits of specific lobectomy pathways (4,5) and the recent publication of Enhanced Recovery after Surgery (ERAS^®) guidelines in thoracic surgery (4-6) the truth is that the description of most of these interventions ends at patients’ discharge, with no clear indications for follow up or measures to prevent unintended hospital readmissions (2,3) (Table 1).

Table 1. Summary of interventions addressed in Thoracic Surgery ERAS^® guidelines [Adapted from Batchelor et al. (6)].

Preoperative phase

Preadmission information, education and counselling

Smoking cessation

Anaemia management

Alcohol dependency management

Pulmonary rehabilitation and prehabilitation

Preoperative fasting and carbohydrate treatment

Preanaesthetic medication

Perioperative phase

Venous thromboembolism prophylaxis

Antibiotic prophylaxis and skin preparation

Preventing intraoperative hypothermia

Standard anaesthetic protocol

PONV control

Regional anaesthesia and pain relief

Perioperative fluid management

Atrial fibrillation prevention

Surgical technique: thoracotomy

Surgical technique: minimally invasive surgery

Postoperative phase

Chest drain management

Urinary drainage

Early mobilization and adjuncts to physiotherapy

PONV, postoperative nausea and vomiting.

Hospital readmissions have been traditionally included as both, an outcome and a quality indicator after lung resection (7,8) but there is scarce thoracic surgery-focused literature with measures to prevent them. Furthermore, unexpected hospital readmissions are not only related with an increased short and long-term mortality risk but also with important economic implications (9-11).

In some series, readmission rates in the first 30 days after lung resection are as high as 6% (7,9,12) whereas they go up until 19% in the first 90 days (8,13). Furthermore, the most frequent diagnosis for readmission in the first 30 days are postoperative complications (13). These data suggest the implementation of an evidence-based follow up protocol to prevent emergent hospital readmissions or unnecessary consultations becomes mandatory, especially in the era of ERAS^®, where maximum quality of care is attempted reducing hospital stay and costs (6,14).

Colorectal cancer surgery has been one of the pioneering specialties not only in ERAS^® guidelines implementation but also in the development of measures to decrease postoperative readmission rates (15).

Halverson et al. (15) in an attempt to identify process measures to reduce unintended postoperative readmissions after bowel resection, highlighted the importance of nutrition, continuity of care, physical therapy, transfer of information to the patient and to the referral physician and follow up in the delivery of high-quality care and in the reduction of postoperative readmissions.

Whether or not these measures will be valid if extrapolated to lung resection still remains unknown. It is even unclear if thoracic surgeons should follow lung cancer resection patients after their hospital discharge (16,17) and some authors have proven it increases costs without necessarily detecting more recurrences or improving long-term survival (16,17). What seems necessary is to establish an efficient communication between the surgeon who has operated on the patient and the primary care or referring physician who is going to follow him. This communication should assure the continuity of care necessary to detect and treat early postoperative complications if they appear and to give the patients the necessary information and support to go through the expected postoperative recovery successfully (7,15).

Although it may sound paradoxical, the successful discharge process should start preoperatively, with the appropriate evaluation of the risk-factors, comorbidities and expected postoperative support of the patient (6,18) in order to prevent possible complications or adverse events delaying hospital discharge. Information given beforehand to both, the patient and the referral physician can help them design the best suitable follow up plan for the postoperative period (18).

Keeping the patient and the referral physician updated on the recovery along the whole postoperative period reinforces their engagement and decreases unplanned postoperative readmissions (5,15). Furthermore, providing the patient and the referral physician with common alert signs after lung resection can improve postoperative recovery and outcomes, even in patients submitted to thoracotomy (4-6,19,20). Among the information to be provided are symptoms and signs of both, systemic and local infection, and early detection of deep venous thromboembolism symptoms. It’s important to encourage patients to consult, either to the responsible surgeon (21) or to the primary care physician (17), when they notice fever higher than 38º, surgical site infection, changes in the quality and quantity of sputum (specially in chronic obstructive disease patients) and changes in the cardiac rhythm or the baseline shortness of breath (7). Instructions and information about basic nutritional recommendations (1,500 kcal diet) and expected recovery (limits of pain, expected exercise exertion, normal wound-healing process) should also be included in the discharge summary as well as an efficient method for communication. Telephone communication has proven to be a suitable alternative for verbal transmission of information (20,22,23) and what is more important, it seems an appropriate follow up alternative for thoracic surgeons (17). However, the most efficient schedule or adequate intervals for this follow up have not been validated in the literature. A call 48 h after discharge, a week and a month later seem the most spread and appropriate schema (5,21-23) but further evidence of its utility is lacking. The need for presential follow up has to be clarified and standardized too (15). This should assure appropriate healing of the wounds and assessment of nutritional status, daily-activities independence, unplanned consultation for surgery-related causes and adequate oncological treatment if needed (15,24). Postoperative follow up dates should be preferably arranged in advance, to increase patient’s adherence and decrease system related errors (18,25).

Finally, making sure the patient, their families and the referral physician understand all the information and agree with it is another important, although sometimes missed, step in order to improve postoperative recovery (5,18).

There is no doubt ERAS^® and fast-track pathways after thoracic surgery have opened a wide range of possibilities, highlighting again, the importance of perioperative care and information in the optimization of results after thoracic interventions. However, most of the recommendations included in these protocols have not been validated in large populations and most of them have been extrapolated from other surgical specialties. If they improve short and long term outcomes after lung resection or decrease the incidence of unplanned readmissions still needs to be investigated, but to ours, appropriate transition of care among the three phases of the perioperative period is something that needs to be encouraged and emphasized, especially at the processes level, assuring efficient reciprocal communication, adequate recovery and improvement of quality after lung resection (Table 2).

Table 2. Summary of pre-discharge and post-discharge interventions as well as those facilitating transition of care [Adapted from Hansen et al. (10)].

Pre-discharge interventions	Post-discharge interventions	Interventions facilitating transitions between phases
Patient education (including alarm signs to prompt consultation)	Outpatient follow up	Adequate discharge information for patients and families
Early discharge planning (Including patient’s support at home)	Clear communication with primary care physician or referring physician	Patient-centered discharge instructions
Medication reconciliation (With clear instructions regarding anti-platelet and anticoagulation medication as well as newly introduced medication)	Telephone follow up after discharge	Continuity of care assurance (either by surgeon, primary care or referring physician)
	48 h
	1 week
	1 month
Follow up appointments organized at discharge	Direct communication method (phone, email, pager) facilitated to patient and family
Primary care or referral physician
Surgeon
Oncologist if needed

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.