The ACS has already begun to recruit hospitals throughout the United States (including Puerto Rico) to participate in the free program and will continue recruitment efforts over the next five years. Its goal is 750 hospitals for the five phases of the program. The ISCR will be divided into five cohorts of surgical specialties, with later cohorts focusing on enhancing care in orthopaedic surgery, gynecologic surgery, emergency general surgery, and bariatric surgery.

Launched July 1, the colorectal surgery cohort will continue to enroll hospitals in the coming months, Dr. Wick stated. Colorectal surgery was chosen as the first cohort, she said, because most enhanced recovery principles are best developed for colorectal operations, and these operations, which include treatment of colon and rectal cancers and inflammatory bowel diseases, are common. She added that variability in hospitals' clinical outcomes and complication rates for colorectal procedures allows "room for improvement."


Evidence-Based Recommendations

To develop the colorectal clinical pathway, the study authors used a systematic approach to reviewing the scientific evidence supporting perioperative care for colorectal operations. For each proposed pathway component drawn from the scientific literature or suggested by subject experts, the researchers reviewed relevant English-language articles published before December 2016. Sources included original studies, systematic review articles, organizational guidelines, and expert opinions.

The investigators identified 12 components, or best practices, to include in the ISCR colorectal pathway encompassing the full scope of surgical care.2 These components range from preoperative measures, such as patient education about the operation, to postoperative steps, including early removal of the urinary bladder catheter to prevent catheter-related UTIs.

Among the postoperative components, Dr. Wick emphasized the importance of hospitals promoting early oral nutrition and mobility "to get the patient better faster and home faster."

Several studies show that introduction of regular food within 24 hours of an operation shortened the hospital stay and reduced complications.3 A review study demonstrated a quicker return of bowel function and shorter hospitalization when patients got out of bed and walked within 12 to 24 hours postoperatively.4

Another pathway component is mechanical bowel preparation, or bowel emptying, plus oral antibiotic therapy before a nonemergency colorectal operation. Although the Europe-based Enhanced Recovery After Surgery Society recommends against the use of routine mechanical bowel preparation because of the risk of dehydration,5 Dr. Wick said this potential risk is outweighed by a reduced chance of SSIs, as reported in the 2016 ACS and Surgical Infection Society guidelines.6

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