Fast tracking to discharge on P7: Postoperative nursing care of esophagectomy patients is critical

Nursing Progress Notes - Fall-Winter 2008

P7 night-shift nurses like Jaya Mathew, left, and Okey Obioma handle critical, hourly monitoring for the first 12 hours their fast-track patients are on the unit.

“The Fast Track program for esophagectomy patients was started because we saw the wonderful care our patients received by the nursing staff on P7 and the dedication they showed,” explains Carla Baker, advanced practice nurse, Thoracic and Cardiovascular Surgery. “They have been superb at picking up problems early so they can be addressed rapidly.”

With their highly specialized skills, attention to the subtlest clinical changes, quick reactions and unwavering dedication to their patients, P7 nurses are revolutionizing the way M. D. Anderson cares for postoperative esophagectomy patients.

Because they are at high risk for complications following surgery (e.g., respiratory insufficiency/pneumonia, cardiac arrhythmias, poor pain control, delay of bowel function, chylothorax and anastomatoic leaks), these patients used to spend two to three days in the Intensive Care Unit before transferring to the floor.

Thoracic surgeons, mid-level providers and P7 nurses wondered if patient outcomes might be improved if they could circumvent the intensive care unit and bring these patients straight to the floor where they could begin ambulating much earlier.

Getting patients on their feet

Since the fast-track program launched in March 2008, patients have been able to begin ambulating within four hours of arrival to the floor. This allows P7 nurses to identify early on those patients who are orthostatic and need additional fluids, those with poor pain control, and those who need additional assistance. In addition, the early ambulation has helped improve pulmonary hygiene, and hastened return of bowel function.

Decreasing length of stay

Nurses can now begin the discharge planning process almost immediately. Support staff, such as case managers, can get involved early to facilitate a smooth discharge process. Since the program’s inception, patient length of stay has decreased by an average of five days.

Increasing satisfaction for patients and staff alike

“Nurses were a bit fearful at first,” remembers Katie Lewis, associate director of clinical nursing, P7. “But they rose to the challenge.” She reports that her staff receives a great sense of fulfillment when patients are discharged early, and complications are minimized.

Patient satisfaction has improved with the consistency and continuity of care the fast track program provides. Once the patient arrives in their room on P7, they will stay there until discharge. “Patients develop a bond with ‘their’ nurse,” reports Lewis.

“Participation and excitement for this program have penetrated the entire surgical and perioperative team. I feel that our ‘home ward,’ P7, is the safest and most efficient area in which to care for this group of high-intensity, high-acuity patients.”

– Wayne Hofstetter, M.D., Associate Professor, Thoracic and Cardiovascular Surgery

What’s next?

The multidisciplinary care team plans to investigate using the fast track program for other thoracic surgery procedures. And, according to Baker and Lewis, they expect outcomes will be just as positive.