Surgery.med.ufl.edu



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DEPARTMENT OF SURGERY

Objectives and information for residents and students

Colorectal Service

Revised 10/17/2017

Faculty members are:

Dr. Atif Iqbal

Dr. Sanda A. Tan

Competency- Based Knowledge and Performance Standards

ACGME Competency 1: Patient Care

Clinical Management of Patients with Colorectal Surgical Disease. The resident must demonstrate progressively detailed and complete knowledge and technical ability for the clinical management of colorectal surgical diseases as they progress from the PGY-1 year through the PGY-5 year by the following actions.

General Patient Care:

1) Pre-op assessment is accurate; identifies patients at risk for complications; requests appropriate pre-operative tests and consultation.

2) Recognizes, evaluates and manages post-operative problems and complications promptly and accurately, seeking advice promptly.

a. At the PGY-1 level, the resident should be able to recognize, manage and/or ask for help with post-operative complications such as wound infection, urinary tract infection, and pneumonia.

b. At the PGY-3 level, the resident should be able to manage the patient post-operatively with support and guidance from the chief resident or the attending. The resident should be able to recognize signs of anastomotic leak and be able to manage it.

c. At the PGY-5 level, the resident should be able to run the service, notice, anticipate and manage complications associated with disease process and from the surgery such as anastomotic leak, enterocutaneous fistula and medically complex patients. The resident should be able to lead the team and help the junior residents on the team.

3) Completes order writing and test ordering in a timely fashion.

4) Progress notes accurately reflect patient condition and progress.

5) Discharge summaries completed in timely fashion (i.e. 24 hours).

6) Dictations reflect understanding of patient problems and management.

7) Demonstrate basic skills.

8) Demonstrate technical mastery of appropriate cases:

a. At the PGY-1 level, this includes simple operative and bedside procedures, such as basic manual skills in operating room, including knot-tying, handling of scissors, scalpel and electrocautery, basic suture techniques, including layered closures, running and interrupted suturing techniques, and subcuticular skin closures, and basic procedures, such as anorectal procedures, and simple operative excisions.

b. At the PGY-3 level, this includes most colorectal procedures, uncomplicated routine laparoscopic bowel resections and colonoscopies.

c. At the Chief Resident level, this includes routine and complex colorectal procedures, such as re-operative colon procedures, complex laparoscopic colon and pelvic resections. Basic introduction to robotic surgery.

ACGME Competency 2: Medical Knowledge

Disease Processes Included in Colorectal Surgery

The residents must gain progressively detailed and complete knowledge of the pathophysiologic processes associated with each of these disease processes, as well as the diagnosis and treatment of each, as they progress from the PGY-1 year through the PGY-5 year. They must be able to recite the anatomy, pathophysiology and relevant management for the diseases treated in colorectal surgery including:

1) Epidemiology, preventive screening, signs/symptoms, work-up, staging and current treatments for colon cancer and rectal cancer.

2) Epidemiology, signs/ symptoms, findings, clinical evaluation, treatments and complications of diverticular disease.

3) Clinical presentation, histological findings, work-up, and current options for treatment of inflammatory bowel disease, ulcerative colitis, including indications for and complications related to restorative proctocolectomy.

4) Clinical presentations, work-up, histopathology, complications, and indications for operation in patients with Crohn’s disease.

5) Genetic basis, clinical course, evaluation and current treatment and counseling of patients with familial cancer syndromes: familial adenomatous polyposis (FAP), Gardner syndrome, Turcot syndrome, hereditary non-polyposis colorectal cancer (HNPCC).

6) Management and potential complications of ileostomy and colostomy.

7) Epidemiology, clinical presentation, histology, work-up and current treatment for other polyposis syndromes- Peutz-Jeghers polyps, Cronkhite-Canada syndrome, juvenile polyposis.

8) Causes, classification, complications, treatment options, and indications for operation for hemorrhoidal disease.

9) Pathogenesis, presentation, current treatments for anal fissures, anal fistulas, perianal and perirectal abscesses.

10) Symptoms, clinical findings, evaluation and current treatments for pelvic floor disorders such as fecal incontinence and rectal prolapse.

11) Symptoms, causes, work-up, and current treatments for large and small bowel obstruction, including volvulus.

12) Viral warts (condylomata.)

13) Pathogenesis, evaluation and treatment options for premalignant anal conditions, such as anal intraepithelial neoplasia (AIN I-III), and anal Paget’s disease.

14) Diagnosis and treatment options for malignant anal disease.

15) Etiology and treatment of hiradentitis suppurativa

16) Etiology, complications, and surgical treatment of pilonidal disease.

Other General Surgery and Critical Care for PGY-3 and PGY-5 residents:

1) Assess patient status and/or change in patient condition, and formulate a plan to treatment. Recognizes when deterioration of patient condition requires transfer to SICU.

2) Indications for, uses and characteristics of various suture materials, including absorbable and non-absorbable, in various clinical settings.

3) Appropriate use of prophylactic antibiotics in surgery.

4) Recognize and treat wound complications, including infection and hematoma.

At the PGY-1 level, the resident is expected to understand the indications for various types of colon and rectal procedures including ano-rectal procedures.

At the PGY-3 level, the resident is expected to understand; to appreciate major steps involved in various colon and rectal procedures; to recognize risks and benefits involved with various procedures and advise patients on what to expect with each procedure post-operatively.

At the PGY-5 level, the resident is expected to understand, to know the steps of colon and rectal surgery; to anticipate the pre-operative requirements and to order appropriate work up of each disease.

ACGME Competency 3: Practice-based learning and improvement

Residents at all levels must demonstrate particular familiarity with the scientific information pertinent to their patients’ care. In addition, they must be able to evaluate the level of evidence supporting that knowledge. The venues for acquiring, disseminating and demonstrating this knowledge are individual reading, and regular conference attendance/participation. The weekly Conference and the Morbidity and Mortality Conference, in particular, are designed to provide venues for specific discussion of individual patient care issues, and critiques of the practice outcomes. Patients discussed at the Morbidity and Mortality Conference are presented by the resident most directly involved in the care related to the complication, who also leads discussion of this aspect of care. These activities are designed to promote habits of lifelong learning and improvement through reading, professional activities and reflecting on patient experiences.

All PGY levels are expected to attend all the conferences. PGY-3 and PGY-5 residents are expected to be able to present the patient at the tumor board conferences. All residents residents are expected to prepare and present patients at the pre-operative conferences each week. PGY-3 resident should be able to teach the medical students while the PGY-5 resident should be able to teach the junior residents. Additionally, the PGY-5 resident should keep up with current literature in patient care and be able to use technology to answer clinical issues.

ACGME Competency 4: Intrapersonal and communication skills

The residents at all levels on the service are all required to consistently communicate with patients, families, and other health care professionals. The quality, quantity, and attitude of communication are all important, via both verbal and written routes. Written documentation is especially critical for documenting patient care for ongoing cooperative management. This is central to the care of both patients on the service, and patients who are evaluated and followed as consult patients. Active monitoring of the timeliness of medical record documentation must demonstrate compliance with Office of Clinical Affairs guidelines.

All levels of residents must:

1) Work in a cooperative manner with other health care personnel, being sensitive to their roles and abilities

2) Give and receive advice in a manner that is consistent with the harmonious operation of the health care team

3) Communicate with patients and their families, explaining recommendations to them in terms each individual can comprehend

4) Respect patients’ rights to privacy

5) Respect the sexual, moral, ethical, or religious characteristics of the patient and family, and other members of the healthcare team.

6) Understand the special psychological needs of the colorectal patient.

Additionally, PGY-3 and PGY-5 residents are expected to be able to answer questions from the family and be able to communicate with physicians from other services who are requesting consults or with whom the service has requested consult.

ACGME Competency 5: Professionalism

The residents on the service must each maintain the highest standards of ethical behavior, with a commitment to continuous, high quality patient care. The professional behavior extends to all patient care interactions, including patients on the service, and those evaluated as consults, and to all interactions with other healthcare professionals. The residents must demonstrate sensitivity to the diversity of ages, genders, cultures, and relationships.

The professionalism expected also encompasses the individual professional behavior necessary to maintain the function of the hospital and training program, including timely medical documentation, completion of licensing and credentialing requirements, documentation of work-hours, and adherence to the ACGME Duty Hours requirements.

The residents at all levels must demonstrate:

1) An appreciation of the ethical and legal aspects of colorectal surgery.

2) Honesty, reliability, and respectfulness in working with patients and colleagues.

3) Dress neatly and appropriately when working with patients in all settings.

ACGME Competency 6: System-based practice

The residents must access the health system resources necessary to practice high-quality, cost-effective patient care. This includes understanding the roles of various specialists and other health care professionals in the care of their patients. The residents must fulfill their important role in the care of patients on other services that are evaluated and followed as consult patients. They should understand the ways that their recommendations and timely communication affect the function of the medical center.

The ability of the residents to utilize the health system resources is demonstrated in the daily care of the patient, and evaluated in daily attending contacts and conferences.

The resident at all levels must:

1) Demonstrate an understanding of how the health system functions to manage patients.

2) Discuss roles that support services, such as pharmacy, security, and social work, physical therapy and enterostomal therapy.

3) Coordinate patient care including obtaining tests and scheduling elective and emergency procedures.

4) Request and use consultations appropriately.

5) Work cooperatively with non-physician care-givers associated with GI surgery (nurse coordinators and discharge planners).

GENERAL GUIDELINES

Resident Responsibilities in Clinic:

Dr. Tan’s Clinic begins at 8:30 am on Monday and Wednesday, Dr. Iqbal’s clinic begins 8:30 am on Tuesday and Thursday. All patients are seen by and/or in conjunction with attending staff.

Dr. Tan’s OR days are Tuesday and Thursday at the South Tower and 1st and 3rd Wednesday afternoon of the month at FSC. Dr. Iqbal’s OR days are Monday and Friday at the South Tower and every 2nd (all day) and 4th (afternoon only) Wednesday at FSC.

Documentation Format:

All clinic/progress notes/letters should be done using the CRS template. They can be found under “ufp amb sur crs”. There are over multiple templates including one for progress note for floor, progress note for ICU and discharge summary. Orders are under bowel resection order set. All the patients who return to clinic for pre-op appointment needs a full H&P and not a short SOAP note in clinic. Some patients who are returning for post-op and pre-op must have a full H&P and not a simple SOAP post-op note. If you are not sure about a note, write a full H&P note. Please use templates whenever possible so that we can have correct documentation regarding risks and benefits that were discussed.

At the time of discharge, patient’s problem list must include updated problems and diseases present on admission including smoking history and BMI. There should be reason why the patients stay in house (example: Patient was kept on clears on POD#1 and advanced to regular diet on POD#2). Just stating no complication and patient stayed until POD# 5 does not document fully why the patient stayed for that many days.

Please note that on this service a Progress note MUST be written even on the day of the discharge as decision is made on that day to discharge the patient. Writing a discharge summary is not adequate documentation for the day.

Especially on the inpatients, prior to discharge, please check and add the referring physicians, primary care outside of the hospital and if applicable who their gastroenterologist is for continue care after discharge.

Pre-Operative Consults:

Complete consult requisition and notify the Clinical Care Coordinator that patient requires cardiology consult (general medicine Pre-Op, Cardiology, Pulmonary, etc.)

Patients Who Require a Cardiology Consultation:

Patients with suboptimal disease management are referred to pre-operative cardiology consultation unless patient has a previous cardiologist.

Patients who DO NOT Require a Consultation:

1. Patients with well controlled hypertension

2. Patients with prior cardiac disease (post- CABG, etc.) that are asymptomatic

3. Patients with a history of heart palpitation but an otherwise normal (with appropriate documentation of stable disease per referring or primary care physician).

Guidelines for Pre-operative Medications:

Take: Cardiac medications, seizure meds, anti-hypertensive agents, bronchodilators, L-thyroxine steroids, immunosuppressives, eye drops for glaucoma (patient needs to tell Anesthesia)

DO NOT take: (unless told by surgery/anesthesia) Aspirin (stop 7 days in advance), NSAIDs, Vitamin E (stop 7 days in advance), Insulin, Oral hypoglycemic or other over the counter herbal medications, diuretics.

Birth control pills may increase the risk of DVT. Discuss with patient and individualize depending on the procedure.

Pre-operative antibiotic prophylaxis should be ordered at time on H&P, to be given in holding room one hour before procedure. Pre-operative orders should be printed out the night before and filled out. The antibiotic of choice is cefotetan 2 grams, unless the patient has penicillin allergy. In which case, the antibiotic of choice is Ciprofloxacin 400 mg IV and Metronidazole 500 mg.

Enterag must be ordered pre-op for lap vs open small and large bowel resection patients who are not on narcotics previously. Order must be placed using “crs bowel resection order set.” Enterag is given until POD#5 or return of bowel function whichever is earliest.

DVT Prophylaxis:

Sequential Compression Device (SCD) is preferred and INDICATED if prior history of DVT, venous disease, Obesity, age> 60, long or laparoscopic procedure, patient with cancer.

SCD’s are not necessary for brief procedures

Heparin 5000 units’ subcutaneous injection prior to surgery or 2 hours after placement of epidural.

Hold anticoagulation (heparin/Lovenox) for patients who have epidural placed prior to surgery

Cardiac Prophylaxis:

Beta-blockers if no contraindications or on call to OR.

Help provided by Clinical Care Coordinators:

• ARNP number is 594 5135 (Jessica Doerrler, PA-C)

• Coordinator number is 594 3750 (Sarah Williams)

• Provide patient liaison & communication, and help coordinate clinical activities on the Colon and Rectal Surgery Service.

• OR and special test scheduling

• Communication with patients regarding medications, instruction, returns visits, new problems, wound management, etc.

• Coordination with Home Care services

• Instruct/assist medical assistants with protocols and procedures

• Clinic visits- examination, instruction, wound management

• Prescription refill orders

• Insurance and disability forms

Care of Colon and Rectal Surgery Patients

Habits, Idiosyncrasies, and Suggestions of

Attending Staff on the Colon and Rectal Surgery Service

These guidelines are recorded to assist residents who share responsibility for care of patients with the faculty. It is assumed that residents have a thorough knowledge of patient care. These guidelines are always based on experience, usually have a rationale, and sometimes are supported by hard data. None are cast in stone and all are subject to change based on better ideas that usually come form residents. Residents are requested to follow these guidelines in general, adopt them for personal use if they wish, and feel free to question the rationale or suggest improvement.

I. RESPONSIBILITIES

1. Patient Amenities. Treat patients and families as you would wish to be treated. When making bedside rounds, always greet the patient and introduce the patient to new physicians or visitors.

2. Referring Physicians. Communication to referring physicians is important. Be sure that a copy of the discharge summary is sent to the patient’s referring and/or primary care physicians. If you don’t know who these persons are, pull up the patients demographics.

3. Resident Responsibilities: Please notify attending staff promptly, day or night, of any major changes in a patient’s condition, particularly any complication or deterioration in condition. If there is any question as to whether or not to call, please call.

The day to day management of all patients is entrusted to the resident staff. It is the residents’ responsibility to know why each patient is in the hospital, what operation has been done, what the plan for care is, and what the current status of the patient is and to be able to report this information daily.

II. THE OPERATING ROOM

Surgery is a branch of human biology

An operation is a tissue dissection under anesthesia

1. See the patient in the pre-op holding area to say hello, answer questions, and verify with the patient the procedure that is to be done.

2. Be in the OR when patient arrives. Avoid the idle chatter. Keep the room quiet and the patient occupied prior to induction of anesthesia. Assist the anesthesia team during induction and positioning.

3. Operative notes must be dictated or written on the day of surgery by the primary operator using the regular hospital system. Notes should be brief. [DO NOT dictate “surgeon” “assistant” or “teaching assistant”] Student names are not listed.

The following format should be used:

Patient Name, Reg #, Date of Operation

Pre-Op Dx:

PostOp Dx:

Operation:

Attending Surgeon:

Resident Surgeon(s):

Anesthesia:

Indications:

Procedure: (give chronologic description, including findings)

EBL:

Complications:

III. PATIENT CARE INSTRUCTIONS

BOWEL RESECTION

Enhanced Recovery Protocol for Bowel Resection

Pre-op:

o Bowel Prep – Clears for 24 hours the day before Surgery; Bowel prep with Nulytely

o Antibiotics – Neomycin PO 1 gm at 2,4, and 10 pm and Metronidazole 500 mg PO at 2, 4, and 10 pm

o Clears up to 3 hours prior to surgery time (instead of MN as our current order stands)

o 240 ml of pre-operative drink at 3 hours prior to scheduled case (Enterade available for distribution at clinic when we distribute the soap).

o Epidural at T8-T10 level

o Heparin 5000 units SQ 2 hours after the epidural placement

o Pre-op Antibiotics of Cefoxitin or Cipro/flagyl if there is PCN allergy

o Entereg (Alvimopan) if pt is not on opioids

o Beta blocker if necessary

o Gabapentin 600 mg for age < 60 or 300 mg for age >60 (will be administered by anesthesia in pre-op)

o Acetaminophen (administered by anesthesia in pre-op)

o Preop Urine Culture for vaginal or bladder fistulas, pts with indwelling foleys, inpatients, pts from other facilties, OR high risk of UTI per surgeon.

Anesthesia:

o GETA and epidural doses (per Dr. Giordano protocol – single epidural hydromorphone at induction, 0.4 -0.8 mg based on body weight and bupivacaine 2.5 mg/ml at 3 -6 ml/hr)

o IVF and cardiac output per Dr. Giordano protocol (LR 1 L at induction and 3 ml/kg/hr for lap cases and 5 ml/kg/hr for open cases)

o Intra-op Tylenol and Ketorolac per Dr. Giodano

o NG for open cases, OG for lap cases.

o Lidocaine infusion post-op per Dr. Giodano

Post-op:

o Diet:

▪ Clears on POD #0

▪ Soft mechanical diet starting POD #1 with boost supplement with each meal

o d/c foley on POD # 1 unless

▪ hematuria from ureteral stents (d/c unless blood clots in foley and urine bag)

▪ bladder repair (per urology recommendations)

▪ deep pelvic dissection (d/c on POD # 3)

▪ Flomax .4mg capsule bid for ALL pelvic cases, oral starting POD 0

o Pain Control:

▪ Epidural bupivacaine 0.125% and hydromorphone 10 mcg/mg for 72 hours then d/c to oral opioids (per APS)

▪ Tylenol and NSAID as needed for break through during epidural

▪ Gabapentin capsule 100 mg tid for 48 hours, oral starting POD 0

▪ Tylenol 650 mg every 6 hours for 48 hours, IV for POD 0 and then switch to oral when PO is tolerated

o Stop IVF when po intake adequate

o (duplicate)OOB POD #0 and for at least 6 hours starting on POD# 1

▪ PT consult for everyone POD 1

o NG d/c on POD#1 unless observed bilious output in the tubing OR unless extensive adhesiolysis intraop?

o Discontinue Negative Pressure Wound incisional dressing on POD 5 or when patient is ready for discharge (whichever is earlier). Setting of Vac at 125 mm pressure setting.

o Consult to Wound/ostomy nurse on POD 1

o Consult to social work for help with dispo planning on POD 1

o Lovenox 30 mg bid for 28 days post op discharge for cancer patients and Lovenox 40 mg once a day for 14 days post op discharge

o DVT prophylaxis should be with lovenox 30 mg bid and not heparin SQ unless the patients still have epidural in place.

Bowel Prep for patients who cannot tolerate electrolyte changes:

Patients for ileostomy take down can have a bottle of magnesium citrate.

Post-op orders for patients after colectomy :

• Incentive spirometry q1 hour x 10 while awake (to prevent atelectasis)

• Ambulating in hallway with assist (Prevent DVT, improve pulmonary toilet)

• After APR, discourage sitting in a chair until POD#3. They can roll to get up and ambulate but go back to bed

• After POD#3, Pt may sit on one gluteal cheek or the other

• Strip drain and record the output

• SCDs on bilateral lower extremities

• Lovenox 30 mg bid for cancer patients and 40 mg qd for all others

• PPI or Zantac 50 mg IV q8 hr

Reason must be documented on the progress note.

• Antibiotic is discontinued after surgery unless otherwise indicated (Crohn’s patients). Then must be documented on progress note.

• All the Crohn’s disease patients are placed on ciprofloxacin and metronidazole unless there is allergy. Patients are sent home on these two medications until their first appointment with GI to resume their medical management of Crohn’s disease. Please stop all the other Crohn’s medications during that time and give steroid only as needed.

o Plan disposition early so that social services can work on discharge planning.

• Please inform that patient they need to make an appointment to follow up with the GI doctors as soon as they are discharged.

• If the patient is to be sent home on medications that will require frequent monitoring (examples: Coumadin, Vancomycin), please contact the PCP to help arrange for monitoring of these patients. Just setting up the home health is not adequate.

IVF:

• LR 125 ml per hr for POD#0 (adjust down if there is a cardiac issue)

• Change to D5 ½ NS with 20 meq/l at 120 ml/hr and adjust to about 75 ml/hr depending on cardiac status and age of the patient.

Drains:

• JP drains can come out if the output is less than 100 ml/day and/or patient is tolerating a regular diet and voiding without Foley catheter. If there is urine leak, the drain will prevent urinoma at least until diversion is possible.

Ostomy care:

• Please consult ostomy nurses early for teaching

• If the stoma is not in danger of retraction, please remove the bridge prior to discharge of patient.

Signs above the beds:

• For post APR, LAR, IPAA – “nothing per Anus”

o We do not want a suppository given or rectal exams done, that might disrupt the anastomosis

Wounds:

• May take the dressing down on POD#2 except for incisional vac

• Incisional negative pressure dressing comes down on POD#5 or before is discharged home.

• Remove staples and place benzoin with Steri-strips prior to discharge if POD #5-7; unless patient is obese or is on Steroids or radiated

Things to look out for:

• CBC and BMP, Mg, Phos, Ca on POD#1, 3, 5 and as necessary

• Need daily BMP on NPO patients

• Look out for excessive drain output or bright red blood in the bulb suction

• Look out for early signs of anastomotic leak:

o Tachycardia

o Atrial Fibrillation

o Fever and increase WBC on POD#5 – 7

Additional instructions for end colostomy or diverting loop ileostomy

• Prevent dehydration.

• When tolerating regular diet: consider bananas, rice, white bread, pasta, potatoes may help to thicken output

• Want stoma output to be of oatmeal consistency 1500 ml/day

• Inpatient regimen to decrease outputs:

o diet,

o consider fiber (absorbs water) such as Metamucil, Konsyl

o PPI (decreased acid/fluids presented to small bowel),

o cholestyramine (absorbs bile salts),

o Imodium (decreases small bowel motility),

o Sandostatin (100 micrograms SQ TID, then LA form if it works),

o DTO (opiate, slows gut motility)

o Iron supplements

Additional instructions for post ileostomy take down

• Check the old ostomy site.

• May need wet to dry dressing changes.

• If there is a Penrose drain, slowly remove little by little each day but remove totally before patient is discharged home. Then cover with dry dressing.

• clears on POD#0 and may advance to regular or soft mechanical on POD#1

Additional instructions for post APR

• Check the perineum wound on post APR patients

o Patients who have had radiation are prone to breakdown.

o Flaps by plastic surgery needs special care

o Roll patients from side-to-side every 2 hours to keep pressure off the perineum wound.

Additional instructions for Rectopexy

• The bowel function return is slower in these patients. Be patient.

Additional instructions for perineal proctectomy

• Nothing per anus

• Avoid digital rectal exam

• May advance diet as tolerated

Additional instruction for TEM or trans-anal excision

• Nothing per anus

Additional instruction for InterStim Placement

• May have frontal shower only for POD# 2 to #4

• Change the dressing with dry gauze if dressing gets wet

Discharge conditions:

1. Patient must be able to tolerate regular diet, pain well controlled with PO pain medications have flatus or bowel movement

2. Patient or family should be able to take care of the wound

3. Make sure patient is able to take care of ostomy on their own or with family help.

4. Please do not give Dulcolax to post colectomy patients unless instructed

5. F/U in 2 weeks unless they have staples and we need to bring them back to remove them

****Please print out the discharge instruction package and give to patients

****Please print out the dehydration instruction package and give to patients who have ileostomy.

ANO-RECTAL SURGERY

Bowel Prep:

• Clear liquids only the day before surgery

• Fleets enema x 2 (one the night before and one on the morning of surgery). However, some patients with anal fissure may want to have Golytely rather than enema due to pain related to placing an enema.

Additional instructions for Hemorrhoidectomy

• Antibiotic: none unless indicated.

• Post-Op

I. Ice on area, intermittent, day of operation

II. Sitz baths, warm water (not hot) beginning day after operation.

III. Pain management:

▪ Ibuprofen 600 mg q 6 hrs around the clock

▪ Tylenol #3 or Vicodin for breakthrough pain only if needed (will constipate)

IV. High fiber diet and stool softeners (Docusate, psyllium)

V. Activity: as tolerated

VI. Return to Work: usually 1-3 weeks, depending on discomfort.

VII. Return visit: 4 weeks

IV. DISCHARGE PLANNING & INSTRUCTIONS

1. Instructions to Patients Going Home Following Major Operations

a. DO: Bathe, shower, shampoo as one normally would.

b. DO: Engage in normal daily activities around the home, go up and down stairs, go outside, take a walk, and ride in a care. Lifting things is ok; straining to lift is not.

c. DO: Call clinician coordinators is any questions (352) 265-0535

d. DON’T: Do anything that causes a lot of incisional pain (straining, lifting heavy objects, vigorous exercise).

e. DON”T: stay in bed all day, have meals in bed, get constipated.

f. EXPECT:

• Some pain and numbness in the area of the incision

• Hardness under the incision (“healing ridge”)

• Tingling or shooting pains in the area of the incision for 1-2 months following operation

• Weakness and fatigue following minimal exertion for 1-2 months following major operation

2. Discharge Summaries.

All patients must have a discharge summary with a copy to the referring physician and the primary care physician is there is one. A discharge summary gives essential information, such as dates of admission and discharge, [principle and active diagnosis, operations performed, condition at discharge, plan for care. It also tells a story that summarizes the hospital course. Don’t repeat detailed information that exists elsewhere in the chart, such as in an operative note. For most patients, the narrative portion of the summary should have six components:

1. Principal diagnosis or problem leading to hospitalization and pertinent supporting physical or lab findings (e.g., reflux esophagitis documented on EGD & biopsy, confirmed by pH testing and manometry).

2. Reason or purpose for admission and continued hospitalization should be made clear (e.g. surgery to treat colon cancer, intravenous nutrition, nasogastric suction, monitor serum calcium).

3. Plan for care, diagnostic work-up and/or therapy (e.g., plan included pre-op CT, bowel prep, and colon resection.)

4. Treatment provided. (after appendectomy for gangrenous, perforated appendicitis, patients was treated with IV antibiotics because of gross peritoneal soiling).

5. Response to that treatment (e.g., patient became afebrile after 5 day course of antibiotics), including condition at time of discharge.

6. Discharge instructions, medications, other needs, and plans for follow-up.

B. Helpful Hints:

DO:

1. list all activities diagnoses (i.e., those that you actively managed, such as diabetes, HBP, etc)

2. Construct a clear, concise summary that tells a story that correlates with the clinical picture.

3. Mention only pertinent H&P findings, operative findings and treatments, labs, x-rays

DON”T:

Don’t say: Instead say:

“S/P” Underwent

“Stable” Discharge status improved, ambulatory

“Uneventful post op course” Mention activity, pain control, resumption of diet, nutrition, bowel function, etc.

Dictation Format:

INPATIENT DISCHARGE SUMMARY

(For Resident or Attending Documentation)

Dictate as work type “1”

1. Patient name & MRN

2. Dictating Physician Name/Number

3. Attending Physician Name/ Number

4. Discharge Department and Service

5. Admission Date

6. Discharge/ Transfer date

7. Diagnosis (including comordidities* and complications**)

8. Operations/ Procedures

9. Discharge/ Transfer Medications

10. Allergies/ Sensitivities

11. Condition of Patient at DC/Transfer

* Chronic conditions not being actively managed during the admission, such as obesity.

** Condition occurring in the hospital, such as pneumothorax, adverse reaction to a drug etc...

Medical history:

Brief summary of admitting history and physical, with only pertinent positives and negatives

Brief Hospital Course: By system (if complex case or multiple systems are involved)

Test results/status at time of discharge:

Pertinent blood work

Cultures Not otherwise

Radio Graphic imaging studies mentioned in hospital

Pathologic studies course.

Discharge physical: Wt, BP, pertinent data at time of discharge (e.g. size of decubitus or open wound)

Discharge plan/ instructions: Diet, activity

Follow-up: Dr. name/address/telephone

Interval of visit

Tests needed at follow-up

Disposition: Home/Transfer/Other: (Be specific)

Indication that this was discussed with patient/family

If resident dictating: state which attending physician physically saw the patient on the day of discharge.

Cc: Referring physician/primary physicians

*Spell names; dictate address, of referring/primary physicians on screen

Record dictation number on discharge summary form.

V. EDUCATION LECTURES/READING MATERIALS

Recommended reading materials:

• Textbook: The ASCRS Textbook of the colon and Rectal Surgery

• Clinical Practice Guidelines from ASCRS



• Core subjects from ASCRS



• Journal : Diseases of the Colon & Rectum

Topics for the pre-operative Conference on Monday at 7 am in Rm 2016 in South Tower (OR conference room):

Week Topic Attending

1 Abscess and fistula Iqbal

2 Screening & surveillance colonoscopy Tan

3 anal Cancer and hemorrhoids Iqbal

4 Surgical Management of IBD Tan

5 Colon & rectal Cancer Iqbal

6 Diverticulitis and other colitis Tan

7 Anorectal Trauma Iqbal

8 Practice Oral board Tan/Iqbal

9 Pelvic floor Tan

10 Colonic obstruction Iqbal

VI. APPENDIX

1. Associated risks for discussion during consent:

Sigmoid Colon Resection:

The risks may be: 1) bleeding or hematoma formation requiring reoperation; 2) wound infection (5-10 %); 3) breakdown or leakage where bowel is sewed together, requiring reoperation, temporary or permanent colostomy or ileostomy (10lbs over 3-4 days.

Inability to urinate for more than 6 hours.

Cloudy or foul smelling urine.

Urge to urinate more often than usual.

Department of Surgery

Division of Colorectal Surgery

Discharge Instructions Following Ileostomy Surgery

Follow-up:

You will be seen by Dr. ___________ in the Colorectal Surgery clinic on ___________ at ___________ for follow-up.

Please call 352-265-0535 to confirm your appointment.

Please call at least one business day in advance to change your appointment.

UF Health Shands Colorectal Surgery Clinic is located at:

UF Health North Tower – 1st Floor

1600 SW Archer Road

Gainesville, FL 32610

Please call 352-265-0535 if you have any problems or have questions regarding your hospitalization.

After hours, please call 352-265-0111 and ask for the Colorectal Surgery Resident on-call.

Diet: You will continue an ileostomy diet started during your hospitalization.

It is important to maintain hydrated. Drink high-sodium content drinks such as Gatorade rather than water.

Your daily intake must be greater than your ileostomy output.

Do not eat within 1.5 hours of sleep to decrease the risk of filling your ostomy bag.

Ileostomy Care:

The ileostomy bag should be sealed well to prevent any odor from leaking.

Do not let the bag get more than half-way full.

Empty the bag frequently.

Follow the detailed ileostomy care instructions provided by your ostomy nurse.

Please call 352-265-0535 if you are having problems with your ostomy.

Ileostomy Output Tracking:

Please document this every day:

Output in milliliters each time you empty the bag throughout the day.

Liquid oral intake in milliliters throughout the day.

Use chart provided and add both columns at the end of each day.

If intake is less than the output please call 352-265-0535 immediately.

Ileostomy Output Reduction Protocol:

Mark the [ ] once you complete each step of the protocol (example [x])

[ ] Start taking 15-30 grams of fiber per day:

Metamucil powder, 1-2 tablespoons 1-2 times/day OR

Benefiber powder, 2 tablespoons 4 times/day.

[ ] If goal output not reached in 2 days:

Take 1 Imodium tablet 3 times/day.

[ ] If goal output not reached in 2 days:

Take 2 Imodium tablets 3 times/day.

[ ] If goal output not reached in 2 days:

Take 2 Imodium tablets 4 times/day.

[ ] If goal output not reached in 2 days:

Take 1 Lomotil tablet 3 times/day.

[ ] If goal output not reached in 2 days:

Take 2 Lomotil tablets 3 times/day.

[ ] If goal output not reached in 2 days:

Take 2 Lomotil tablets 4 times/day.

If goal output reduction not reached at this time please call 352-265-0535.

If you are concerned about high output at any time during this protocol please call 352-265-0535.

Activity: Increase your activity level gradually.

Walking is a good form of light exercise. Go for a walk at least 3 times per day.

No heavy lifting (over 15 pounds) for at least 4-6 weeks from surgery.

Check with your doctor before you start full-intensity exercise and are cleared for heavy lifting.

Return to work when cleared by MD/PA/ARNP.

No driving or operating motorized vehicles while on prescription pain medications

No swimming until wound is fully healed.

Bathing: Shower daily.

Gently let soap and water run over your incision and pat dry. Do not scrub the incision/wound.

Don’t soak in a bath until your incision is healed and evaluated by your physician at follow-up.

Wound Care: General Instructions

You may leave your incision open to air.

Keep your incision clean and dry.

No lotions, creams, ointments, or powders on incisions until they are well-healed.

If you have glue over the incision(s), allow it to fall off naturally in 1-2 weeks.

Abdominal stables/sutures, if present, will be removed 2-3 weeks after surgery during your follow-up clinic visit.

If present, change dressing/bandage when soaked/soiled as needed.

Observe wound daily, checking for signs and symptoms of infection including: increased redness, increased pain at incision, drainage from incision, increased swelling at incision site.

Wet to Dry Dressing Changes

Change dressings twice daily.

Take pain medication 30 minutes prior to changing wound dressings.

Wash your hands prior to handling bandages (wear gloves if recommended).

Gently remove old packing dressing (light bleeding/oozing is expected).

Have someone observe for and clear debris/hair.

Pack with damp dressing as instructed.

Cover with bandage and secure with tape.

Change outer dressing when soaked or soiled as needed.

Drain Care

You may shower with the drain in place.

Strip/milk the drain tubing towards the bulb to remove clots at least twice daily and as needed.

Empty the drain bulb at least two times daily and as needed by popping the top of the collection bulb and squeezing into measuring cup. Record the amount of fluid drained every time on a chart along with the time emptied. Once empty, squeeze the empty bulb and pop the top back on.

Pain Control:

Expect post-operative pain for 1-4 weeks after surgery, which will improve gradually

You have been provided with prescription medication for pain. Please take as directed, and be aware of side effects such as drowsiness, constipation and mild stomach discomfort. Pain pills on an empty stomach can cause nausea, so eat a small amount of food, such as crackers, when taking these pills.

Pain regimen:

First

Take Gabapentin _____ mg every _____ hours.

Take Tylenol _____ mg every _____ hours.

Take Motrin _____ mg every _____ hours.

IF you are still in pain after the above regimen:

Take Oxycodone _____ mg every _____ hours.

Call immediately if you have any of the following 352-265-0535:

Pain that gets worse or is not relieved by medication.

Warmth, redness, or swelling in the skin around the wound.

Foul drainage from incision.

Extensive bruising or discoloration.

Wound that opens up or pulls apart.

Fever above 101.5°F or shaking chills.

Nausea or vomiting.

Severe diarrhea or severe constipation.

Dizziness or fainting.

Chest pain, shortness of breath, or increased work of breathing.

Weight gain >10lbs over 3-4 days.

Inability to urinate for more than 6 hours.

Cloudy or foul smelling urine.

Urge to urinate more often than usual.

Care of Ileostomy Patients on CRS

• POD #1

o PICC line request

o Social Services consult for PICC line and IV Fluid 1 L/day at night

• Diet

o Start on ileostomy diet POD#1 (routine CRS post-op order)

o Add fiber tid with ileostomy diet

• Discharge

o Pt is d/c home when clinically ready. Ignore ileostomy output volume and consistency.

o Phone call to patient starting Post discharge #2

o Escalate the medications per CRS ileostomy output reduction protocol

o D/C IV fluid if patient has recorded 3 days of ileostomy output < 1.5 L/day or intake > output

o D/C PICC one week after stopping fluid

CRS ILEOSTOMY OUTPUT REDUCTION PROTOCOL

1. REQUIREMENT:

a. Accurately record liquid intake and ostomy output on the page on the back (Make more if needed)

b. Make sure that during the protocol below you are drinking more than output otherwise you will get dehydrated

2. AIM:

a. Intake needs to be 500 cc/day more than output

b. Ileostomy output needs to be less than 1500 cc/day

c. Whenever the above aim is achieved, stop the protocol below

d. Call our office at 352-265-0535 for any questions or concerns

3. PROTOCOL (Follow this strictly please and stop if above aim is achieved – wait two days between each step):

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