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System-Wide Improvement for Transitions After Ileostomy Surgery

Can Intensive Monitoring of Protocol Compliance Decrease Readmissions? A Randomized Trial

Grahn, Sarah W., M.D.1; Lowry, Ann C., M.D.1; Osborne, Marc C., M.D.1; Melton, Genevieve B., M.D., Ph.D.2; Gaertner, Wolfgang B., M.D., M.Sc.2; Vogler, Sarah A., M.D., M.B.A.1; Madoff, Robert D., M.D.2; Kwaan, Mary R., M.D., M.P.H.2

Diseases of the Colon & Rectum: March 2019 - Volume 62 - Issue 3 - p 363–370
doi: 10.1097/DCR.0000000000001286
Original Contributions: Socioeconomic
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BACKGROUND: Hospital readmission is common after ileostomy formation and frequently associated with dehydration.

OBJECTIVE: This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission.

DESIGN: This is a randomized controlled trial.

SETTING: This study was conducted in 3 hospitals within a single health care system.

PATIENTS: Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected.

INTERVENTION: Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care.

OUTCOME MEASURES: Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured.

RESULTS: One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2–16.9); p = 0.03). Direct costs and patient satisfaction were similar.

LIMITATIONS: This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care.

CONCLUSIONS: A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at

1 Colon and Rectal Surgery Associates, Ltd, St. Paul, Minnesota

2 Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Funding/Support: This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UL1TR000114 and the University of Minnesota- Fairview Health Services System Engagement Award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Financial Disclosures: None reported.

Presented at the meeting of the American College of Surgeons, Washington DC, October 18, 2016.

Correspondence: Mary R. Kwaan, M.D., M.P.H., Division of Colon and Rectal Surgery, MMC 450, 420 Delaware St SE, Minneapolis, MN 55455. E-mail:

© 2019 The American Society of Colon and Rectal Surgeons