Abstract
BackgroundRandomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes.MethodsA cross-sectional questionnaire was administered to surgeons and nurses in August–October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013–15.Results218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management.ConclusionsStandardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.
Highlights
ThemeStandardisation of care Components of peri-operative care based upon the ERP Organization of the clinical team for routine care Monitoring of patients for post-operative deterioration Clinical response to post-operative deterioration Team functioning Resources and staffing Collection and use of clinical informationThe Enhanced Recovery Program (ERP) is a complex, multidisciplinary peri-operative care package that can reduce length of stay after surgery [1,2,3]
Higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management
281/301 (93.4%) respondents agreed or strongly agreed that there was a defined management protocol for elective patients, such as an ERP, for their patients. 278/301 (92.4%) participants agreed or strongly agreed that patients normally started drinking and/or eating within the first 24 h after surgery, and 277/300 (92.3%) indicated that they usually mobilised in the first 24 h. 190/300 (63.3%) of participants replied that elective patients rarely had abdominal drains or nasogastric tubes (NGTs)
Summary
ThemeStandardisation of care Components of peri-operative care based upon the ERP Organization of the clinical team for routine care Monitoring of patients for post-operative deterioration Clinical response to post-operative deterioration Team functioning Resources and staffing Collection and use of clinical informationThe Enhanced Recovery Program (ERP) is a complex, multidisciplinary peri-operative care package that can reduce length of stay after surgery [1,2,3]. Much research has examined adherence to ERP components and length of stay at the patient level [4,5,6,7] While this approach is important, it overlooks the influence of the clinical team on outcomes and does not explain persistent outcome variation between units after risk adjustment. Higher-level approach asked participants about key ERP components We situated this within a broad assessment of care within the unit, to explore a wide range of factors that may influence outcomes, based on previous work [8]. Higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. Careful implementation and adherence by all of the team is vital to achieve the best results
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