Implementation Of Enhanced Recovery Pathway Research Articles

Decreased Length of Stay and Opioid Usage After Liver Cancer Surgery With Enhanced Recovery Pathway Implementation.

Enhanced recovery after surgery (ERAS) pathways are associated with better postoperative recovery; however, evidence is lacking in liver cancer surgery. This study aimed to evaluate the impact of an ERAS pathway in US veterans undergoing liver cancer surgery. We initiated an ERAS pathway for liver cancer surgery with preoperative, intraoperative, and postoperative interventions, which included a novel regional anesthesia technique, erector spinae plane block, for multimodal analgesia management. A retrospective quality improvement study was conducted with patients undergoing elective open hepatectomy or microwave ablation of liver tumors before and after ERAS pathway implementation. With 24 patients in the post-ERAS group and 23 patients in the pre-ERAS group, we found a significant decreased length of stay in the ERAS group (4.1 days ± 3.9) compared with traditional care (8.6 days ± 7.1, P = .01) and decreased perioperative opioid consumption including intraoperative opioids (post-ERAS 49.8 mg ± 28.5 vs pre-ERAS 98 mg ± 42.3, P = 4.1E-5), postoperative opioids (post-ERAS 65.3 mg ± 59.9 vs pre-ERAS 175.7 mg ± 210.6, P = .018), and patient-controlled analgesia requirements (post-ERAS 0% vs pre-ERAS 50%, P < .001). The implementation of ERAS for liver cancer surgery in our veteran population translates into decreased length of stay and perioperative opioid consumption. Although this study is limited as a quality improvement project implemented at one institution with a small sample size, our results are clinically and statistically significant and sufficient to warrant further investigation into the efficacy of ERAS as the surgical needs of the US veteran population increase.

Impact of enhanced recovery pathway in 408 gallbladder cancer resections

Gallbladder cancer (GBC) is the sixth most common gastrointestinal malignancy with poor prognosis. Enhanced Recovery Pathway (ERP) is associated with improved outcomes following abdominal surgical procedures. Currently, there is no study evaluating ERP in patients undergoing GBC surgery. The objective was to assess compliance with ERP elements and evaluate its impact on postoperative outcomes. Prospective study conducted from February 2014-2019, including elective GBC surgery. Team was educated prior to ERP implementation. Compliance with the protocol, functional gastrointestinal (GI) recovery, mobilisation, and postoperative outcomes were recorded. Impact of degree of compliance (more or less than 80%) with ERP and postoperative outcomes was evaluated. In 408 patients, compliance with ERP was 84.6% (53.8-100%). Compliance >80% with ERP elements was observed in 245 patients (60%). Patients with >80% compliance had lower rate of minor (18.8% vs. 27%, p=0.050) and significantly less major (0.8% vs. 6.1%, p=0.002) and postoperative stay (5.84±4.86 vs. 7.55±6.6 days, p<0.001) and earlier functional GI recovery. Intraoperative blood loss more than 600ml, lower compliance (<80%) with ERP and preoperative albumin independently predicted postoperative complications. This study demonstrates safety and efficacy of enhanced recovery pathway in gallbladder cancer. Higher compliance with the pathway was associated with significantly improved postoperative outcomes following gallbladder cancer surgery.

Implementation of Enhanced Recovery in Gynecologic Surgery to Improve Outcomes at an Urban Safety-Net Hospital

Background: This study aims to implement an enhanced recovery pathway (ERP) for patients undergoing gynecologic surgery and to track clinical outcomes, including perioperative opioid use and adverse events. Methods: Patients undergoing gynecologic surgery with a planned overnight stay were eligible. The primary outcome measure was perioperative opioid use in oral morphine milligram equivalents. Secondary outcome measures included bundle completion and length of stay. Balancing measures included rates of total and specific adverse events. Data were stratified by route of surgery and univariate analyses were performed between pre- and post-ERP groups to compare demographic factors and outcome measures. Linear regression analyses were run to assess mean differences in perioperative opioid use and length of stay when adjusting for route of surgery, age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, surgical subspecialty, and postoperative hemoglobin change, and/or bundle completion score. Results: The ERP was implemented in 16 weeks and selected in 63 eligible patients from February 1 to April 30, 2017. ERP bundle completion was significantly higher for all surgical categories following formal pathway implementation. Compared to the pre-ERP cohort, the ERP cohort demonstrated significantly decreased total opioid use in laparotomies (175.5 mg vs. 209.8 mg, P = 0.03) and minimally invasive surgeries (125 mg vs. 170.3 mg, P = 0.018). Additionally, significantly decreased intraoperative opioids were used in both laparotomies (95 mg vs. 105 mg, P = 0.03) and minimally invasive surgeries (75 mg vs. 108.5 mg, P < 0.0001), as well as significantly decreased postoperative opioid use in minimally invasive surgeries (15 mg vs. 45 mg, P = 0.04). A one-point increase in ERP bundle completion score was associated with a 9.2 mg decrease in total opioid used (P = 0.0375) as well as a 4.8 h decrease in length of stay (P < 0.0001) when adjusting for route of surgery, age, BMI, ASA status, surgical subspecialty, and case length. There were no significant differences in adverse events when ERP was used. Conclusions: ERP implementation was rapidly accomplished at our urban, safety-net hospital. The pathway reduced perioperative opioid use without increasing adverse events. Continued monitoring of enhanced recovery quality improvement measures, including bundle completion, is essential to ensure adherence, safety, and effectiveness. J Clin Gynecol Obstet. 2020;9(3):43-52 doi: https://doi.org/10.14740/jcgo666

High Compliance to an Enhanced Recovery Pathway for Patients ≥65 Years Undergoing Major Small and Large Intestinal Surgery Is Associated With Improved Postoperative Outcomes.

This study was performed to evaluate compliance to an Enhanced Recovery Pathway (ERP) among patients ≥65 years and determine the effect of compliance on postoperative outcomes. ERPs improve postoperative outcomes in patients undergoing major surgery. Given the inherent decline of the older surgical patient, the benefit of an ERP in this population has been questioned. Patients undergoing major small and large intestinal surgery prior to and following ERP implementation at the Johns Hopkins Medical Institutions were entered into the ACS-NSQIP database. Outcomes included ERP compliance rates, complications, length of stay (LOS), and 30-day readmission rates were determined for older patients. Nine hundred seventy-four patients (693 < 65 yrs and 281 ≥ 65 yrs) were included. Of those ≥ 65 years, 142 (51%) were entered prior to and 139 (49%) were entered following ERP implementation. More ERP than pre-ERP patients underwent laparoscopic procedures (45.3% vs. 32.4%, P = 0.02), had disseminated malignancies (9.4% vs. 2.8%, P = 0.03), and smoked (14.4% vs. 4.9%, P = 0.01). Overall compliance was 74.5%, and 47% of older ERP patients achieved high compliance (≥75% compliance with ERP variables). High compliance was associated with a 30% decrease LOS (IRR: 0.7 P = 0.001) and 60% decrease in major (CD ≥ II) complications (OR: 0.4 P = 0.05). LOS and complication rates following implementation of an ERP were significantly improved in highly compliant elderly patients. Interventions to further improve outcomes should target decreasing variability by increasing individual compliance with an effective clinical pathway.

Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery.

The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery. ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS. A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS. We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS. Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.

Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes

BackgroundEnhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. MethodsPatients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II–IV), and 30-day readmission. ResultsThis study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6% vs 50.2%, P = .89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43% vs 75%, P = .01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P = .01), postoperative day 1 (43% vs 88%, P < .01), and postoperative day 2 (60% vs 100%, P < .01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P < .01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P < .01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P = .04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63–0.82, P < .01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14–0.65, P < .01. ConclusionThis study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.

Practitioners’ conceptualisations of ‘evidence-based practice’ as a barrier to changing practice

The promotion of evidence-based, healthcare practice is a key concern for healthcare professionals both in the UK and internationally. However, what healthcare professionals understand by the term ‘evidence-based practice’ varies, and this can have implications for changing practice. This discussion piece describes a doctoral research project exploring the implementation of a new Enhanced Recovery Pathway (ERP) in three NHS hospitals. ERPs are evidence-based approaches to streamlining surgery and research demonstrates the positive impacts that their introduction has had for patient hospital stay, morbidity and mortality, post-surgical complications and quality of life. The ERP discussed in this article was designed to address the specific, complex needs of patients with cognitive impairment who fracture their hip. These patients are currently underrepresented in published literature regarding ERP effectiveness. As such, the evidence informing the ERP’s design consolidated current best practice guidelines, expert consultation and guidance from public and patient involvement groups. Staff members who were tasked with coordinating the implementation interpreted this to mean that the ERP was not sufficiently ‘evidence-based’. This presented an unexpected barrier to changing staff behaviour and successful ERP implementation. To promote successful intervention implementation, policy makers need to carefully consider how staff conceptualise ‘evidence-based practice’ and their attitudes towards newly introduced practices.

Real time compliance monitoring with NSQIP: Successful method for enhanced recovery pathway implementation

BackgroundCompliance with Enhanced Recovery Pathway (ERP) variables improves clinical outcomes. The National Surgery Quality Improvement Program (NSQIP) database includes ERP variables. We wish to determine if modifying NSQIP workstation workflow would increase compliance with ERP and improve outcomes following gastrointestinal surgery. MethodsNSQIP ERP variables were abstracted from patients enrolled in ERP and undergoing elective surgery within 2 weeks following surgery. The compliance was monitored and shared with a multi-disciplinary group of providers bi monthly. Clinical outcomes and patient experience was measured as a surrogate for successful implementation. Results71 patients were entered into ERP and compared to 98 baseline patients (non-ERP). Over eight months, compliance improved from 67% to 85%. However, compliance remained lower among postoperative variables (52% - 82%). The median length of stay was educed by 2 days (p = 0.01). There was a trend towards reduction in readmissions, hospital acquired conditions, mean direct variable charge and an improvement in patient experience (Press Ganey) outcomes among the ERP patients compared to non-ERP patients. DiscussionReal time monitoring of NSQIP ERP variables provides a structure for ERP implementation. As more programs engage in NSQIP, this workflow may become a key means for improving patient outcomes and safety.