Implementation Of Enhanced Recovery Pathways Research Articles

Framework, component, and implementation of enhanced recovery pathways.

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19). Supplementary InformationThe online version contains supplementary material available at 10.1007/s00540-022-03088-x.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis.

BACKGROUNDOver the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.AIMThe present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.METHODSA literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.RESULTSForty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.CONCLUSIONThis study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay.

There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. 494 patients underwent open pancreaticoduodenectomy - 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p=0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p<0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p=0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p=0.615). ERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.

An Enhanced Recovery Pathway after Open Pancreaticoduodenectomy Reduces Postoperative Length of Hospital Stay without Reducing Composite Length of Stay

Introduction: There is limited data regarding the use of enhanced recovery pathways (ERP) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. We asked if initially discharging patients home earlier after pancreaticoduodenectomy might result in more time spent in the hospital after initial discharge due to readmissions; thus, having no effect on overall hospitalization time after surgery. Methods: Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90-days after surgery and complications were severity graded using the Modified-Accordion-Grading-System. A retrospective analysis of patient-outcomes was compared before and after instituting ERP. 1:1 propensity-score-matching was used to compare ERP patient-outcomes to those of matched pre-ERP patients. Composite length of stay (CLOS) is defined as postoperative-length-of-hospital-stay (PLOS) plus readmission-length-of-hospital-stay within 90-days after surgery. Results: 494 patients underwent open pancreaticoduodenectomy – 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p=0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p<0.0001) compared to matched pre-ERP patients. However, overall complication rate, 30-day, and 90-day readmission rates were not significantly different between matched groups. Propensity-score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p=0.615). Conclusion: ERP may reduce PLOS, but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.

Implementation and sustainability of an enhanced recovery pathway in pediatric bladder reconstruction: Flexibility, commitment, teamwork

Although enhanced recovery pathways (ERP) provide a safe and effective way to improve the recovery of children undergoing bladder reconstruction, ERPs have not been widely adopted in pediatric urology. We describe a quality improvement initiative and outcomes after implementing a 24-element ERP at a single, freestanding children's hospital. Multiple stakeholder meetings were planned and executed, initially with pediatric practitioners with ERP experience to understand potential implementation barriers then with anesthesiologists, nurses, case managers, and other ancillary staff to draft our institution-specific ERP. A standardized order set was generated to improve ERP adherence. ERP adherence audits and cyclic performance evaluations held every 6-9 months facilitated continuous pathway refinement. Patient outcomes were compared with a pre-ERP historic cohort. Time from initial ERP planning to first implementation was 7 months. ERP was implemented in twenty consecutive patients undergoing bladder reconstruction (median age 11.3 years, range 4.1-21.1) who were compared to twenty consecutive pre-ERP patients (median age 11.4 years, range 7.7-25.1). Median post-operative length of stay (LOS) significantly decreased from 9 days (range 2-31) pre-ERP to 4 days (range 3-29) post-ERP (p<0.05). A median of 16 (range 12-19) of 24 institutional pathway elements were implemented for each patient. Balancing measures showed no significant increases in highest Clavien complication grade, readmission rate, or unplanned return to the operating room within 30 post-operative days. Implementation of ERP is feasible but requires commitment from multi-disciplinary stakeholders. While we were unable to consistently achieve 80% of the elements, we successfully implemented the pathway and improved our patients' recovery processes (indirectly reflected by a decreased post-operative LOS) with adherence to a median of 67% of elements. Our implementation and effectiveness results are specific to our center and may not be generalizable. However, our experience may offer some insight for others interested in ERP implementation and encourage initiation of their own institutional pathways. Successful ERP implementation at our hospital for children undergoing bladder reconstruction was facilitated by open communication, early stakeholder involvement, and monitoring ERP adherence. ERP implementation significantly decreased LOS without increasing post-operative complications and readmissions (Summary figure).

An enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay

Presenter: Rony Takchi MD | Washington University, St. Louis Background: There is limited data regarding the use of enhanced recovery pathways (ERP) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. We asked if initially discharging patients home earlier after pancreaticoduodenectomy might results in more time spent in the hospital after initial discharge due to readmissions; thus, having no effect on overall hospitalization time after surgery. Methods: Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes was compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. Composite length of stay (CLOS) is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. Results: 494 patients underwent open pancreaticoduodenectomy – 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p=0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p<0.0001) compared to matched pre-ERP patients. However, overall complication rate, 30-day, and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p=0.615). Conclusion: ERP may reduce PLOS, but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.

Best Practices in Data Use for Achieving Successful Implementation of Enhanced Recovery Pathway

Although enhanced recovery pathways (ERPs) have demonstrated promising results in published literature, their effectiveness has been inconsistent. The objective of this study was to identify the most important data use practices associated with successful implementation of ERPs. As part of a national ERP implementation initiative, data regarding hospitals' previous ERP implementation experience were collected. Specifically, 4 data use practices (data collection, report generation, feedback to leadership, and feedback to frontline providers) and 2 data types (process measures and outcome measures) were correlated with ERP implementation outcomes (hospital-reported success and patient outcomes from the American College of Surgeons [ACS] NSQIP data). Of 140 hospitals evaluated, 73 (52.1%) reported previous ERP implementation, with wide variations in data use practices. Of these, 33 (45.2%) reported successful implementation. Feedback of both process and outcome measure data was performed by only 15.1% of hospitals, but was associated with significantly higher likelihood of successful implementation when compared with no feedback (relative risk [RR] 2.45, 95% CI 1.69 to 3.56; p < 0.001) and feedback of only outcome measure data (RR 2.73, 95% CI 1.06 to 7.00; p= 0.037). Using ACS NSQIP data from 6,888 colorectal surgery patients from 52 hospitals with colorectal ERPs, hospital-reported success was associated with significantly lower surgical site infection rates (6.6% vs 8.1%; p= 0.011) and shorter length of stay (6.2 vs 7.0 days; p < 0.001). The most important data use practice associated with successful ERP implementation was data feedback to frontline providers of both process and outcome measures. However, this was rarely performed in a national cohort of hospitals and represents a substantial but straightforward opportunity for improvement.

Enhanced Recovery Protocol Improves Postoperative Outcomes and Minimizes Narcotic Use Following Resection for Colon and Rectal Cancer

Background: Enhanced recovery pathways (ERP) are associated with improved recovery. However, data on outcomes following the ERP implementation in colorectal cancer (CRC) are limited. We set out to study the postoperative outcomes, opioid use patterns, and cost impact for patients undergoing colon or rectal resection for cancer. Methods: A retrospective review of all elective CRC resections from January 2015 to June 2018 at a single institution was performed. Patient demographics, operative details, and postoperative outcomes were collected. Colon and rectal patients were studied separately, with comparison of pre-ERP to post-ERP patients. Results: 192 patients underwent elective colorectal resection for cancer. In January 2016, an ERP was implemented for all elective resections – 71 patients underwent surgery in the pre-ERP period (33 colon and 38 rectal) and 121 (56 colon and 65 rectal) occurred in the post-ERP period.There were differences with regard to age, gender, or BMI before or after the implementation of ERP for both groups (all p > 0.05). For both colon and rectal cancer patients, ERP reduced time to regular diet (both p < 0.05) and length of stay (colon: 3 vs. 4 days; rectal: 4 vs. 6 days; both p< 0.01). ERP patients also consumed fewer total narcotics (colon: 44 vs. 184 morphine milligram equivalents (MME), p < 0.01; rectal: 121 vs. 393 MME, p < 0.01). Conclusions: ERP use reduced length of stay and narcotic use with similar total costs and no difference in 30-day complications for both colon and rectal cancer resections.

An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy

Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions. Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions. We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05). Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.

An enhanced recovery pathway decreases duration of stay after esophagectomy

Enhanced recovery pathways (ERP) decrease morbidity and duration of stay after colorectal surgery. There is little information about their role in complex procedures, such as esophagectomy. The purpose of this study was to determine the impact of an ERP on duration of stay, complications, and readmissions after esophagectomy. Patients undergoing esophagectomy for cancer or high-grade dysplasia from June 2009 to December 2011 were identified from a prospectively maintained database. Beginning in June 2010, all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan, indications for intensive care admission, early structured mobilization, and diet and drain management. Short-term (30-day) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway. Data are expressed as median values [interquartile range]. We identified 106 patients; 47 underwent esophagectomy before ERP implementation and 59 after. Patients were similar with respect to age, gender, diagnosis, and operative time. Hospital stay was shorter in the ERP group (8 [7-17] vs 10 [9-17] days; P = .01). There were no differences in rates of complications (59% vs 62%) or readmissions (6% vs 5%). Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay, without an increase in complications or readmissions.