Enhanced recovery protocols for elective colectomy shortened length of stay (LOS) by more than a day and decreased complications without increasing readmissions, at 15 hospitals in a pilot study of the Enhanced Recovery in National Surgical Quality Improvement Program.

Guidance from experts, engaged multidisciplinary team leadership, continuous data collection and auditing, and collaboration across institutions were all key to success. “The pilot may serve to inform future implementation efforts across hospitals varied in size, location, and resource availability,” investigators led by Julia R. Berian, MD, a surgery resident at the University of Chicago, wrote in a study published online in JAMA Surgery .

The American College of Surgeons launched the Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) several years ago to help hospitals develop enhanced recovery protocols (ERPs), standardized perioperative care plans to improve outcomes. ERIN provided the 15 hospitals with experts in implementation, sample patient education materials and order sets, and opportunities for personnel to share ideas and trouble shoot through workshops and monthly conference calls. Each hospital formed a steering committee with surgery, anesthesia, and nursing leaders; and ERIN helped them to track protocol adherence and outcomes.

The program suggested 13 measures aimed at improved pain control, reduced gut dysfunction, and early nutrition and physical activity. Recommendations included shorter fluid fasts and better preop patient counseling; discontinuation of IV fluids and mobilization of patients within 24 hours of surgery; and solid diets within 24-48 hours.

The measures weren’t mandatory; each hospital tailored its protocols, and timing of implementation was at their discretion.

The report didn’t name the 15 hospitals, but they varied by size and academic status. Hospitals were selected for the program because they were outliers on elective colectomy LOS. The study ran during 2013-2015.

There were 3,437 colectomies at the hospitals before implementation, and 1,538 after. Results were compared with those of 9,950 colectomies over the study period at hospitals not involved in the efforts. Emergency and septic cases were excluded.

ERPs decreased mean LOS by 1.7 days, from 6.9 to 5.2 days. After taking patient characteristics and other matters into account, the adjusted decrease was 1.1 days. LOS fell by 0.4 days in the control hospitals (P less than .001).

Serious morbidity or mortality in the ERP hospitals decreased from 485 cases (14.1%) before implementation to 162 (10.5%) afterward (P less than .001); there was no change in the control hospitals. After implementation, serious morbidity or mortality was significantly less likely in ERP hospitals (adjusted odds ratio, 0.76; 95% confidence interval, 0.60-0.96).

Meanwhile, there was no difference in readmission rates before and after implementation.

“The ERIN pilot study included hospitals of various sizes, indicating that both small and large hospitals can successfully decrease LOS with implementation of an ERP. … Regardless of resource limitations, small hospitals may have the advantage of decreased bureaucracy and improved communication and collaboration across disciplines. … We strongly believe that surgeon engagement and leadership in such initiatives are critical to sustained success,” the investigators wrote.

The ACS; Johns Hopkins’ Armstrong Institute for Patient Safety and Quality, Baltimore; and the Agency for Healthcare Research and Quality have recently launched the “ Improving Surgical Care and Recovery ” program to provide more than 750 hospitals with tools, experts, and other resources for implementing ERPs. “The program is one opportunity for hospitals seeking implementation guidance,” the investigators noted.

Dr. Berian reported receiving salary support from the John A. Hartford Foundation. Her coinvestigators reported receiving grant or salary support from the foundation and the Agency for Healthcare Research and Quality. One investigator reported relationships with a variety of drug and device companies.

SOURCE: Berian J et. al. JAMA Surg. 2017 Dec 20. doi: 10.1001/jamasurg.2017.4906


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