Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle

Enhanced recovery after cardiac surgery program to improve patient outcomes

This article details the obstacles of implementing a cardiac-specific enhanced recovery after surgery (ERAS) program in a 919-bed not-for-profit community-based health system and the benefits of ERAS programs for different patient populations.

Laparoscopic Surgery Within an Enhanced Recovery after Surgery (ERAS) Protocol Reduced Postoperative Ileus by Increasing Postoperative Treg Levels in Patients with Right-Side Colon Carcinoma

Background

The aim of this study was to determine the effects of laparoscopic surgery within an ERAS program on outcomes and immunological function in patients with a carcinoma in the right colon.

Material/Methods

Patient data were acquired from a prospectively maintained database, and 176 patients diagnosed with right colon carcinoma with surgery were selected from the database. These patients were divided into a laparoscopic group (Lap group, n=86) and an open operation group (Open group, n=90). All patients received treatment according to a standardized ERAS protocol. We collected data on CRP levels, CD4⁺/CD8⁺ ratios, and Treg values in peripheral blood, baseline and surgical characteristics, postoperative complications, and postoperative ileus (POI).

Results

Circulating CD4⁺/CD8⁺ ratios and Treg values were decreased and CRP levels were increased in both groups after the operation. However, the values in the Lap group patients recovered much more quickly than those of patients in the Open group (P<0.05). Patients undergoing laparoscopic surgery had significantly less preoperative bleeding (P<0.01), reduced ratio of overall POI (mainly early ileus), and shorter postoperative hospital stay (P=0.03). Multivariate logistic regression analysis showed that POD1 Treg value was an independent predicator for postoperative ileus in patients with right colon carcinoma resection.

Conclusions

In patients with a carcinoma in the right colon, laparoscopic surgery within an ERAS protocol leads to better immunity preservation after surgery, and POD1 Treg value may be an independent predicator for postoperative ileus, which could, at least in part, explain the shorter hospital stay after surgery.

The Evolution of Surgical Enhanced Recovery Pathways: a Review

PURPOSE OF REVIEW

Enhanced recovery pathways are a well-defined perioperative health care program utilizing evidence-based interventions in a protocol-like manner designed to standardize techniques including drug selection and dosing to improve results and to reduce overall costs including facilitating earlier discharge from hospitals after surgery.

RECENT FINDINGS

A PubMed and World Wide Web search was performed with the following key words: enhanced recovery, surgical enhanced recovery, recovery pathways, and enhanced recovery pathways surgery. This introduction to enhanced recovery pathways reflects its 20-year history, worldwide appeal, and ever growing presence in our practices. Many clinical teams have not, as of yet, incorporated enhanced recovery pathway principles to their practices and therefore, continued evolution should include increasing outreach and formalized guidelines in the future.

Nursing Perspectives on Enhanced Recovery After Surgery

A growing body of evidence suggests that the implementation of an enhanced recovery after surgery (ERAS) clinical pathway can accelerate recovery and reduce length of stay through the use of a multimodal program that includes guidelines for optimal pain relief, stress reduction, early nutrition, and early mobilization. The article discusses the importance of the nursing body in improving institutional compliance to ERAS clinical pathway measures and describes specific nursing barriers observed in the ERAS implementation in an academic medical center.

Implementation Science in Perioperative Care

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.

The impact of enhanced recovery pathways on cost of care and perioperative outcomes in patients undergoing gastroesophageal and hepatopancreatobiliary surgery

INTRODUCTION

Enhanced recovery after surgery protocols have been increasingly adopted to standardize patient care and decrease overall costs. This study evaluated the impact of a prospectively implemented enhanced recovery after surgery protocol for patients undergoing surgery for gastroesophageal and hepatopancreatobiliary disease at an academic institution.

METHODS

Patients undergoing either hepatopancreatobiliary or gastroesophageal procedures between January 2013 and May 2017 were classified according to whether or not they were placed on an enhanced recovery after surgery protocol. Groups were compared along demographic, perioperative, outcomes, and financial variables.

RESULTS

Of a total of 377 patients, 149 were placed on an enhanced recovery after surgery protocol. There was a significant association between enhanced recovery after surgery protocol use and increased perioperative antibiotic use (98.0% enhanced recovery after surgery vs. 87.3% non-enhanced recovery after surgery, P < .001), decreased intraoperative crystalloid use (1,155 ± 705 mL enhanced recovery after surgery vs. 1,576 ± 826 non-enhanced recovery after surgery, P < .001), decreased requirement for intensive care unit stay (20.1% enhanced recovery after surgery vs. 36.4% non-enhanced recovery after surgery, P < .001), and decreased total hospital costs ($10,688.38 ± 10,518.22 vs. $15,439.22 ± 14,201.24, P < .001). On multivariable analysis, enhanced recovery after surgery protocol use was independently associated with decreased rate of intensive care unit admission (odds ratio 0.39, 95% confidence interval 0.23-0.66, P < .001).

CONCLUSION

Enhanced recovery after surgery pathways can be safely implemented in patients undergoing hepatopancreatobiliary and gastroesophageal procedures and can help standardize perioperative practices, decrease requirement for intensive care unit admission, and decrease total hospital costs.

Accelerating surgical quality improvement in Ontario through a regional collaborative: a quality-improvement study

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) collaborative in Ontario, the Ontario Surgical Quality Improvement Network (ON-SQIN), was launched in January 2015. We describe its approaches to support surgical quality improvement and examine its early impact on member hospitals.

METHODS

All Ontario hospitals that participated in the ON-SQIN and NSQIP were included in this quality-improvement study. The primary intervention was the introduction of the ON-SQIN, and the secondary interventions included a community of practice and access to quality-improvement resources and tools. Outcome measures included the level of quality-improvement capacity, collaborative-wide aggregate data on postoperative complications, and self-reported rates of surgical site and urinary tract infections.

RESULTS

Eighteen hospitals that enrolled in the ON-SQIN in 2015 reported an increase in their capacity for quality improvement after 18 months. Analysis of the collaborative-wide aggregate data in a 6-month period (14 748 surgical cases) revealed a substantial reduction of acute renal failure (relative risk 0.48, 95% confidence interval 0.25-0.95) and urinary tract infection (relative risk 0.77, 95% confidence interval 0.61-0.97). Most hospitals that targeted prevention of surgical site infection and urinary tract infection reported reduction of these occurrences during a 1-year period.

INTERPRETATION

The ON-SQIN supported the uptake of the NSQIP in Ontario hospitals and promoted targeted surgical quality-improvement initiatives, resulting in increased quality-improvement capacity and development of the community of practice. Furthermore, our early experience suggests that improvements in surgical care are being realized.

The Kaiser Permanente Northern California Enhanced Recovery After Surgery Program: Design, Development, and Implementation

Complications are common after surgery, highlighting the need for innovations that reduce postsurgical morbidity and mortality. In this report, we describe the design, development, and implementation of an Enhanced Recovery After Surgery program in the Kaiser Permanente Northern California integrated health care delivery system. This program was implemented and disseminated in 2014, targeting patients who underwent elective colorectal resection and those who underwent emergent hip fracture repair across 20 Medical Centers. The program leveraged multidisciplinary and broad-based leadership, high-quality data and analytic infrastructure, patient-centered education, and regional-local mentorship alignment. This program has already had an impact on more than 17,000 patients in Northern California. It is now in its fourth phase of planning and implementation, expanding Enhanced Recovery pathways to all surgical patients across Kaiser Permanente Northern California.

How to implement an enhanced recovery programme after colorectal surgery?

INTRODUCTION

Although the concept of enhanced recovery after surgery was introduced more than 20 years ago, its implementation in daily practice still remains difficult.

RESULTS

This article addresses bottlenecks and barriers to the development of enhanced recovery programme (ERP). Barriers to the implementation are multifactorial and are raised by the different actors of these programmes: surgeons, anaesthetists, nurses, patients. Solutions and steps that must be respected to succeed in introducing ERP in an hospital are proposed.

CONCLUSIONS

Large-scale implementation of ERP continues to face mainly lack of trust and communication. Solutions exist and are based particularly on team work and interdisciplinary collaboration.

Nutritional Therapy in Gastrointestinal Cancers

Malnutrition is the most frequent nutritional disorder in patients with gastrointestinal cancer and is associated with cachexia syndrome, worsening of prognosis, and shortened survival rate. Early nutrition screening, assessment, and intervention are able to favorably modify the clinical evolution of affected patients. The adequate provision of nutritional requirements has been associated with improvement of immunologic status, and avoidance of further complications related to poor nutritional status, surgical treatment, and anticancer therapy. In malnourished patients, the supplementation of perioperative immunonutrition might contribute to fewer infectious and noninfectious complications, shorter length of hospitalization, and improved wound healing.

Using Activity Trackers to Quantify Postpartum Ambulation

Background

Early postoperative ambulation is associated with enhanced functional recovery, particularly in the postpartum population, but ambulation questionnaires are limited by recall bias. This observational study aims to objectively quantify ambulation after neuraxial anesthesia and analgesia for cesarean delivery and vaginal delivery, respectively, by using activity tracker technology. The hypothesis was that vaginal delivery is associated with greater ambulation during the first 24 h postdelivery, compared to cesarean delivery.

Methods

Parturients having first/second cesarean delivery under spinal anesthesia or first/second vaginal delivery under epidural analgesia between July 2015 and December 2016 were recruited. Patients with significant comorbidities or postpartum complications were excluded, and participants received standard multimodal analgesia. Mothers were fitted with wrist-worn activity trackers immediately postdelivery, and the trackers were recollected 24 h later. Rest and dynamic postpartum pain scores at 2, 6, 12, 18, and 24 h and quality of recovery (QoR-15) at 12 and 24 h were assessed.

Results

The study analyzed 173 patients (cesarean delivery: 76; vaginal delivery: 97). Vaginal delivery was associated with greater postpartum ambulation (44%) compared to cesarean delivery, with means ± SD of 1,205 ± 422 and 835 ± 381 steps, respectively, and mean difference (95% CI) of 370 steps (250, 490; P &lt; 0.0001). Although both groups had similar pain scores and opioid consumption (less than 1.0 mg of morphine), vaginal delivery was associated with superior QoR-15 scores, with 9.2 (0.6, 17.8; P = 0.02) and 8.2 (0.1, 16.3; P = 0.045) differences at 12 and 24 h, respectively.

Conclusions

This study objectively demonstrates that vaginal delivery is associated with greater early ambulation and functional recovery compared to cesarean delivery. It also establishes the feasibility of using activity trackers to evaluate early postoperative ambulation after neuraxial anesthesia and analgesia.

Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery.

METHODS

All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis.

RESULTS

A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01-1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14-1.58, p < 0.001), and open operative approach (RR 1.63, 95%CI 1.28-2.09, p < 0.001). Independent factors associated with hospital readmissions included rectal surgery (RR 1.89, 95%CI 1.34-2.77, p < 0.001), formation of a stoma (RR 1.34, 95%CI 1.04-1.74, p = 0.026), and reoperation during first admission (RR 4.60, 95%CI 3.50-6.05, p < 0.001). Length of stay of 5 days or less was not associated with ER visits or readmission (RR 0.99, 95%CI 0.72-1.35 and RR 0.91, 95%CI 0.71-1.18, respectively).

CONCLUSION

Following colorectal surgery using an ERAS pathway, shortened length of stay is not associated with an increased return to the ER or hospital readmission. The majority of return visits to the hospital are ER visits not requiring readmission and the predominant reason for return are surgical site infections and wound complications.

Perioperative Outcomes From the Prospective Multicenter Least Invasive Fast-Track EVAR (LIFE) Registry

Purpose: To determine the feasibility, perioperative resource utilization, and safety of a fast-track endovascular aneurysm repair (EVAR) protocol in well-selected patients. Methods: Between October 2014 and May 2016, the LIFE (Least Invasive Fast-track EVAR) registry ( ClinicalTrials.gov identifier NCT02224794) enrolled 250 patients (mean age 73±8 years; 208 men) in a fast-track EVAR protocol comprised of bilateral percutaneous access using the 14-F Ovation stent-graft, no general anesthesia, no intensive care unit (ICU) admission, and next-day discharge. The primary endpoint was major adverse events (MAE) through 30 days. The target performance goal for the MAE endpoint was 10.4%. Results: Vascular access, stent-graft delivery, and stent-graft deployment success were 100%. A total of 216 (86%) patients completed all elements of the fast-track EVAR protocol. Completion of individual elements was 98% for general anesthesia avoidance, 97% for bilateral percutaneous access, 96% for ICU avoidance, and 92% for next-day discharge. Perioperative outcomes included mean procedure time of 88 minutes, median blood loss of 50 mL, early oral nutrition (median 6 hours), early mobilization (median 8 hours), and short hospitalization (median 26 hours). Fast-track EVAR completers had shorter procedure time (p<0.001), less blood loss (p=0.04), faster return to oral nutrition (p<0.001) and ambulation (p<0.01), and shorter hospital stay (p<0.001). With 241 (96%) of the 250 patients returning for the 30-day follow-up, the MAE incidence was 0.4% (90% CI 0.1% to 1.8%), significantly less than the 10.4% performance goal (p<0.001). No aneurysm rupture, conversion to surgery, or aneurysm-related secondary procedure was reported. There were no type III endoleaks and 1 (0.4%) type I endoleak. Iliac limb occlusion was identified in 2 (0.8%) patients. The 30-day hospital readmission rate was 1.6% overall. Conclusion: A fast-track EVAR protocol was feasible in well-selected patients and resulted in efficient perioperative resource utilization with excellent safety and effectiveness.

Cost-Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery.

METHODS

A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed.

RESULTS

Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (n = 18 ERAS, n = 9 pre-ERAS, p = 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (p = 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days, p = 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (p = 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation.

CONCLUSIONS

ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.

Compliance with Urinary Catheter Removal Guidelines Leads to Improved Outcome in Enhanced Recovery After Surgery Patients

OBJECTIVE

The objective of the study was to determine whether compliance with Enhanced Recovery after Surgery (ERAS) urinary catheter recommendations is associated with decreased urinary tract infections (UTI) and length of stay (LOS).

METHODS

Patients having colorectal surgery at 15 academic hospitals were included. Patient and outcome data were collected prospectively. The guideline recommends that urinary catheters following colonic and rectal procedures should be removed at or before 24 and 72 h, respectively.

RESULTS

Two thousand nine hundred and twenty-seven patients (1397 females and 1522 males; mean age 60.3 years) were enrolled. Small bowel or colonic procedures were performed in 1897 (64.9%) and rectal procedures in 1030 (35.2%) patients. Overall, 53.2% of patients had their catheter removed in compliance with the guidelines (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 0.8% of patients who were guideline compliant had a UTI compared to 4.1% non-compliant patients (RR 0.20, 95% CI 0.07-0.58; p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were non-compliant (RR 0.37, 95% CI 0.20-0.68; p = 0.001). Median LOS was decreased in compliant patients: 4 vs 5 days following colonic procedures (RR 0.73, 95% CI 0.66-0.82; p < 0.0001) and 5 vs 8 days following rectal procedures (RR 0.54, 95% CI 0.49-0.59; p < 0.001).

CONCLUSION

Early removal of urinary catheters is associated with a decreased risk of UTI and LOS.

Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System

Importance

Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures.

Objective

To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair.

Design, Setting, and Participants

A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system.

Exposures

A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement.

Main Outcomes and Measures

The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates.

Results

The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007).

Conclusions and Relevance

Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.

Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system

Background

Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).

Methods

ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.

Results

Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.

Conclusions

Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.

Enhanced recovery after surgery: Current research insights and future direction

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.

Achieving 90% Adoption of Clinical Practice Guidelines Using the Delphi Consensus Method in a Large Orthopedic Group

BACKGROUND

Little is known about the implementation rate of clinical practice guidelines (CPGs). Our purpose was to report on the adoption rate of CPGs created and implemented by a large orthopedic group using the Delphi consensus method.

METHODS

The draft CPGs were created before the group's annual meeting by 5 teams each assigned a subset of topics. The draft guidelines included a statement and a summary of the available evidence. Each guideline was debated in both small-group and plenary sessions. Voting was anonymous and a 75% supermajority was required for passage. A Likert scale was used to survey the patient's experience with the process at 1 week, and the Kirkpatrick evaluation model was used to gauge the efficacy of the process over a 6-month time frame.

RESULTS

Eighty-five orthopedic surgeons attended the meeting. Fifteen guidelines grouped into 5 topics were created. All passed. Eighty-six percent of attendees found the process effective and 84% felt that participating in the process made it more likely that they would adopt the guidelines. At 1 week, an average of 62% of attendees stated they were practicing the guideline as written (range: 35%-72%), and at 6 months, 96% stated they were practicing them (range: 82%-100%).

CONCLUSION

We have demonstrated that a modified Delphi method for reaching consensus can be very effective in both creating CPGs and leading to their adoption. Further we have shown that the process is well received by participants and that an inclusionary approach can be highly successful.

Value from the Patients' and Payers' Perspectives

Health care costs continue to increase, and the approach of countries and insurers is to focus on the value of the care delivered. Value is a function of quality in relation to costs. The perspective of the individual measuring value is important. Calculation of costs may include return to work if the employer's perspective is taken. The patients' perspectives include out-of-pocket expenses and work lost for both patients and potentially caregivers. The authors provide one example in the area of sleep apnea in which the anesthesiologist can provide value uniquely by being part of the team making the diagnosis.

Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure

BACKGROUND

Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates.

MATERIALS AND METHODS

We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions.

RESULTS

A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications.

CONCLUSIONS

Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.

Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study

BACKGROUND

Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children.

METHODS

Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach.

RESULTS

Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057.

CONCLUSION

Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.

Analysis of the barriers and enablers to implementing lifestyle management practices for women with PCOS in Singapore

BACKGROUND

Polycystic ovary syndrome (PCOS) is a condition that affects women of reproductive age and manifests with adverse reproductive, metabolic and psychological consequences. Evidence-based PCOS guidelines recommend lifestyle management first line for infertility. In Singapore women with PCOS can attend the PCOS Clinic at the Kandang Kerbau Women and Children's Hospital for infertility treatment. However lifestyle integration into infertility management is currently limited and barriers and enablers to progress remain unclear.

METHODS

All PCOS clinic staff undertook semi-structured interviews to investigate perceived barriers for staff and consumers for the integration of lifestyle into infertility management. This study utilised various tools including an 8P Ishikawa diagram model to identify and categorise barriers. A modified Hanlon method was then used to prioritise barriers within the Singaporean context considering organisational, cultural and financial constraints. Propriety, economics, acceptability, resources and legality (PEARL) criteria were also incorporated into this decision-making tool.

RESULTS

In the 8P model, there were five factors contributing to the 'procedure (consultations and referral processes)' barrier, one 'policy (government and hospitals)' factor, five 'place' factors, two 'product (lifestyle management programme)' barriers, two 'people (programme capacity)' factors, four 'process (integration)' factors, three 'promotion' barriers and three 'price' factors. Of the prioritised barriers, two were identified across each of 'procedures', 'place', 'product' and 'people' and four related to 'processes'. There were no barriers identified that for 'policies', 'promotion' and 'price' that can be addressed.

CONCLUSIONS

There is a clear need to integrate lifestyle into infertility management in PCOS, in line with current national and international evidence-based guidelines. The highest priority identified improvement opportunity was to develop a collaborative lifestyle management programme across hospital services. Reductions in variation of delivery and strengthening support within the lifestyle programme are other identified priorities. The strength of this study is that this is the first study to utilise a pragmatic quality improvement method for barriers identification and prioritisation in the area of lifestyle management for women with PCOS. This project identified factors that may provide easy improvements, but also identified some local factors that may be very difficult to change. The major limitation of this study is that it is only looking at the Singapore setting, so may have limited applicability to other countries. However, results from quality improvement projects are meant to be context specific.

Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons

BACKGROUND

Despite guidelines recommending restrictive red blood cell transfusion (RBCT) strategies, perioperative transfusion practices still vary significantly. To understand the underlying mechanisms that lead to gaps in practice, we sought to assess the attitudes of surgeons regarding the perioperative management of anemia and use of RBCT in patients having gastrointestinal surgery.

METHODS

We conducted a self-administered Web-based survey of general surgery staff and residents, in a network of eight academic institutions at the University of Toronto. We developed a questionnaire using a systematic approach of items generation and reduction. We tested face and content validity and test-retest reliability. We administered the survey via emails, with planned reminders.

RESULTS

Total response rate was 48.1 % (62/125). Half (51.0 %) of respondents stated that they were unlikely to conduct a preoperative anemia work-up. About 54.0 % reported ordering preoperative oral iron supplementation for anemia. Most respondents indicated using a 70 g/L hemoglobin trigger (92.0 %) for transfusion. Factors increasing thresholds above 70 g/L included cardiac comorbidity (58.0 %), acute cardiac disease (94.0 %), symptomatic anemia (68.0 %), and suspected bleeding (58.0 %). With those factors, the transfusion threshold often increased above 90 g/L. Respondents perceived RBCTs to increase the postoperative morbidity (62 %), but not to impact the mortality (48 %) and cancer recurrence (52 %). Institutional protocols (68.0 %), blood conservation clinics (44.0 %), and clinical practice guidelines (84.0 %) were believed to encourage restrictive use of RBCTs.

CONCLUSION

Self-reported perioperative transfusion practices for GI surgery are heterogeneous. Few respondents investigated preoperative anemia. Stated use of RBCT indications varied from recommendations in published guidelines for patients with symptomatic anemia. Establishing team consensus and implementing local blood management guidelines appear necessary to improve uptake of evidence-based recommendations.

Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection

Background

Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery.

Methods

An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire.

Results

There were no differences in patient or disease characteristics between pre-ERAS (42 patients) and post-ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P &lt; 0·001). Duration of hospital stay was shorter in the post-ERAS group (median 5 (i.q.r. 4–7) days versus 6 (5–7) days in the pre-ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (−US $333; −€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (−US $394; −€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation.

Conclusion

The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers.

Enhanced Recovery After Surgery: It's Time to Change Practice!

Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes.

Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.

METHODS

A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.

RESULTS

Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.

CONCLUSIONS

Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.