E. George1, G. Krapohl3, S. E. Regenbogen2,3 1University Of Michigan,Health Science Scholars Program,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University Of Michigan,Michigan Surgical Quality Collaborative,Ann Arbor, MI, USA
Introduction: Enhanced Recovery Protocols (ERP) are widely demonstrated to improve perioperative outcomes after colectomy, yet it remains unknown to what extent ERPs have been successfully implemented outside the high-volume and highly specialized institutions that pioneered them. Thus, we sought to quantify the extent of ERP uptake within a representative, population-based, statewide hospital collaborative, and to understand obstacles to further dissemination.
Methods: We conducted a statewide survey among 70 member hospitals of the Michigan Surgical Quality Collaborative. Through interviews with key stakeholders, we identified hospitals with full ERPs and those in the process of implementation, and described the time course of their development. Respondents named key obstacles to ERP implementation and detailed specific practices included in their protocols. Hospital characteristics were obtained from the American Hospital Association Annual Survey and compared using chi square tests for proportions.
Results: Interim results from 46 respondent hospitals (66% interim response) revealed that between 2010 and 2016, 13 (28%) hospitals fully implemented an ERP, while 22 hospitals (48%) did not. The time course of uptake is detailed in the Figure. At present, 11(24%) hospitals are still in development, but have not yet fully implemented their ERP. Hospitals with ERPs identified coordination of time and logistics of development and implementation (54%) as the most common obstacle, followed by disagreement on standard practices (15%), and nursing preferences (8%). For those without ERPs, the most common obstacles are surgeon engagement (52%), disagreement on standard practices (15%), coordination of time and logistics for development and implementation (15%), and anesthesiology preferences (12%). ERP hospitals were no more likely than non-ERP hospitals to be either teaching institutions (77% vs. 61%, p=0.50) or large hospitals with more than 300 beds (54% vs. 42%, p=0.53).
Conclusion: Despite increasing consensus around the value of ERPs for colectomy and years of emphasis among our statewide collaborative, implementation continues to be a challenge. Administrative support, logistical burden, and surgeon engagement are the most commonly reported challenges to more widespread ERP adoption. Interestingly, the likelihood of ERP implementation is no different in large academic hospitals than that of small non-academic ones. These findings suggest that broader implementation of ERP will require a three-pronged approach: improved dissemination of evidence-based standardized protocols to foster wider consensus, administrative support to incentivize the time and logistical burden of implementation, and opportunities to educate and engage surgeon leaders.
