D. S. Urias1, J. Di Como1, M. Marley1, T. Tersine1, W. Fritz1, R. Dumire1 1Conemaugh Memorial Medical Center,Johnstown, PA, USA
Introduction: The evidence on the success of enhanced recovery pathways (ERP) at small and large medical facilities is robust. ERP addresses the surgical stress and postoperative physiology of patients undergoing surgery and has resulted in faster recovery, shorter hospital stay, decreased costs, and improved quality of life. The implementation of these types of protocols can be lengthy, complex, and costly. Therefore small private community hospitals with limited resources and limited experience with these methods find implementation a challenge. Through a quality improvement process, a resident run team established an ERP for elective colorectal surgeries with the goal of mirroring the outcomes reported in the literature.
Methods: We conducted an observational analysis of patients who underwent elective colon resection surgery from May 2016 through July 2017 and were placed on an ERP at our 453 bed private, rural, community hospital. This group was compared to patients that underwent this surgery prior to ERP implementation from January 2015 through April 2016. Implementing the ERP included shifting the paradigms of private practicing surgeons and anesthesiologists, anesthetists, nursing staff and pharmacists, thus convincing them to adopt the new pathway. Administrators, physicians, residents and nurses were educated on the ERP through a series of board committee meetings, group lectures, and countless direct encounters which led to its execution. Outcomes and complications that were compared included length of stay, readmission rate, time to ambulation, flatus, and first bowel movement, surgical site infections (SSI), and cost.
Results: Sixty-nine pre-ERP patients (54% male) were compared with sixty ERP patients (57% male). The ratio of open to laparoscopic procedures was 61:8 pre versus 31:29 for the ERP group. The median length of stay was decreased from 5 to 3 days (P = .0005) with a readmission rate of 15.9% vs 8.3% (P = .190). The median time to ambulation decreased from 2 days to 1 (P = 0005). Patients reported flatus sooner, the median was reduced from 3 to 2 days (P = .0005). The median time to first bowel movement also decreased from 3 days to 1 (P = .0005). SSI rate was decreased from 8.7% in the pre ERP (6 SSI – 5 intra-abdominal (IAB) and 1 superficial (SIP)) to 3.3% (2 SSI – 1 IAB and 1 SIP) in the ERP group (P = .208). Based on preliminary cost data, the mean direct cost of stay per patient is expected to hold at a decrease of approximately $2,000.
Conclusion: Despite the strong evidence of ERP, considerable time and effort was required to overcome organizational inertia and individual bias due to long-standing beliefs of the healthcare team. Adoption of ERP was achieved through persistent education of all team members; the excellent results confirm its acceptance and has stamped its placement in perioperative management of colorectal surgery patients.