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VARIABLE ADOPTION OF A POST-OPERATIVE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL FOR COLORECTAL SURGERY AT A COMMUNITY HOSPITAL
Juliane Y. Cruz*1, Gabriel Akopian2, Howard S. Kaufman2
1Surgery/GME, Huntington Hospital, Los Angeles, CA; 2Surgery, Huntington Hospital, Pasadena, CA
Background: Time to recovery of gastrointestinal function is a major factor in determining length of stay (LOS) in patients undergoing colorectal surgery. Enhanced recovery after surgery (ERAS) pathways are evidence-based protocols designed to reduce variation in process by standardizing perioperative care and have been associated with improved clinical and economic outcomes. A structural factor that may lead to variable adoption of ERAS components is an open medical staff model. In March 2013, a specific order set including the post-operative components of an ERAS pathway for colorectal surgeries became available for every surgeon to use at our open staff structured community hospital. The aim of this study was to quantify the use of the ERAS pathway components following implementation of the electronic medical records system. We also desired to determine the utilization of the ERAS pathway and the resulting impact on LOS following elective minimally invasive (MIS) colorectal surgery.
Methods: A retrospective chart review was performed on all adult patients who underwent elective MIS colorectal surgery from March 1, 2013 to December 31, 2015. Data collected included demographics, comorbidities, LOS, and whether an ERAS pathway or any of its components had been used. Chi-square, Mann-Whitney U, and Kruskal-Wallis tests were used to compare variables. A p-value of 0.05 was considered statistically significant.
Results: A total of 150 patients were identified who underwent elective MIS colorectal procedures. Only 42 patients (28%) had use of all components of the post-operative ERAS pathway, which included use of Alvimopan, early feeding, early ambulation, multi-modal pain management, and avoidance of nasogastric tubes. Patients who had initiation of the post-operative ERAS pathway had a shorter median LOS by 1 day (p=0.007) when compared to the group that did not. One or a few components of the protocol were used more frequently. A shorter LOS was also observed as more components of the protocol were used in a stepwise fashion. For patients who had 1-2, 3-4, or 5 components of the pathway used; the median LOS were 6, 5, and 4 days, respectively (p<0.001).
Conclusion: Patients undergoing elective minimally invasive colorectal surgery with the use of an ERAS protocol had a shorter median LOS by 1 day. In addition, a stepwise shorter median LOS was observed as more components of the ERAS protocol were implemented. Despite existing evidence that use of an ERAS protocol is associated with a reduction in LOS, the use of an ERAS protocol among all elective MIS colorectal cases after implementation of electronic medical records at our community hospital was variable. This variability may be attributed to individual surgeon preference. It will be necessary to examine the barriers to adoption of standardized protocols in order to improve patient outcomes.
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