ENHANCED RECOVERY PATHWAY FAILURES
Frank Gleason*, Emily B. Malone, Samantha Baker, Carl Johnson, Joshua Richman, Melanie Morris, Gregory D. Kennedy
General Surgery, University of Alabama at Birmingham, Birmingham, AL
INTRODUCTION: The incorporation of Enhanced Recovery Pathways (ERP) into surgical care has decreased hospital length-of-stay and decreased hospital cost without increasing complications or readmission rates. However, not all patients realize these benefits. The purpose of this study is to identify factors associated with ERP failure. We hypothesized that postoperative complications would result in failure of ERP.
METHODS: Patients undergoing elective surgery under ERP from January 2016 to March 2018 at a single Veterans Affairs Hospital were included. Demographic and procedural information was collected through Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients undergoing emergent surgery or who had an in-hospital mortality were excluded. Patients were stratified into ERP failure or non-failure groups. ERP failure was defined as an observed postoperative length of stay (pLOS) that was at least 1-day greater than the expected pLOS calculated by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator. Patient demographics, surgery characteristics, and complication rates were compared across groups using Chi-square, Fisher's exact, and Wilcoxon rank-sum tests.
RESULTS: Of 117 ERP patients, 87 (74%) succeeded with ERP and 30 (26%) failed ERP. Of those who succeeded with ERP, 63% were white (n=55), 34% were African American (n=30), and 96% were male (n=84). Median postoperative length of stay for those who succeeded was 3 days. Among those who failed ERP, 46% (n=14) were white, 50% (n=15) were African American, and 90% (n=27) were male. Median length of stay for those who failed ERP was 12 days. There were no significant differences in comorbidities between the two groups. Failure of ERP was associated with the development of 1 or more VASQIP defined complications in 50% of patients (p<0.01). Of all postoperative complications examined, only deep organ space surgical site infection (SSI) was significantly associated with ERP failure (p<0.01). There was no significant association between urinary tract infection, wound dehiscence, or superficial SSI with ERP failure.
CONCLUSION: The development of postoperative complications, specifically deep organ space SSI was associated with failure of ERP. The early identification and treatment of deep organ space SSI is one opportunity for improved patient care for those who deviate from standard recovery.
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