Improving Colectomy Outcomes in the Enhanced Recovery In NSQIP (ERIN) Pilot Julia R. BerianMD; Kristen A. Ban MD; Sanjay MohantyMD,MS; Jennifer L. ParuchMD,MS; Clifford Y. KoMD,MS,MSHS; Julie K. Thacker MD; Liane S. Feldman MD
Disclosure James C. Thompson Geriatric Surgery Research Fellow, supported by the John A. Hartford Foundation
Colectomy: Morbidity, mortality and excess hospital days Prioritizing quality improvement in general surgery. Schilling, Dimick, Birkmeyer JACS 2008. 207(5):698-704
Healthcare costs a lot
And it takes longer to recover than we thought Lawrence et al. JACS (2004) 199:762-772
K. Aston Five Silos 2014
Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized
Enhanced Recovery Integrated, evidence-based, multi-modal, interdisciplinary care Targeted interventions along the continuum of surgical care Decreases surgical stress Improves outcomes Decreases variability of care Decreases costs
Methods: Enhanced Recovery In NSQIP (ERIN) Pilot 16 ACS NSQIP hospitals, voluntary engagement (Hundreds of other NSQIP hospitals using the template) Procedure: Colectomy Goal: Decrease LOS Guided implementation: monthly conference calls for collaborative experience and expert guidance Enhanced recovery protocols tailored to the hospital Data collection before and after implementation using 14 novel ERIN variables
ERIN Pilot Process Variables 1. Preadmission counseling 2. Preoperative clears until 3 hours before induction 3. Epidural anesthesia for open resections 4. Multi-modal pain management 5. Normothermia on arrival to recovery room 6. Intraoperative goal directed IVF therapy 7. PONV assessment and prophylaxis 8. Mobilization, POD 0-1, POD 1-2, and POD 2-3 9. Clear liquids provided in the first 24 hours postop 10. Solids provided in 24-48 hours postop 11.Foley removed on or before POD 1 12. IVF discontinued POD 0-1
ERIN Year 1 Site selection NSQIP session Site participation agreements (Prelim data collection) Sites selected team members Teams start weekly/monthl y meetings Materials distributed (templates, patient education, etc.) Workshop at ACS meeting Sites developed protocols and infrastructure December: -Roll out plans -Educational materials -Variable discussion Jan & Feb calls: -focus on trouble areas: patient education, preopclear fluids, multimodal pain management March focus: - normothermia goal-directed fluid therapy and multimodal antiemetic prophylaxis April: postop variables (diet, mobilization, fluids) Site updates and NSQIP planning July 24 th, 2015 NSQIP Meeting
ERIN Year 2 Data collection In person meeting at NSQIP Data call: Review of current cases 2013-2015(q1) Data update: 2013-2015(q2) Details on maintaining adherence Compliance tracking tips from NSQIP Clinical Team Sites presented their progress In-depth discussion & edits to ERIN variables Plan for data collection, with quarterly conference calls in Y2
Methods Inclusion: Procedure Targeted Colectomy cases ERIN Pilot hospitals Exclusion: Emergency cases or Preoperative Sepsis Data Source: ACS NSQIP PT Colectomy data July 2013 June 2015 Analysis: ChiSq, t-test, Mann- Whitney U Multivariable logistic regression with forward selection
Results: ERIN Colectomy N= 2523 pre- vs n = 823 post-implementation colectomies No difference Sex, preopfunctional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, steroid use for inflammatory bowel disease (IBD) Significantly more: Post-implementation white race(68 vs. 77%) congestive heart failure (CHF) (1.2 vs 2.8%), chronic obstructive pulmonary disease (COPD) (5.3 vs 7.8%), ASAClass I&II (44.7 vs 50.2%), smokers (16.7 vs 21.6%), unintentional weight loss (5.7 vs 7.7%), mechanical bowel prep use (77 vs 53%) and oral antibiotic use (68 vs 33%). Significantly fewer: bleeding disorders (6.4 vs 3.9%); preopsirs (5.4 vs 2.9%); open approach (42.3% vs 31.7%).
Results: ERIN decreases LOS AvgLOS decreased by 1.2 days (6.6 vs 5.4, p<.0001) Decreased morbidity (11% vs 14%, p =.01) No difference readmission (11% vs 11%, p=.85) Pre Post
Adjusted model for prolonged LOS Implemented Protocol, Yes vs No ASA Class, 2-Mild Disturb vs 1-No Disturb ASA Class, 3-Severe Disturb vs 1-No Disturb ASA Class, 4-Life Threat vs 1-No Disturb Postop Death or Serious Morbidity Mechanical Bowel Prep, Unk vs No Mech Bowel Prep, Yes vs No Indication, Diverticular Dz vs Cancer or Polyp Indication, IBD vs Cancer or Polyp Indication, Other vs Cancer or Polyp Approach, Hand assist vs Lap or Robotic OR 0.6 (0.5-0.8) OR 3.1 (2.4-3.9) OR 3.2 (2.3-4.4) OR 5.9 (4.8-7.5) OR 3.0 (1.3-7.6) Approach, Unplanned conversion to open vs Lap or Robotic Approach, Open vs Lap or Robotic Odds Ratio +/- 95% Confidence Interval
Summary Implementation of an enhanced recovery protocol at pilot hospitals decreased LOS 1.2 days In addition, ERIN implementation demonstrated: Decreased complications No increase in readmissions ERIN Protocol implementation decreased the risk for prolonged length of stay by 40% (OR 0.6)
Conclusions Multi-hospital collaboration and implementation of enhanced recovery has the ability to improve outcomes Given the importance of patient engagement enhanced recovery has potential to improve patient experience Enhanced recovery contributes tohigh-value health care
Acknowledgements Dr. Jeffrey Matthews Dr. Mitchell Posner Dr. Kevin Roggin Dr. Clifford Ko Dr. Kristen Ban Dr. Julie Thacker Dr. Liane Feldman Marcus Escobedo
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