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Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program

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Abstract

Introduction

Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection.

Methods

Prospectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0–100). Regression analyses were adjusted for potential confounders.

Results

A total of 347 patients were included in the study. Median primary LOS was 4 days (IQR 3–7). Patients were adherent to median 18 (IQR 16–20) elements. A total of 156 (45 %) patients had successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0–22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, p < 0.001), LOS (11 % reduction for every additional element, p < 0.001), 30-day postoperative morbidity (OR 0.78, p < 0.001), and the CCI (17 % reduction, p < 0.001). Laparoscopy (OR 4.32, p < 0.001), early mobilization out of bed (OR 2.25, p = 0.021), and early termination of IV fluid infusion (OR 2.00, p = 0.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity.

Conclusions

Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.

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References

  1. Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248:189–198

    Article  PubMed  Google Scholar 

  2. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O, Enhanced Recovery After Surgery Society fPC, European Society for Clinical N, Metabolism, International Association for Surgical M, Nutrition (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS((R))) Society recommendations. World J Surg 37:259–284

    Article  CAS  PubMed  Google Scholar 

  3. Gianotti L, Beretta S, Luperto M, Bernasconi D, Valsecchi MG, Braga M (2014) Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target? Int J Colorectal Dis 29:329–341

    Article  PubMed  Google Scholar 

  4. Birkmeyer JD, Dimick JB, Birkmeyer NJ (2004) Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg 198:626–632

    Article  PubMed  Google Scholar 

  5. Bakker N, Cakir H, Doodeman HJ, Houdijk AP (2015) Eight years of experience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery 157:1130–1136

    Article  PubMed  Google Scholar 

  6. Eras Compliance Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261:1153–1159

    Article  Google Scholar 

  7. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J, Enhanced Recovery After Surgery Study G (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146:571–577

    Article  PubMed  Google Scholar 

  8. Larson DW, Lovely JK, Cima RR, Dozois EJ, Chua H, Wolff BG, Pemberton JH, Devine RR, Huebner M (2014) Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. Br J Surg 101:1023–1030

    Article  CAS  PubMed  Google Scholar 

  9. Simpson JC, Moonesinghe SR, Grocott MP, Kuper M, McMeeking A, Oliver CM, Galsworthy MJ, Mythen MG, National Enhanced Recovery Partnership Advisory B (2015) Enhanced recovery from surgery in the UK: an audit of the enhanced recovery partnership programme 2009–2012. Br J Anaesth 115:560–568

    Article  CAS  PubMed  Google Scholar 

  10. Carli F, Charlebois P, Baldini G, Cachero O, Stein B (2009) An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth 56:837–842

    Article  PubMed  Google Scholar 

  11. Lee L, Mata J, Ghitulescu GA, Boutros M, Charlebois P, Stein B, Liberman AS, Fried GM, Morin N, Carli F, Latimer E, Feldman LS (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262:1026–1033

    Article  PubMed  Google Scholar 

  12. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:1453–1457

    Article  Google Scholar 

  13. Kolozsvari NO, Capretti G, Kaneva P, Neville A, Carli F, Liberman S, Charlebois P, Stein B, Vassiliou MC, Fried GM, Feldman LS (2013) Impact of an enhanced recovery program on short-term outcomes after scheduled laparoscopic colon resection. Surg Endosc 27:133–138

    Article  PubMed  Google Scholar 

  14. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  CAS  PubMed  Google Scholar 

  15. Tekkis PP, Prytherch DR, Kocher HM, Senapati A, Poloniecki JD, Stamatakis JD, Windsor AC (2004) Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg 91:1174–1182

    Article  CAS  PubMed  Google Scholar 

  16. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N (1999) A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 91:693–700

    Article  CAS  PubMed  Google Scholar 

  17. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7

    Article  PubMed  Google Scholar 

  18. Baldini G, Fawcett WJ (2015) Anesthesia for colorectal surgery. Anesth Clin 33:93–123

    Article  Google Scholar 

  19. Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, Watcha M, Chung F, Angus S, Apfel CC, Bergese SD, Candiotti KA, Chan MT, Davis PJ, Hooper VD, Lagoo-Deenadayalan S, Myles P, Nezat G, Philip BK, Tramer MR (2014) Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 118:85–113

    Article  PubMed  Google Scholar 

  20. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  PubMed Central  Google Scholar 

  21. Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery. Surg Laparosc Endosc Percutaneous Tech 23:259–265

    Article  Google Scholar 

  22. Vittinghoff E, McCulloch CE (2007) Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 165:710–718

    Article  PubMed  Google Scholar 

  23. Green SB (1991) How many subjects does it take to do a regression analysis. Multivar Behav Res 26:499–510

    Article  CAS  Google Scholar 

  24. Glantz SA, Slinker BK (1990) Primer of applied regression and analysis of variance. McGraw-Hill, Health Professions Division, New York

    Google Scholar 

  25. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38:1531–1541

    Article  PubMed  Google Scholar 

  26. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug A, Kehlet H, Ljungqvist O, Fearon KC, von Meyenfeldt MF (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94:224–231

    Article  CAS  PubMed  Google Scholar 

  27. Fawcett WJ, Baldini G (2015) Optimal analgesia during major open and laparoscopic abdominal surgery. Anesthesiol Clin 33:65–78

    Article  PubMed  Google Scholar 

  28. Dimick JB, Ghaferi AA (2015) Hospital readmission as a quality measure in surgery. JAMA 313:512–513

    Article  CAS  PubMed  Google Scholar 

  29. Neville A, Lee L, Antonescu I, Mayo NE, Vassiliou MC, Fried GM, Feldman LS (2014) Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 101:159–170

    Article  CAS  PubMed  Google Scholar 

  30. Fiore JF Jr, Faragher IG, Bialocerkowski A, Browning L, Denehy L (2013) Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery. World J Surg 37:2927–2934

    Article  PubMed  Google Scholar 

  31. Hubner M, Blanc C, Roulin D, Winiker M, Gander S, Demartines N (2015) Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg 261:648–653

    Article  PubMed  Google Scholar 

  32. Keller DS, Ermlich BO, Schiltz N, Champagne BJ, Reynolds HL Jr, Stein SL, Delaney CP (2014) The effect of transversus abdominis plane blocks on postoperative pain in laparoscopic colorectal surgery: a prospective, randomized, double-blind trial. Dis Colon Rectum 57:1290–1297

    Article  PubMed  Google Scholar 

  33. van Bree SH, Vlug MS, Bemelman WA, Hollmann MW, Ubbink DT, Zwinderman AH, de Jonge WJ, Snoek SA, Bolhuis K, van der Zanden E, The FO, Bennink RJ, Boeckxstaens GE (2011) Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology 141:872–880

    Article  PubMed  Google Scholar 

  34. Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, Bonjer HJ, Bemelman WA, Cuesta MA (2012) Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg 255:216–221

    Article  CAS  PubMed  Google Scholar 

  35. Kennedy RH, Francis EA, Wharton R, Blazeby JM, Quirke P, West NP, Dutton SJ (2014) Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. J Clin Oncol 32:1804–1811

    Article  PubMed  Google Scholar 

  36. Convertino VA (1997) Cardiovascular consequences of bed rest: effect on maximal oxygen uptake. Med Sci Sports Exerc 29:191–196

    Article  CAS  PubMed  Google Scholar 

  37. Castelino T, Fiore JF Jr, Niculiseanu P, Landry T, Augustin B, Feldman LS (2016) The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review. Surgery 59:991–1003

    Article  Google Scholar 

  38. Francis NK, Mason J, Salib E, Allanby L, Messenger D, Allison AS, Smart NJ, Ockrim JB (2015) Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme. Colorectal Dis 17:O148–O154

    Article  CAS  PubMed  Google Scholar 

  39. Lawrence JK, Keller DS, Samia H, Ermlich B, Brady KM, Nobel T, Stein SL, Delaney CP (2013) Discharge within 24–72 h of colorectal surgery is associated with low readmission rates when using enhanced recovery pathways. J Am Coll Surg 216:390–394

    Article  PubMed  Google Scholar 

  40. Day RW, Fielder S, Calhoun J, Kehlet H, Gottumukkala V, Aloia TA (2015) Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement. Br J Surg 102:1594–1602

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Keller DS, Bankwitz B, Woconish D, Champagne BJ, Reynolds HL Jr, Stein SL, Delaney CP (2014) Predicting who will fail early discharge after laparoscopic colorectal surgery with an established enhanced recovery pathway. Surg Endosc 28:74–79

    Article  PubMed  Google Scholar 

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Acknowledgments

We are indebted to Berson Augustin, BSc, for his effort in collecting data, and to Debbie Watson, BSc, coordinator of the Mcgill University Health Centre ERP for all her work.

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Authors and Affiliations

  1. Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada

    Nicolò Pecorelli, Olivia Hershorn, Julio F. Fiore Jr. & Liane S. Feldman

  2. Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada

    Gabriele Baldini & Franco Carli

  3. Department of Surgery, McGill University Health Centre, Montreal, QC, Canada

    Barry L. Stein, A. Sender Liberman, Patrick Charlebois & Liane S. Feldman

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  1. Nicolò Pecorelli
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  2. Olivia Hershorn
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Correspondence to Liane S. Feldman.

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Disclosures

Nicolò Pecorelli, Olivia Hershorn, Gabriele Baldini, Julio F. Fiore Jr., Barry L Stein, A Sender Liberman, Patrick Charlebois, and Francesco Carli have no conflicts of interests or financial ties to disclose. Liane S. Feldman is the recipient of an unrestricted educational grant from Medtronic.

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Pecorelli, N., Hershorn, O., Baldini, G. et al. Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc 31, 1760–1771 (2017). https://doi.org/10.1007/s00464-016-5169-2

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