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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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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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  • DOI: https://doi.org/10.1007/s00464-016-5169-2

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