NEW YORK (Reuters Health) – Implementing enhanced-recovery protocols (ERPs) is associated with reduced length of stay (LOS) and complication risk after colectomy, a new pilot study in 15 U.S. hospitals confirms.
ERPs are perioperative care plans based on evidence-based best practices for improving surgical outcomes, Dr. Julia R. Berian of the University of Chicago and her colleagues explain in JAMA Surgery, online December 20. These protocols aim to improve recovery in surgical patients by minimizing physiologic stress, they add, and have been shown in several studies to reduce LOS and morbidity.
Despite evidence for their benefits, implementation of ERPs is “slow and challenging,” the researchers note. The American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP) launched the Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot in 2014 to help facilitate ERP implementation.
In the new study, Dr. Berian and her team looked at nearly 5,000 colectomies performed at ERIN pilot hospitals from 2013 to 2015, comparing outcomes before and after ERP implementation. A cohort of 9,950 propensity-matched colectomy patients treated at non-ERIN hospitals served as controls.
At the ERIN hospitals, mean LOS after colectomy declined from 6.9 days to 5.2 days after ERP implementation, while for control patients LOS went from 6.4 days to 6.0 days during the same time span. After risk adjustment, the pilot program was associated with a significant 1.1-day decrease in LOS compared to the control group.
There were no changes before or after implementation in readmission rates. Serious morbidity or mortality occurred in 14.1% of the pilot hospital patients before implementation and 10.5% afterwards (P<0.001).
“The ERIN pilot study included hospitals of various sizes, indicating that both small and large hospitals can successfully decrease LOS with implementation of an ERP,” Dr. Berian and colleagues write.
The American College of Surgeons, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and the Agency for Healthcare Research and Quality have established a program to provide over 750 hospitals with resources for implementing ERPs, the researchers note.
“The program is one opportunity for hospitals seeking implementation guidance,” they add. “Whichever implementation strategy is selected, we strongly believe that surgeon engagement and leadership in such initiatives are critical to sustained success.”
It is not clear that the success of the current program is replicable, Dr. Scott E. Regenbogen and Dr. Justin B. Dimick of the University of Michigan, Ann Arbor, note in an accompanying editorial.
“The pilot hospitals were handpicked because they were high outliers for length of stay before the study intervention,” they note. “Therefore, some of their improvements could have resulted, in part, from regression back to the mean after a period of unusually poor results.”
Many barriers exist to implementing ERPs, the editorialists add. “To achieve practice change on a larger scale, for ERPs and other interventions, leaders in surgical quality improvement will need to become fluent in implementation science and address these barriers head-on,” they conclude.
Dr. Berian was not available for an interview by press time.
SOURCE: http://bit.ly/2zMevgP and http://bit.ly/2zKLjql
JAMA Surg 2017.
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