E. Stearns1, M. A. Plymale1, D. L. Davenport2, C. Totten1, S. Carmichael1, C. Tancula1, J. S. Roth1 1University Of Kentucky,General Surgery/Surgery/Medicine,Lexington, KY, USA 2University Of Kentucky,Surgery/Medicine,Lexington, KY, USA
Introduction: Enhanced Recovery after Surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes. Building on the previously-reported protocol for abdominal wall reconstruction (AWR) that addresses optimal pain control and acceleration of intestinal recovery, a 17-element ERAS protocol for AWR was developed. The purpose of this study was to compare short-term outcomes for patients cared for after protocol implementation to a cohort of historical controls. Process evaluation was conducted to pinpoint level of adherence to protocol details in order to identify opportunities for improvement.
Methods: After obtaining IRB approval, surgical databases were searched for AWR cases for two-years prior and eleven months after protocol implementation. The two groups were compared on characteristics including age, body mass index, comorbidities, operative details, and clinical outcomes using chi square, Fisher’s exact test or Mann Whitney U test, as appropriate. Process evaluation consisted of determining the level of adherence to protocol details at the patient, health care provider and system levels.
Results: 173 patients underwent AWR by one surgeon during the time period described (46 patients with ERAS protocol in place and 127 controls). Preoperative characteristics of age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups. Body mass index was slightly lower among ERAS patients (p = .042). Just over three-fourths of the cases in each group were CDC Wound Class 1; ERAS patients were more likely than controls to have had synthetic mesh implanted as opposed to other mesh types. In terms of clinical outcomes, ERAS patients had earlier return of bowel function (median 3 days vs. 4 days) (p = .002) and decreased incidence of superficial surgical site infection (SSI) (7% vs. 25%) (p = .004) than controls. Hospital length of stay was similar between the two groups. Protocol adherence by ERAS component ranged from a low of 54% (acceleration of intestinal recovery) to 100 % (postoperative glucose control). Protocol adherence by case varied from 55% (1 patient) to 94% (4 patients).
Conclusion: A comprehensive ERAS protocol for AWR demonstrates evidence for hastened return of bowel function and decreased incidence of SSI. Process evaluation identified specific areas of less than optimal adherence to protocol details, providing substantiation for increased education at all levels. A system-wide culture focused on enhanced recovery is needed to improve protocol adherence and subsequent patient outcomes.
