Development and Impact of an Institutional Enhanced Recovery Program on Opioid Use, Length of Stay, and Hospital Costs Within an Academic Medical Center: A Cohort Analysis of 7774 Patients.

BACKGROUND: Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care. METHODS: Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model. RESULTS: There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period. CONCLUSIONS: Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.

Non-invasive, minute-to-minute estimates of systemic arterial pressure and pulse pressure variation using radial artery tonometry.

The Tensys T-line uses tonometry to reproduce the arterial blood pressure tracing non-invasively. The purpose of this study was to assess the agreement between estimates of the T-line and an intra-arterial catheter (for both mean arterial pressure [MAP] and pulse pressure variation [PPV]) in the setting of spine surgery. Continuous blood pressure data were collected for 7507 minutes from 25 patients. Five increasingly aggressive T-line filters were applied. The mean bias for mean, diastolic and systolic blood pressure ranged from 3.4-6.4, 3.1-7.1 and 0.1-0.8 mmHg and 6.5-11.8% for PPV. Ninety-five per cent confidence intervals for mean, diastolic and systolic blood pressure ranged from 24-28, 23.1-24.7 and 33.4-35.6 mmHg for 14-21% for PPV. The limits of agreement preclude the use of the T-line for reliable estimation of MAP or PPV in spine surgery.