A 2-Year Experience With Enhanced Recovery After Surgery: Evaluation of Compliance and Outcomes in Pancreatic Surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs reduce recovery time, length of stay (LOS), and complications after major surgical procedures. PURPOSE: We evaluated our 2-year experience with a newly implemented comprehensive ERAS program at a high-volume center after pancreatic surgery. METHODS: Outcomes, cost, and compliance metrics were assessed in 215 patients who underwent elective pancreatic surgery (pre-ERAS; n = 99; post-ERAS: n = 116). Mann-Whitney U and χ2 tests were used to evaluate continuous and categorical variables. RESULTS: There were significant decreases in LOS and cost in the post-ERAS cohorts. There were significant increases in compliance with ERAS implementation. Postoperative complication, readmission, and survival rates did not increase. CONCLUSIONS: Implementation of ERAS at a large-volume hospital may improve compliance and reduce costs and LOS without increasing adverse outcomes.

Implementing Enhanced Recovery After Surgery (ERAS) Program on a Specialty Nursing Unit.

Implementing Enhanced Recovery After Surgery (ERAS) guidelines is an effective method to standardize patient care, improve patient outcomes, and develop quality improvement projects. Completing the required ERAS Implementation Program provided by the International ERAS Society enabled the hepatopancreaticobiliary surgery team at Carolinas HealthCare System to successfully implement evidence-based practice changes for pancreaticoduodenectomy patients on an acuity-adjustable unit resulting in improved care and cost reduction.

Using a Mobile Application for Real-Time Collection of Patient-Reported Outcomes in Hepatopancreatobiliary Surgery within an ERAS® Pathway.

Patient-reported outcomes (PROs) are essential for patient-centered health care. This pilot study implemented a mobile application customized to an hepatopancreatobiliary Enhanced Recovery After Surgery (ERAS®) program-a novel environment-for real-time collection of PROs, including ERAS® pathway compliance. Patients undergoing hepatectomy, distal pancreatectomy, or pancreaticoduodenectomy through the ERAS® program were prospectively enrolled over 10 months. The application provided education and questionnaires before surgery through 30 days postdischarge. Thresholds were set for initial adoption of the application (75%), PRO response rate (50%), and patient satisfaction (75%). Daily postdischarge health checks integrated customized responses to guide out-of-hospital care. Of 165 enrolled patients, 122 met inclusion criteria. Application adoption was 93 per cent (114/122) and in-hospital engagement remained high at 88 per cent (107/122). Patients completed 62 per cent of PRO on quality of life, postoperative pain, nausea, opioid consumption, and compliance to ERAS® pathway items, including ambulation and breathing exercises. During postcharge tracking, 12 patients reported that the application prevented a phone call to the hospital and three patients reported prevention of an emergency room visit. PRO collection through this mobile device created an integrated platform for comprehensive perioperative care, patient-initiated outcome tracking with automatic reporting, and real-time feedback for process change. Improving proactive outpatient management of complex patients through mobile technology could help restructure health-care delivery and improve resource utilization for all patients.

Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery.

Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.

Perioperative Care Implementation: Evidence-Based Practice for Patients With Pancreaticoduodenectomy Using the Enhanced Recovery After Surgery Guidelines 
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BACKGROUND: Pancreatic adenocarcinoma is an aggressive cancer that carries a poor prognosis. Pancreaticoduodenectomy (PD) offers the only potential cure, but the associated morbidity is high. The Enhanced Recovery After Surgery (ERAS) evidence-based guidelines for perioperative care for PD can be used to reduce variations in practice.
. OBJECTIVES: The primary aim was to evaluate the feasibility of the ERAS guidelines for patients undergoing PD. Secondary aims were to assess length of stay (LOS), readmission within 30 days, 30-day mortality, and total surgical complication rates.
. METHODS: Guideline feasibility was evaluated by percentage completion and compliance to each of the perioperative phases of the guideline. Hospital LOS, 30-day readmission, 30-day mortality, and total surgical complication rates were compared before and after ERAS implementation. 
. FINDINGS: The ERAS guidelines were feasible and safely implemented with no change in LOS, readmission, morbidity, and mortality rates.