Enhanced Recovery after Surgery recommendations that most impact patient care: A multi-institutional, multidiscipline analysis in the United States.

BACKGROUND: Compliance to the entire Enhanced Recovery after Surgery (ERAS) protocol improves surgical recovery, where higher compliance improves outcomes. However, specific items may predict improved recovery more than others. Studies have evaluated the impact of individual ERAS recommendations though they are either single center, not based in the United States (US), or focus on colorectal procedures only. This study aims to evaluate compliance on surgical outcomes in two large healthcare systems in the US across four surgery types. METHODS: Compliance to individual recommendations, limited patient characteristics, and outcomes data from two US ERAS Centers of Excellence (CoE) for hepatectomy, pancreatectomy, radical cystectomy, and head and neck (HN) resections were evaluated. Outcomes included 30-day Clavien-Dindo≥3, readmission, mortality, and length of stay (LOS). Multivariate regressions were performed as appropriate for the data for each surgery type. Clavien≥3 was included to control for severity of complications, and the CoE variable was force-retained. RESULTS: A total of 2886 records were analyzed. Controlling for CoE and severity of patient complications, early removal of Foley catheter was associated with significant reductions in LOS in the liver, pancreas, and HN procedures and reductions in complications in the liver and pancreas. Limited use of NG tubes reduced LOS in the pancreas and complications in urology. Oral carbohydrate loading reduced LOS in the pancreas, and patient education reduced mortality in HN patients. CONCLUSIONS: This study reports the effect of ERAS compliance on outcomes, by surgery type, in a multi-institutional US setting. Future studies should validate these findings and consider surgery-specific predictive models comprised of individual ERAS recommendations in real-world applications.

Impact of Multidisciplinary Audit of Enhanced Recovery After Surgery (ERAS)® Programs at a Single Institution.

BACKGROUND: As Enhanced Recovery After Surgery (ERAS®) programs expand across numerous subspecialties, growth and sustainability on a system level becomes increasingly important and may benefit from reporting multidisciplinary and financial data. However, the literature on multidisciplinary outcome analysis in ERAS is sparse. This study aims to demonstrate the impact of multidisciplinary ERAS auditing in a hospital system. Additionally, we describe developing a financial metric for use in gaining support for system-wide ERAS adoption and sustainability. METHODS: Data from HPB, colorectal and urology ERAS programs at a single institution were analyzed from a prospective ERAS Interactive Audit System (EIAS) database from September 2015 to June 2019. Clinical 30-day outcomes for the ERAS cohort (n = 1374) were compared to the EIAS pre-ERAS control (n = 311). Association between improved ERAS compliance and improved outcomes were also assessed for the ERAS cohort. The potential multidisciplinary financial impact was estimated from hospital bed charges. RESULTS: Multidisciplinary auditing demonstrated a significant reduction in postoperative length of stay (LOS) (1.5 days, p < 0.001) for ERAS patients in aggregate and improved ERAS compliance was associated with reduced LOS (coefficient - 0.04, p = 0.004). Improved ERAS compliance in aggregate also significantly associated with improved 30-day survival (odds ratio 1.04, p = 0.001). Multidisciplinary analysis also demonstrated a potential financial impact of 44% savings (p < 0.001) by reducing hospital bed charges across all specialties. CONCLUSIONS: Multidisciplinary auditing of ERAS programs may improve ERAS program support and expansion. Analysis across subspecialties demonstrated associations between improved ERAS compliance and postoperative LOS as well as 30-day survival, and further suggested a substantial combined financial impact.

Qualities and characteristics of successfully matched North American HPB surgery fellowship candidates.

BACKGROUND: Hepato-pancreato-biliary (HPB) fellowships in North America are difficult to secure with an acceptance rate of 1 in 3 applicants. Desirable characteristics in an HPB surgery applicant have not been previously reported. This study examines the perceptions of trainees and HPB program directors with regards to positive attributes in applicants for HPB fellowships. METHODS: Parallel surveys were distributed by email with a web-link to current and recent HPB fellows in North America (from the past 5 years) with questions addressing the following domains: surgical training, research experience, and mentorship. A similar survey was distributed to HPB fellowship program directors in North America requesting their opinion as to the importance of these characteristics in potential applicants. RESULTS: 32 of 60 of surveyed fellows and 21 of 38 of surveyed program directors responded between November 2014-February 2015. Fellows overall came from fairly diverse backgrounds (13/32 were overseas medical graduates) about one third of respondents having had some prior research experience. Program directors gave priority to the applicant's interview, curriculum vitae, and their recommendation letters (in order of importance). Both the surveyed fellows and program directors felt that the characteristics most important in a successful HPB fellowship candidate include interpersonal skills, perceived operative skills, and perceived fund of knowledge. CONCLUSION: Results of this survey provide useful and practical information for trainees considering applying to an HPB fellowship program.

Enhanced Recovery After Surgery® in Octogenarians Undergoing Hepatopancreatobiliary Surgery.

Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80 years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Patients ≥80 years old in a single HPB ERAS program (September 2015-July 2018) were prospectively tracked in the ERAS Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, P=.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions.

Novel use of REDCap to develop an advanced platform to display predictive analytics and track compliance with Enhanced Recovery After Surgery for pancreaticoduodenectomy.

BACKGROUND: Prediction models are increasingly being used with clinical practice guidelines to inform decision making. Enhanced Recovery After Surgery (ERAS®) protocols are standardized care pathways that incorporate evidence-based practices to improve patient outcomes. Predictive analytics incorporated within a data management system, such as Research Electronic Data Capture (REDCap), may help clinicians estimate risk probabilities and track compliance with standardized care practices. METHODS: Predictive models were developed from retrospective data on 400 patients who underwent pancreaticoduodenectomy from 2008 through 2014. The REDCap was programmed to display predictive analytics and create a data tracking system that met ERAS guidelines. Based on predictive scores for serious complication, 30-day readmission, and 30-day mortality, we developed targeted interventions to decrease readmissions and postoperative laboratory tests. RESULTS: Predictive models demonstrated a receiver-operating characteristic area (ROC) ranges of 641-856. After implementing the REDCap platform, the readmission rate for high-risk patients decreased 15.8% during the initial three months following ERAS implementation. Based on predictive outputs, patients with a low-risk score received a limited set of postoperative laboratory tests. Targeted interventions to decrease hospital readmission for high-risk patients included home care orders and post-discharge instructions. CONCLUSIONS: The REDCap platform offers hospitals a practical option to display predictive analytics and create a data tracking program that meets ERAS guidelines. Prediction models programmed into REDCap offer clinicians a support tool to assess the probability of patient outcomes. Risk calculations based on predictive scores enabled clinicians to titrate postoperative laboratory tests and develop post-discharge home care orders.