Background Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. Methods To improve the quality of ERAS reporting, ERASÒ USA and the ERAS Ò Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. Results The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. Conclusions The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERASrelated studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84–0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72–0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

IMPORTANCE Enhanced recovery pathways (ERPs) have the potential to reduce length of hospital stay, costs, and complications following surgery but can be challenging to implement. OBJECTIVE To examine the body of literature on ERPs to assess how authors describe barriers and facilitators of ERP implementation and identify, in aggregate, the best practices that should be considered utilizing the Consolidated Framework for Implementation Research (CFIR) to extract these elements and summarize common barriers and facilitators according to its 5 major domains: (1) intervention characteristics, (2) inner setting, (3) outer setting, (4) characteristics of the individuals, and (5) the process of implementation.EVIDENCE REVIEW A systematic review was conducted in accordance with the PRISMA statement. An ERP was defined as a bundle of multiple perioperative interventions that involve a multidisciplinary team, had a label different than traditional care, and had a formal way of measuring outcomes. Six databases (PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, PsychINFO, and Cochrane Central Register of Controlled Trials) of articles published from 1990 to November 30, 2016, were searched. Articles that were included had to address barriers and facilitators of ERP implementation and provide sufficient detail that the CFIR domain could be identified. Data were abstracted by 2 independent researchers using a standardized extraction form.FINDINGS The initial search strategy returned 4563 results; 3883 studies were eliminated by screening titles and abstracts, leaving 680 articles for full-text screening. Of these, 53 studies were included in the review. The key facilitating factors were (1) adapting the program to fit local contexts, (2) achieving and demonstrating early "wins," (3) gaining buy-in from both frontline clinicians and hospital leadership, (4) having a strong ERP team that met regularly, and (5) leveraging supporters and full-time ERP staff. The major barriers identified were (1) meeting with resistance to change from frontline clinicians, (2) not having enough resources for implementation, and (3) external factors, such as patient complexity or rural hospital location. CONCLUSIONS AND RELEVANCEMost ERP literature focuses on the efficacy, safety, or cost-effectiveness of these protocols. To promote the spread of ERP programs, more high-quality studies on the implementation process are needed.

No abstract

Intraoperative LTV ventilation in conjunction with PEEP and intermittent recruitment maneuvers is associated with significantly improved clinical pulmonary outcomes and reduction in length of hospital stay in otherwise healthy patients undergoing general surgery. Providers should consider application of all the 3 elements for a comprehensive protective ventilation strategy.

A novel ERAS protocol for open hepatectomy successfully reduced reliance on perioperative opioids without expensing adequate analgesia compared with traditional care. Patients within ERAS benefitted from application of epidural, which further reduced opioid requirements and optimized pain control without increasing complication rates. Epidurals should remain an integral part of ERAS protocols for liver resection surgery.

BackgroundMultimodal analgesia is a fundamental part of modern surgery and enhanced recovery pathways. Duloxetine, a serotonin and norepinephrine reuptake inhibitor, has been validated for the treatment of chronic neuropathic pain. The evidence for duloxetine as an adjunct for the treatment of acute postoperative pain remains controversial. We conducted a meta-analysis to determine the efficacy of duloxetine in the acute perioperative setting.MethodsA literature search was conducted in the major databases (PubMed, EMBASE and Google Scholar) for randomized controlled trials (RCTs) evaluating duloxetine compared with placebo control for acute postoperative pain. The primary outcome was postoperative pain assessed at 2, 4, 6, 24 and 48 hours time frames. Secondary outcomes included postoperative opioid administration, as well as side effects, such as postoperative nausea/vomiting (PONV), pruritus, dizziness and headache.Results574 patients (n=9 RCTs) were included in the analysis, divided between duloxetine (n=285 patients) and placebo (n=289 patients). Duloxetine use was associated with a significant reduction in pain scores as early as 4 (mean difference (MD) −0.9, 95% CI −1.33 to −0.47) and as late as 48 (MD −0.94, 95% CI −1.56 to −0.33) hours postoperatively compared with placebo. In addition, duloxetine was associated with a significant reduction in opioid administration at 24 (standardized MD (SMD) −2.24, 95% CI −4.28 to −0.19) and 48 (SMD −2.21, 95% CI −4.13 to −0.28) hours as well as a significant reduction in PONV (risk ratio 0.69, 95% CI 0.49 to 0.95, p=0.03) compared with placebo. There was no difference between groups in other side effects.ConclusionDuloxetine, a non-opioid neuromodulator, may provide efficacy for the treatment of acute perioperative pain. Additional prospective studies are required to establish optimal perioperative dosing regimens, role in the setting of a comprehensive multimodal analgesic plan and impact on chronic postsurgical pain.PROSPERO registration numberCRD42019121416

Enhanced Recovery After Surgery (ERAS) programs are transdisciplinary, evidence-based perioperative protocols that aim to standardize best practices and increase the value of delivered healthcare. Quality improvement programs such as ERAS for colorectal surgery have been linked to a reduction in rates of hospital-acquired infections (HAIs) including surgical site infection as well as a reduction in overall length of stay. Importantly, to achieve these results, hospitals must commit to fostering transdisciplinary collaboration across surgery, anesthesiology, and nursing, as well as alignment between frontline providers and hospital executives. This requires upfront investment as well as ongoing resource allocation to sustain the program but given the magnitude of the potential impact of a successful ERAS program on multiple domains of quality and safety, the investment will easily reap ongoing rewards. The purpose of this manuscript is to outline implementation and sustainability costs of an ERAS program as well as discuss the potential cost savings related to the program to further inform hospitals considering adoption of this approach to care.