IMPORTANCE Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. OBJECTIVE To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. DESIGN, SETTING, AND PARTICIPANTS A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. EXPOSURES A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. MAIN OUTCOMES AND MEASURES The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. RESULTS The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46–0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45–0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03–0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06–1.44; P = .007). CONCLUSIONS AND RELEVANCE Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.
INTRODUCTION: Enhanced Recovery After Surgery (ERAS) programs are evidence-based care pathways that focus on optimizing pain control, nutrition, fluids, and mobility. We evaluated implementation of a multi-faceted ERAS program among a cesarean section surgical population within Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system. We compared process measures before and after ERAS implementation at two pilot hospitals. METHODS: We evaluated changes in perioperative pain management (morphine equivalents and multimodal analgesics), mobility (early ambulation within 12 hours) and nutrition (early feeding within 12 hours), from pre-Implementation (March 2015-August 2015, n=1390 cesarean patients) to post-Implementation (March 2016-August 2016, n=1471 cesarean patients) of the multifaceted ERAS program. All urgent and elective cases were included. We quantified these metrics based on medication administration records, preoperative checklists, and/or nursing shift assessments recorded in the EMR. RESULTS: Process metrics among ERAS patients demonstrated significant changes between pre- and post-Implementation phases. The rate of early ambulation increased from 33% to 51% (p<0.001), early postoperative resumption of nutrition increased from 17% to 57% (p<0.001), and opioid consumption decreased significantly from 13.1 mg morphine equivalents to 7.7 mg (p<0.001), while the use of multimodal analgesics increased from 5% to 87% (p<0.001). CONCLUSION: ERAS program implementation successfully altered the process-of-care metrics for cesarean section surgical patients across two pilot hospitals. Further research is needed to determine the impact of ERAS implementation on complications and other outcomes following surgery among women undergoing cesarean sections.
Opioids are a cornerstone of surgical pain management; however, opioid exposures during healthcare may also persist into long-term use. 1-3 Although multidisciplinary protocols designed to improve surgical recovery-enhanced recovery after surgery (ERAS) programs 4-6-can reduce the inpatient use of opioids, their impact on longer term use is poorly understood. We evaluated how ERAS program implementation at 20 hospitals within Kaiser Permanente Northern California (KPNC) impacted postsurgical opioid use up to 180 days after surgery. METHODS This study was approved by the KPNC Institutional Review Board. In 2014, KPNC implemented an ERAS program targeting 2 populations-elective colorectal and nonelective hip fracture surgical patients-which altered care processes, reduced inpatient opioid use, and improved outcomes when compared with contemporaneous comparator patients (elective abdominal and emergent orthopedic surgery, respectively). 4,7 After ERAS implementation, hip fracture patients typically received the following nonopioid adjuncts: a peripheral nerve block, scheduled intravenous acetaminophen, and optional celecoxib. Colorectal surgery patients typically received scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, local anesthetics, and optional gabapentin. Before and after ERAS implementation, we assessed patients' ongoing opioid use after 7, 30, 90, and 180 days and through 365 days after surgery to assess whether implementation was associated with decreased postoperative use based on medication dispensing records from KPNC pharmacies. We used generalized linear models adjusted for age, comorbid disease burden, and opioid use in the prior 90 days to estimate the impact of ERAS on post-180-day opioid use.
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