Implementation of an Enhanced Surgical Recovery Programme (ESRP) in gynaecologic oncology: Has the development of a preoperative order set improved compliance for preventive analgesia and deep venous thromboembolic (DVT) prophylaxis?

Abstract

Objectives: To describe a process change and evaluate compliance with use of preventive analgesia and deep venous thromboembolic (DVT) prophylaxis in an ESRP pathway following implementation of order set. Methods: The ESRP at MD Anderson was initiated in the Department of Gynaecologic Oncology in November 2014. We used the following medications for preventive analgesia; pregabalin (neuropathic pain), celecoxib (non-steroidal anti-inflammatory), and tramadol (mu-opioid receptor, synthetic opioid). An order set was developed to include these medications in all patients undergoing gynaecologic surgery provided there were no contraindications. All patients were also written in the order set to receive subcutaneous heparin 5,000 units administered subcutaneously on arrival to the holding area. Medications were administered upon arrival in the preoperative holding area by the nursing staff. Training on the new order set was provided prior to ESRP rollout in November 2014 to members of the gynaecologic oncology team as well as to the nurses in the preoperative holding area. To improve adherence to the process change, a repeat training was performed for the clinic staff 6 weeks after implementation. Attending anaesthesiologist for the case had final say on the medications to be administered to the patients. Statistical analyses with Wilcoxon ranksum, Fisher's exact, and unpaired t test were used for comparisons. Results: All 272 patients on our ESRP pathway had order set completion at the time of arrival to the surgical holding area for preventive analgesia and DVT prophylaxis. The rate of administration of each of the pre-medications found in the order set were as follows: heparin 262 (96.3%), celecoxib 251 (92.3%), pregabalin 254 (93.4%), and tramadol 257 (94.5%), respectively. The reasons for failure to achieve full compliance in these were: contraindications or allergic reactions. Conclusion: Development of a specific order set in ESRP gynaecologic surgery programme demonstrated excellent compliance with order completion. However, as with any new process change, audits of process flow can identify areas for improvement.Objectives: Generalisability of enhanced recovery after surgery (ERAS) programmes has been widely demonstrated. Spread of ERAS from colorectal surgery towards other intra-organisational settings could be expected, particularly after running a quality improvement collaborative (QIC). To examine the influence of QICs on interdepartmental spread, we examined spread of ERAS from colorectal towards gynaecologic surgery. Methods: A retrospective observational multicentre study was performed in 23 Dutch hospitals. Data of a consecutive sample of gynaecologic oncology patients who underwent open surgery in 2012-2013 were collected per hospital. Hospitals of which colorectal surgical teams participated in a breakthrough project were included in the intervention group (n¼10). The hospitals that did not have followed this project acted as controls (n¼13). The breakthrough project was a multidisciplinary programme...