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Staged Implementation of an Enhanced Recovery Protocol for Patients Undergoing Bowel Resection: A Promising Approach to Improve Patient Outcomes
*Andrew Pellet, *Jesse Moore, *Peter Callas
University of Vermont/Fletcher Allen Health Care, Burlington, VT

Objective: Enhanced Recovery Protocols (ERP) in bowel surgery apply evidence based medicine and standards of care practices throughout the perioperative experience. ERP’s can improve pain management, shorten postoperative ileus and reduce hospital length of stay (LOS) without increasing complications or readmissions. A previous ERP implementation attempt at our institution failed due to low compliance. We seek to identify if re-implementing an ERP over three stages, utilizing intensive in-service training of involved members and introducing user-friendly pathway specific electronic ordersets can improve adherence and outcomes.
Design: Retrospective Chart Review
Setting: Academic Medical Center, 4/2012-7/2013. Three board-certified surgeons partook in the study
Patients: 116 patients (58 open, 58 laparoscopic) undergoing elective bowel resection following the ERP
Main Outcome Measures: Adherence to key ERP elements, LOS, complication, readmission and nasogastric tube (NGT) reinsertion rates.
Results: Compliance to major pathway elements were captured and noted within the included table.
Enhanced Recovery Protocol Compliance
Phase of CareMedication/Intervention# of Adhering Patients (%)
Pre-OpVTE Chemoprophylaxis (e.g. Enoxaparin, Heparin)113 (97.4)
VTE Mechanical Prophylaxis113 (97.4)
Pre-op analgesia/anti-emesis bundle(celecoxib, gabapentin, granisetron, dexamethasone)107 (92.2)
Intrathecal Morphine95 (81.9)
Intra-OpIV fluid restriction71 (61.2)
IV Lidocaine112 (96.6)
IV Ketamine110 (94.8)
Post-OpScheduled Acetaminophen105 (90.5)
Scheduled Ketorolac82 (70.7)
IV Fluid Discontinued <24 hours69 (59.5)
Regular diet ordered on arrival to inpatient ward59 (50.9)

Median and average LOS was 3 and 4.8 days respectively. Previously median LOS was 6 days. When patients whose stay exceeded the 95th percentile (13.3 days) were excluded, average LOS dropped to 3.7 days. NGT reinsertion, readmission and complications occurred in 15 (12.9%), 14 (12.1%) and 35 (30.2%) patients respectively, consistent with national outcomes.
Conclusions: Significant improvements in ERP compliance was achieved with reimplementation. Peri-operative medication administration improved as did compliance to IV fluid restriction. Median LOS was cut in half as a result. In sum, staging ERP implementation, incorporating in-service training and utilizing electronic order-sets may help in achieving success.

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