Benefits of an Enhanced Recovery Program in Frail Populations

General Information 

Institution Name: Saint Francis Hospital and Medical Center, Trinity Health of New England

Submitter Name and Title: David S. Shapiro, MD, MHCM, FACS, FCCM, Chief Quality Officer

Authors: Daniel Mullins, MD, FACS; Amanda Ayers, MD, FACS; Saumitra Banerjee, MD, FACS; Steven Brown, MD, FACS; Robert Lewis, MD, FACS; Daniel Mullins, MD, FACS; Andrew Raissis, MD, FACS; Rachel Scott, MD; Ly Tran, PA-C; Maryann Mecca, PA-C; and David S. Shapiro, MD, FACS

Name of the Case Study: Benefits of an Enhanced Recovery Program in Frail Populations

What Was Done? 

Global Problem Addressed 

The population is aging, and while care for chronic medical conditions has improved, optimization for surgical procedures is a complicated process. Medical and surgical complications continue to threaten the elderly and those with complicating comorbid conditions.^1,2 Connecticut has some of the highest hospital complication rates and serious safety event rates nationwide. Multiple efforts to improve these outcomes have been condensed into the constellation of “enhanced recovery” processes to optimize patients and improve outcomes after surgery. These programs vary location to location, but overall have made a significant impact in the readiness for surgery, expectation management for patients and families, and an improvement in the overall surgical patient experience. Improved and innovative surgical and anesthetic techniques have contributed to improvements, but low-cost, high-impact efforts like an enhanced recovery program, can make all the difference.

Using a variety of methods and risk assessments, frailty has been demonstrated in between 4.1 and 50.3 percent of surgical patients and is predictive of mortality, postoperative complications, and disposition at discharge.^3,4 Complications after surgery are costly—they can increase a case-mix-adjusted costs by $9419 to $13,832 per case.⁵ More notably, complications worsen patient experience, are concerns to regulatory bodies, and can contribute to higher utilization of health care resources. Enhanced recovery programs (ERP) are being used nationwide and improve complications, reduce lengths of stay, and lower costs of care per patient.^6-8 It is widely accepted that no single implemented change will improve outcomes of surgery across all patient populations, and that the approach to perioperative and postoperative care must incorporate multiple disciplines, multiple modalities, and multiple components to optimize care for every patient.

Identification of Local Problem 

Complications documented by local data assessments, the National Healthcare Safety Network (NHSN), and the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP^®) data identified our hospital as an outlier with respect to overall morbidity, increased lengths of stay, postoperative surgical site infection, sepsis (Source: ACS NSQIP Semiannual Report) as well as transfer to extended care facilities in the post-acute setting, hospital-acquired infections, and postoperative opiate use (Source: NHSN, local data). All listed complications were important to patient experience—events like ileus, reinsertion of a nasogastric tube, and other data not publicly reported.

Our goal was not only to improve care at our campus and within our regional health system, but to disseminate what we have learned locally and from our peer hospitals in the state, and to help to reduce variation and hospital-acquired conditions statewide. Support for the Connecticut Surgical Quality Collaborative has developed a collaborative relationship, where grant funding has provided technology and education statewide, allowing for data collection to be uniform and for techniques to evolve toward being more unified with the best practices demonstrated in the published evidence. This collaboration has borne fruit, with creation of a resource website, the Connecticut Geriatric Program in Surgery (ctgps.org), and a sharing of data to improve care regionally. Lastly, we are not so arrogant as to not recognize our own shortcomings; we have identified several opportunities for systemic improvements through this program and are on the journey toward consistent practice, high reliability, and the safest, most effective surgical providers in the nation.

Saint Francis Hospital, now a part of Trinity Health of New England, has evolved a constellation of practices to reduce hospital-acquired infections (HAI) and conditions over the last several years. As early adopters of large-volume, risk- adjusted surgical data subscriptions, like ACS NSQIP, we have improved multiple metrics across the continuum of care. We have reduced ventilator-associated events, reduced surgical site infections, and adopted enhanced recovery processes (ERP) in our colorectal surgery patients to improve every aspect of their experience. These processes have now begun for patients undergoing hysterectomy and other procedures, and other programs in Connecticut have had success. This project began with pilot data on the implementation of team-based training, best practice utilization, and the idea that state programs would benefit from transparent data sharing. A grant was sought and awarded, and we began our leadership and collaboration with the Connecticut Surgical Safety Collaborative, a partner to the ACS Connecticut Chapter. With a goal of enhancing the patient experience, providing low-cost care, and minimizing complications, we were set to lead the journey toward zero harm.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Saint Francis Hospital is a not-for-profit, urban, tertiary care, Level I trauma center located in Hartford, CT. It is the largest Catholic hospital in the northeast. The hospital was a primary partner in the development of the Connecticut Surgical Quality Collaborative, a surgical safety collective that includes every acute care hospital in Connecticut. Grant funding has provided technology and education statewide, allowing for data collection to be uniform and for the promotion of best practices demonstrated in the published evidence surrounding surgical success.

Measures include:

• NHSN: NHSN-published infection and event data provide our hospital event rates and actionable items in addition to benchmarks.
• ACS NSQIP: ACS NSQIP provides risk-adjusted data for our submitted patient data, allowing us to benchmark surgical patients here against surgical patients in our State Collaborative and compare further with nationally reported benchmarked data.
• Locally collected outcomes: We use these outcomes, including identified surgical and medical complications and adverse or unexpected events, rates of transition to nursing facilities post-acute, readmission data, lengths of stay, and postoperative milligram morphine equivalents, to monitor opiate use and prescribing.

Other clinical data, such as tolerance of enteral nutrition, use of urinary catheters, and more, are collected in real time.

Planning and Development Process 

Our own performance with patient experience has been a journey. Saint Francis recognizes the level of care available in Connecticut matters to our citizens.

When we are compared with the remainder of the nation, we do not excel. Our complications, hospital-acquired conditions, and other parameters are higher than the majority of the U.S. Our goal was not only to improve care at our campus and within our regional health system, but to disseminate what we have learned locally and from our peer hospitals in the state and help reduce variation statewide.

In 2016, the noted performance reflected in the ACS NSQIP data suggested the need for improvement, and the ERP was instituted. Monthly development and implementation meetings were held to educate, and the colon surgery specialty group committed to the process with early adoption of outpatient and post-acute measures. Inpatient measures were implemented simultaneously.

Description of the Quality Improvement Activity 

We targeted improvement in these events in an effort to enhance the patient experience and sought support from the private foundation of a medical professional liability provider, who found interest in our preliminary work. With their support, Saint Francis was able to obtain a large grant to support enhanced recovery programs, and, in collaboration with the American College of Surgeons local chapter, supported the ERP efforts statewide and at Saint Francis. More recently, further efforts to focus ERP on more frail populations (patients with diabetes, patients older than 70 years, and patients with American Society of Anesthesiology Classification [ASA] >2) have been endeavored. Perioperative optimization in these patients has resulted in similar improvements in outcomes.

Briefly, an enhanced recovery program was instituted at our urban, tertiary care hospital over the last three years. Consecutive patients undergoing colorectal resections performed after January 1, 2016, have been followed. Outcome measures, including overall complications, post-acute disposition to skilled nursing facility (ECF), readmissions, length of hospital stay, duration to flatus, and morphine milligram equivalents (MME) were collected prospectively. Statistical analysis for all interventions and an overall assessment on patient experience were performed.

Overall complications were assessed in the patients before institution of ERP and subsequent to the start of the program. Subgroups of patients included the “frail patients,” including highly comorbid patients (those with ASA > 2), patients with advanced age (defined as age > 70), and patients with diabetes (DM, defined as preoperative glycosylated hemoglobin > 6.5%).

Initially, 183 consecutive patients underwent colorectal resection prior to the initiation of the enhanced recovery program. Subsequent to the program starting, 509 consecutive patients were included in the ERP. For the sake of data analysis, seven patients were excluded because of absence of important data. Demographics collected included age, gender, body mass index, and tobacco use, which did not differ between groups.

Complications were identified by individual chart abstraction and included surgical complications (return to operating room, leak, bleeding, wound drainage, and others) and medical complications (acute kidney injury, hypotension, oliguria, myocardial infarction, thromboembolic event, and others, including events that are not often publicly reported such as ileus, wound erythema, dislodgement and replacement of devices, dysuria and urinary retention, changes of level of care, and more). Data from the state hospital association, locally collected hospital data, and annual and semiannual reports from ACS NSQIP were utilized to identify events and outliers.

This process began at our hospital in 2016 and continues today.

Resources Used and Skills Needed

• Existing staff, including nursing providers in the perioperative center, a single physician assistant, supported by office staff members, and clinical providers in the hospital were all engaged. Dedicated staff to the enhanced recovery program included a portion of the PA’s dedicated time. Leadership included a dedicated quality nurse provider and the service line executive director and chair of surgery, as well as an extremely dedicated colon and rectal surgery group.
• Surgeons in a private specialty colon and rectal surgery practice were the primary surgical providers, foundational participants, and the push to engage the remainder of the hospital staff.
• Funding: Saint Francis was able to obtain a large grant to support enhanced recovery programs, and in collaboration with the American College of Surgeons local chapter, supported the ERP efforts statewide and at Saint Francis.
• Participation in ACS NSQIP, while not required, provides significant improvements with risk adjustment in the data collected.
• Continued updates to the inpatient, post-acute, and perioperative staff.

What Were the Results?

Overall Results 

Overall, complications of any kind occurred in 47.5 percent of the pre-ERP patients. Though this number seems high overall, it includes even transient increases in creatinine, adynamic ileus, vomiting events requiring interventions, and other patient dissatisfiers. In patients experiencing surgery with ERP, this number dropped to 23.2 percent. These results are shown in Tables 1 and 2.

Separate analysis revealed improvements in frail patient groups as well.

Comorbid patients (n=237; Table 3) and patients with diabetes (n=139, Table 4) both demonstrated identical improvements (p<0.001). Patients with advanced age (n=255, Table 5) improved significantly with respect to surgical and medical complications, days to flatus, and hospital LOS (p<0.001).

In addition to these improvements, inpatient data and the Connecticut Prescription Monitoring Program (PMP) allowed assessment for postoperative opiate use (Table 1). Multimodal pain management options included in ERP allows patients to have their pain management tailored to meet their needs. The use of opiate pain medication averaged 119.03 MME before ERP, and it decreased to only 31.4 MME for those in the ERP program. Further, the number of patients who tolerated their experience opiate free improved from 4.1 percent to more than 18 percent.

*Includes all listed complications and events described in ACS NSQIP, inclusive of ileus, wound events, and events not otherwise discovered in public reportability

§ Surgical site infections, deep space infections, bleeding, returns to OR, others

‡Mortality, cardiac events, pneumonia, urinary tract infection, respiratory events, kidney dysfunction, evidence of ileus, thromboembolic events

Setbacks

Setbacks are commonplace. Adherence to the constellation of requirements for particular enhanced recovery program goals are occasionally in opposition to the preferences of individual hospital surgical providers. These may include mechanical bowel prep, particular antibiotic preferences, and others. When these parameters cannot be met, groups may choose to develop a more customized local version of enhanced recovery needs. Use caution, however, as local preference may not be aligned with the majority of best practices recommendations. Adherence to the published guidelines are often best, and cultural adaptation to these changes—for surgeons, anesthesiologists, nurses, and even patients—can prove a fruitful, albeit slow, process.

Grand rounds speakers, sharing transparent data, and inviting participating and nonparticipating providers to statewide meetings and local educational events each can help support adoption of ERP goals. Gaining champions in each discipline is always beneficial.

Cost Savings

This project represents investments in educational, experiential, and training efforts that saved hospitals from expenditure in these arenas.

• Grant funding supported multiple educational events, including:
  • High-Reliability Training events for more than 130 clinicians
  • TeamSTEPPS training for multiple hospital teams
  • Support of the Statewide Surgical Collaborative
  • Teaching events, networking conferences, and so on
• Support for technology platforms for multiple collaborative hospitals
• Project managers can facilitate compliance, dissemination, and education without high-cost providers being relegated to these important tasks

Patient Care Estimates of Savings

Cost savings were noted in a variety of colonic surgery patients. A savings of approximately $3,000 per patient was realized with a reduction in both complications and length of stay. Overall impact of the reduction in complications is challenging to quantify given the variability between patients, but for nearly 500 patients in the post-ERP group, savings can be approximated at $1.5 million over the 2.5 years of the study, averaging $600,000 annually. Further, a slight improvement in readmission rates, while not statistically significant, does offer potential improvements, as reduced readmissions are an important goal.

Tips for Others 

• Start simply; most interventions are reasonably low cost and do not require additional technology, but data collection is important.
• Funding, whether local, private, or from large grants, can help but isn’t required. If funding is sought, collaborative efforts from peer organizations can be extremely useful. Unusual sources can be helpful—your hospital claims data may provide fodder for conversations with malpractice providers, quality organizations, and others, and savings can manifest from reduced claims and reduced complications, all resulting in decreased payments for third-party payers. Support from hospital leadership can be better gleaned by transparency, internal cost-analysis, and a target of reducing variability between patients. Launching a program that can save $3,000 per patient, applied across the entire surgical volume, can be extremely convincing.
• Data sharing should be regular and transparent. Group metrics and individual metrics can be shared in the OPPE process and can be demonstrated successes for a hospital over time. Motivation should come from within.

In all, Saint Francis has been a leader in Connecticut, with efforts to improve hospital-acquired condition rates, avoid serious safety events, and learn and maintain best practices for the provision of surgical care. These efforts have manifested in our adoption of an enhanced recovery program, an adaptation of Enhanced Recovery After Surgery (ERAS) programs used nationwide. The group of colon and rectal surgeons and physician assistants were the force behind the majority of the interventions and guided most of the interventions, in association with the hospital’s department of surgery. The investment in this program was inclusive of reorganization and collaboration, rather than a large spend of funds. The costs were minimal, and the results were demonstrative of a valuable investment. Our work continues, and our collaborative support of other efforts in Connecticut will as well. 

Acknowledgments

This project represents collaboration from dozens of providers, without whom these results would be impossible. Included in this group are surgical physician assistants, surgical and anesthesia providers, leadership, nursing, case management, and many others. Most importantly among them are Kimberly Bellavance, PA-C; Anna Karpinski, BSN; Linda Simpson, BSN; Christopher Comey, MD, FACS; Maureen Gethings, MSN, RN; Craig Dennen, MD; Philip Corvo, MD, FACS; and Alan Meinke, MD, FACS.

References

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