What Was Done?
Global Problem Addressed
Enhanced Recovery After Surgery (ERAS) is a well-established multimodal program that encompasses all phases of care with standardized pathways in order to decrease variability amongst surgeons and improve patient outcomes. In colorectal surgery, ERAS has been shown to decrease length of stay, accelerate recovery postoperatively and improve outcomes leading to an overall decrease in cost.1-3 Improving Surgical Care and Recovery (ISCR) is grounded in these principles and offers tools and educational materials to facility implementation of these pathways.4
Identification of Local Problem
We recognized the opportunity to improve our quality of care for patients undergoing colorectal surgeries by providing standardization and frequent analysis of our data in order to increase efficiency, decrease length of stay, and improve outcomes. Our adult ACS NSQIP data indicated a need for improvement in our rates of urinary tract infection, post op surgical site infection, length of stay, and postop vein thrombosis.
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
Augusta University Medical Center is a 478-bed academic health center with a Level 1 trauma center, a 154-bed children’s hospital, and more than 80 outpatient practice sites serving Augusta, GA, and surrounding counties.
There is considerable institutional focus on quality care with the introduction of a Director of Quality and Safety and Surgeon Champions. The hospital already had a robust ERAS program for the bariatric and colorectal surgeries service; however, there was still inter-physician variation with use of all aspects of ERAS. The decision was made by the organization to enroll in the ISCR program that was established between the American College of Surgeons and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality.
Planning and Development Process
The project was initiated by our Surgeon Champion and Chief of Surgery. The decision was made to enroll in the ISCR program with an initial focus on the colorectal service line with plans to incorporate additional service lines such as orthopaedic, gynecology, and emergency general surgery. The program provides prototypes for enhanced recovery pathways based on current evidence review. With this framework in place, we created a multidisciplinary team that meets biweekly to review data and identify areas of improvement and adapt the protocols to the local hospital culture. Buy-in was achieved through frequent communication with nursing staff and attending surgeons and residents via meetings and educational seminars during didactic conferences.
From January 1, 2019, to June 30, 2019, baseline data from the colorectal procedures was abstracted and analyzed which helped us focus on key deficit areas that were relatively simple to address with progression to more complex issues. For instance, we focused on implementing the protocols on elective cases prior to working on implementing these protocols in the emergency colorectal procedures.
Once the protocols were established and the staff education on the principles was completed, adherence to the project goals improved over time. The frequency of the multidisciplinary meetings decreased. This was achieved by streamlining the protocols at the beginning of the project and including all staff involved in patient
care such as nursing, surgery residents, anesthesia, and pharmacy. Once the barriers were identified and solutions incorporated, the protocols became the standard of care and the focus was diverted to booster training as needed due to staff turnover.
Description of the Quality Improvement Activity
Key components of our quality improvement project were education and standardization. This was achieved through creation of a patient information booklet that detailed the various steps, expectations, and goals for our patients’ health journey before, during, and after hospitalization. The patients would meet with the Nurse Navigator prior to their scheduled operation and they would review incentive spirometry, how to shower with CHG soap prior to surgery, carb loaded drink prior to surgery, preoperative oral medications and bowel prep as applicable, benefits of early ambulation, concepts behind multimodal pain control and diet/nutrition.
Prior to their procedures, patients would have completed a mechanical bowel prep and oral antibiotics at home. They would discontinue oral intake of solids 8 hours prior to their procedure or prior to starting their bowel prep. They would continue consuming liquids with the last intake being a carbohydrate drink 2 hours prior to their procedure. During preop, patients would be started on a multimodal pain control that included gabapentin, acetaminophen and regional anesthesia as appropriate (epidural, spinal, or TAP block). Appropriate anti-emetic would be initiated as well (intraoperative intravenous anti-emetics).
Post-procedure, patients would be started on a clear liquid diet and multimodal pain regimen, including acetaminophen, gabapentin, nonsteroidal anti-inflammatory drugs (ketorolac or ibuprofen), muscle relaxant, lidocaine patch, and PRN oral and IV opioids. Patients would be encouraged to take oral pain medications over IV pain medications, and this was started in the PACU. During the hospitalization, goals would include early removal of foley, frequent ambulation, frequent use of incentive spirometry, and discontinuation of IV fluids as early as possible. Early alimentation was encouraged with a clear liquid diet on POD 0 and diet advanced guided by patient preference. Prior to discharge, patients would meet with the Nurse Navigator to reiterate the importance of activity at home, eating a healthy diet, and wound care instructions.
Baseline data collection was initiated January 1, 2019, and the implementation of ISCR protocols was initiated on July 1, 2019, and is ongoing.
Resources Used and Skills Needed
Staff
We used a multidisciplinary team approach that included a surgeon champion; surgical resident; anesthesiologist; nurse navigators; various floor nursing, clinic nursing, and perioperative representatives; nurse managers; integrated clinical practice strategist; and ACS NSQIP coordinator (SCR).
Costs
There were no additional costs beyond the normal operating costs and current personnel expenses with no additional hires during this timeframe. There was no additional funding designated for this quality improvement project.
What Were the Results?
Overall Results
Outcome measures for colorectal surgeries were collected from January 1, 2019, to June 30, 2019, prior to ISCR implementation to serve as a baseline. ISCR protocols were initiated on July 1, 2019, and over the course of 10 months, 57 cases were analyzed. Table 1 includes demographic data for the patients undergoing colorectal procedures before and after ISCR implementation. A reduction in mean postop days for return of bowel function (2.91 to 1.84), diet tolerance (3.35 to 2.20), and pain control with PO medications (3.80 to 3.18) was observed after initiation of ISCR protocols (as noted in Table 2).
