Impact of Adherence to Care Pathway Interventions on Recovery Following Bowel Resection Within an Established Enhanced Recovery Program.

Nicolo Pecorelli, MD1, Olivia Hershorn1, Gabriele Baldini, MD, MSc2, Julio F Fiore Jr., MSc, PhD1, Barry L Stein, MD2, A S Liberman, MD2, Patrick Charlebois, MD2, Franco Carli, MD, MPhil2, Liane S Feldman, MD2. 1Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, 2McGill University Health Centre

Introduction: Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention is unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes, and to identify key ERP elements predicting successful recovery following bowel resection.

Methods: Prospectively collected data entered in an international registry specifically designed for ERPs was reviewed. Patients undergoing elective bowel resection in a single university-affiliated center between 2012 and 2014 were treated within an ERP implemented in 2010 and comprising 23 care elements. Primary outcome was successful recovery defined by absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were 30-day complication rate and severity as measured by the comprehensive complication index (CCI). Regression analyses adjusted for potential confounders were conducted to evaluate the association between adherence to ERP interventions and outcomes, and to identify key ERP interventions predicting successful recovery.

Results: 347 patients were included in the study (mean age 63.2 years, males 52%, laparoscopy 80%, pelvic surgery 35%, malignancy 65%). Median primary LOS was 4 days (IQR 3–7). Median overall patient adherence to the pathway was 78% (IQR 70–87%). Adherence to single ERP elements ranged from 25% for balanced intraoperative IV fluids to 100% for preoperative education, opioid-sparing multimodal analgesia, antibiotic and thromboembolic prophylaxis. 156 (45%) patients had a successful recovery. Morbidity occurred in 175 (50%) patients with median CCI 8.6 (IQR 0–22.6). There was a positive dose-effect relationship between adherence and successful recovery (OR 1.43 for every additional element, 95%CI 1.27-1.60, p<0.001), 30-day postoperative morbidity (OR 0.76, 95%CI 0.69-0.85, p<0.001), and CCI (coefficient -0.18, 95%CI -0.25 to -0.12, p<0.001). A laparoscopic approach (OR 4.51, 95%CI 2.35-8.65, p<0.001), early termination of IV infusion (OR 2.08, 95%CI 1.21-3.57, p=0.008) and early mobilization out of bed (OR 2.11, 95%CI 1.07-4.20, p=0.031) significantly predicted successful recovery. In addition to laparoscopy, early mobilization and early termination of IV infusions, intraoperative balanced IV fluids was significantly associated with a reduction in complication rate and reduced CCI.

Conclusions: Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall compliance was high, laparoscopic approach, perioperative fluid policy and patient mobilization remain key elements associated with improved outcomes.

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