Rishi Megha, MD, Braden Paschall, Paul Szotek, MD. Indiana University Health
Introduction: Complex ventral hernia repair often results in lengthy ICU and hospital stays that ultimately result in excessive cost to the system. Recently, Enhanced Recovery After Surgery (ERAS) have been increasingly utilized without changes in outcomes in many surgical subspecialties. ERAS protocols are based on multimodal pain control and intestinal recovery acceleration. In an effort to improve our process, we elected to implement an ERAS protocol in our complex ventral hernia program.
Methods and Procedures: A retrospective review of prospectively collected complex ventral hernia patients was performed on a cohort from February 2012 to August 2015. In order to analyze the data, we developed a outcomes dashboard for our institution that can be used to compare cost and other parameters within our institution as a single institution quality measure. The ERAS protocol consisted of:
Pre-op: Entereg 12mg and Gabapentin 300mg PO
Intra-Op: Experel/Bupivicaine TAP block,
POD#0 Dilaudid PCA, Tylenol 650mg PO Scheduled, Gabapentin 300mg TID, Oxycodone 5mg prn, and Entereg 12mg BID until discharge
POD#1- Add Naproxen 500mg PO AM & 250mg PM, Limited Clears, D/C Foley, Ambulate
POD#2 – Add Clear Liquid Diet & Hep Lock IV
POD#3 Reg Diet and disposition.
Results: In June 2015 we implemented the ERAS protocol in our series of 53 patients. 4 patients have been managed by ERAS at this point. Utilizing the IU Surgical Materials Dashboard, we evaluated the ICU Length of stay, the hospital length of stay, and the facility cost of repairs. The implementation of the ERAS protocol produced a significant decrease in the average ICU LOS from 3.75 to 0.75 Days, the average hospital LOS from 9.3 to 3.25 days, and a decrease in average facility cost from $37,000 per case to $22, 000 per case. Based on the cost data we analyzed, it would have cost our hospital system approximately $48,000 more in facility costs in one month and an estimated savings of $660,000 had we used the ERAS protocol for all case of complex hernia repair.
Conclusion: ERAS implementation results in a significant decrease in ICU days, LOS, and facility costs. ERAS protocols can safely be used in complex abdominal wall repair and result in a significant cost savings to the healthcare system.