DOI QR코드

DOI QR Code

Evolution of Process and Outcome Measures during an Enhanced Recovery after Thoracic Surgery Program

  • Lee, Alex (Ottawa Hospital Research Institute, The Ottawa Hospital) ;
  • Seyednejad, Nazgol (Division of Thoracic Surgery, Department of Surgery, University of Ottawa) ;
  • Lawati, Yaseen Al (Division of Thoracic Surgery, Department of Surgery, University of Ottawa) ;
  • Mattice, Amanda (Ottawa Hospital Research Institute, The Ottawa Hospital) ;
  • Anstee, Caitlin (Ottawa Hospital Research Institute, The Ottawa Hospital) ;
  • Legacy, Mark (Ottawa Hospital Research Institute, The Ottawa Hospital) ;
  • Gilbert, Sebastien (Division of Thoracic Surgery, Department of Surgery, University of Ottawa) ;
  • Maziak, Donna E. (Division of Thoracic Surgery, Department of Surgery, University of Ottawa) ;
  • Sundaresan, Ramanadhan S. (Division of Thoracic Surgery, Department of Surgery, University of Ottawa) ;
  • Villeneuve, Patrick J. (Division of Thoracic Surgery, Department of Surgery, University of Ottawa) ;
  • Thompson, Calvin (Department of Anesthesiology and Pain Medicine, University of Ottawa) ;
  • Seely, Andrew J.E. (Ottawa Hospital Research Institute, The Ottawa Hospital)
  • Received : 2021.11.17
  • Accepted : 2021.12.14
  • Published : 2022.04.05

Abstract

Background: A time course analysis was undertaken to evaluate how perioperative process-of-care and outcome measures evolved after implementation of an enhanced recovery after thoracic surgery (ERATS) program. Methods: Outcome and process-of-care measures were compared between patients undergoing major elective thoracic surgery during a 9-month pre-ERATS implementation period to those at 1-3, 4-6, and 7-9 months post-ERATS implementation. Outcome measures included length of stay, the 30-day readmission rate, 30-day emergency department visits, and minor and major adverse events. Process measures included first time to activity, out-of-bed, ambulation, fluid diet, diet as tolerated, as well as removal of the first and last chest tube, epidural, patient-controlled analgesia, and Foley and intravenous catheters. Results: In total, 704 patients (352 pre-ERATS, 352 post-ERATS) were included. Mobilization-related process measures, including time to first activity (16.5 vs. 6.8 hours, p<0.001), out-of-bed (17.6 vs. 8.9 hours, p<0.001), and ambulation (32.4 vs. 25.4 hours, p=0.04) saw statistically significant improvements by 1-3 months post-ERATS implementation compared to pre-ERATS. Time to Foley removal improved by 4-6 months post-ERATS (19.5 vs. 18.2 hours, p=0.003). Outcome measures, including the 30-day readmission rate and emergency department visits, steadily decreased post-ERATS. By 7-9 months post-ERATS, both minor (18.2% vs. 7.9%, p=0.009) and major (13.6% vs. 4.4%, p=0.007) adverse events demonstrated statistically significant improvements. Length of stay trended towards improvement from 6.2 days pre-ERATS to 4.8 days by 7-9 months post-ERATS (p=0.06). Conclusion: The adoption of ERATS led to improvements in multiple process-of-care measures, which may collectively and gradually achieve optimization of clinical outcomes.

Keywords

Acknowledgement

The study was funded with awards through The Ottawa Hospital Academic Medical Organization Innovation Fund (TOH-18-006) and the University of Ottawa Anesthesiology and Pain Medicine Grant Program (uOAPM 2018-0419).

References

  1. Lee L, Mata J, Ghitulescu GA, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 2015;262:1026-33. https://doi.org/10.1097/sla.0000000000001019
  2. Williams JB, McConnell G, Allender JE, et al. One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program. J Thorac Cardiovasc Surg 2019;157:1881-8. https://doi.org/10.1016/j.jtcvs.2018.10.164
  3. Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV. Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 2016;202:165-76. https://doi.org/10.1016/j.jss.2015.12.051
  4. Ljungqvist O, Young-Fadok T, Demartines N. The history of enhanced recovery after surgery and the ERAS Society. J Laparoendosc Adv Surg Tech A 2017;27:860-2. https://doi.org/10.1089/lap.2017.0350
  5. Jones NL, Edmonds L, Ghosh S, Klein AA. A review of enhanced recovery for thoracic anaesthesia and surgery. Anaesthesia 2013;68:179-89. https://doi.org/10.1111/anae.12067
  6. Madani A, Fiore JF Jr, Wang Y, et al. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery 2015;158:899-908. https://doi.org/10.1016/j.surg.2015.04.046
  7. Ayanian JZ, Markel H. Donabedian's lasting framework for health care quality. N Engl J Med 2016;375:205-7. https://doi.org/10.1056/NEJMp1605101
  8. Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J. Enhanced recovery after surgery protocols: compliance and variations in practice during routine colorectal surgery. Colorectal Dis 2012;14:1045-51. https://doi.org/10.1111/j.1463-1318.2011.02856.x
  9. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011;146:571-7. https://doi.org/10.1001/archsurg.2010.309
  10. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet 2003;362:1225-30. https://doi.org/10.1016/S0140-6736(03)14546-1
  11. Oxman AD, Flottorp S. An overview of strategies to promote implementation of evidence-based health care. In: Silagy C, Haines A, editors. Evidence-based practice in primary care. 2nd ed. London: BMJ Books; 2001. p. 101-19.
  12. The ERATS Research Team. The Ottawa Hospital ERATS Program [Internet]. Ottawa: The Ottawa Hospital; [date unknown] [cited 2021 Mar 4]. Available from: https://ottawaerats.org.
  13. Seely AJ, Ivanovic J, Threader J, et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010;90:936-42. https://doi.org/10.1016/j.athoracsur.2010.05.014
  14. Fiore JF Jr, Bejjani J, Conrad K, et al. Systematic review of the influence of enhanced recovery pathways in elective lung resection. J Thorac Cardiovasc Surg 2016;151:708-15. https://doi.org/10.1016/j.jtcvs.2015.09.112
  15. Basse L, Thorbol JE, Lossl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004;47:271-7. https://doi.org/10.1007/s10350-003-0055-0
  16. Leeds IL, Ladd MR, Sundel MH, et al. Process measures facilitate maturation of pediatric enhanced recovery protocols. J Pediatr Surg 2018;53:2266-72. https://doi.org/10.1016/j.jpedsurg.2018.04.037
  17. Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project. J Hosp Med 2016;11:341-7. https://doi.org/10.1002/jhm.2546
  18. Okamoto T, Ridley RJ, Edmondston SJ, Visser M, Headford J, Yates PJ. Day-of-surgery mobilization reduces the length of stay after elective hip arthroplasty. J Arthroplasty 2016;31:2227-30. https://doi.org/10.1016/j.arth.2016.03.066
  19. Killewich LA. Strategies to minimize postoperative deconditioning in elderly surgical patients. J Am Coll Surg 2006;203:735-45. https://doi.org/10.1016/j.jamcollsurg.2006.07.012
  20. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999;354:1229-33. https://doi.org/10.1016/S0140-6736(98)10063-6
  21. Story SK, Chamberlain RS. A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus. Dig Surg 2009;26:265-75. https://doi.org/10.1159/000227765
  22. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations: 2018. World J Surg 2019;43:659-95. https://doi.org/10.1007/s00268-018-4844-y
  23. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144:961-9. https://doi.org/10.1001/archsurg.2009.170
  24. Khandhar SJ, Schatz CL, Collins DT, et al. Thoracic enhanced recovery with ambulation after surgery: a 6-year experience. Eur J Cardiothorac Surg 2018;53:1192-8. https://doi.org/10.1093/ejcts/ezy061
  25. Ali ZS, Flanders TM, Ozturk AK, et al. Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine 2019;30:532-40. https://doi.org/10.3171/2018.9.SPINE18681
  26. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009;110:1139-57. https://doi.org/10.1097/ALN.0b013e31819f7aea
  27. Batchelor T, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019;55:91-115. https://doi.org/10.1093/ejcts/ezy301
  28. Nayak R, Shargall Y. Modern day guidelines for post lobectomy chest tube management. J Thorac Dis 2020;12:143-5. https://doi.org/10.21037/jtd.2020.01.21
  29. Thompson C, French DG, Costache I. Pain management within an enhanced recovery program after thoracic surgery. J Thorac Dis 2018;10(Suppl 32):S3773-80. https://doi.org/10.21037/jtd.2018.09.112
  30. Brunelli A, Thomas C, Dinesh P, Lumb A. Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2017;154:2084-90. https://doi.org/10.1016/j.jtcvs.2017.06.037