S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work

• Authors: S. Davis Jr, Emory University; Elizabeth Hechenbleikner, Emory University; Melissa C Majumdar, Emory University Hospital Midtown; Trent Gillingham, Emory Healthcare; Cooper J Jannuzzo, Emory Healthcare; Zachary Grunewald, Emory University; Jay Sanford, Emory University; Maggie Diller, Emory University; Omobolanle Oyefule, Emory University; Federico Serrot, Emory University; Jamil Stetler, Emory University; Ankit Patel, Emory University; Jahnavi Srinivasan, Emory University; Scott S Davis, Emory University; Edward Lin, Emory University
• Journal Title: SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
• Publisher: SPRINGER | 2022-06-28, Pages 1-9
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1007/s00464-022-09390-9
• Subjects: Health Sciences, Medicine and Surgery
• Keywords: Science & Technology; Life Sciences & Biomedicine; Surgery; Bariatric surgery; Enhanced recovery; Quality improvement; Standard work; OUTCOMES; TRIAL; CARE

Abstract

Background: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. Methods and procedures: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student’s t-tests. Results: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4–80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. Conclusion: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.