Resident Implementation of an Enhanced Recovery Pathway for Colorectal Surgery in a Rural Community

Abstract

Enhanced recovery pathways (ERPs), enhanced recovery after surgery (ERAS ), or fast track protocols address the surgical stress and postoperative physiology of patients undergoing surgery. These care plans have resulted in faster recovery, shorter hospital stay, decreased complications, decreased costs, and improved quality of life. Multiple studies reviewing the successes of ERAS protocols were critically evaluated by the residency program at our institution, and the residents envisioned our patients benefiting from a similar protocol. However, we found little interest from our attending surgeons in implementing the protocol themselves. Ultimately, implementing the ERP at our facility required more persuasion than anticipated because the surgeons were not the only parties to influence. Thus, through a quality improvement process, a resident-run team established an ERP for elective colorectal surgeries with the goal of mirroring reported outcomes: reduced length of stay (LOS), decreased postoperative complications, and ultimately improved patient quality of life. We conducted an observational analysis of patients who underwent elective colon resection surgery from May 2016 through July 2017 and were placed on an ERP at our 453-bed, private, rural, community hospital. This group was compared with patients who underwent elective colon resection before ERP implementation from January 2015 through April 2016. Implementing the ERP included shifting the paradigms of private practicing surgeons and anesthesiologists, anesthetists, nursing staff, and pharmacists, thus, urging them to adopt the new pathway. Outcomes and complications that were compared included LOS, readmission rate, time to ambulation, flatus, first bowel movement (BM), SSIs, and costs. Our ERP was modeled after ERAS society guidelines with modifications that conformed to our surgeon’s preferences, anesthesiologist experience, and staffing limitations.1 The design and implementation was led by a second-year surgical resident, the surgery program director (a general/trauma surgeon), a nurse anesthetist, and the chief of anesthesia. Before applying the finished product, the protocol was presented for approval from the five general surgeons whowould use the protocol and the chief of anesthesia. Once approved, the training began simultaneously with the surgery clinic staff, surgery residents, staff surgeons, anesthesia and surgery department staff, pretesting unit, ambulatory surgery unit, postanesthesia care unit, the surgical ward, and the ICU. A patient educational brochure was created detailing the ERP that was to be given to all patients in the outpatient setting. The ambulatory surgery unit was counseled on preoperative dietary orders and preoperative medications. The anesthesia providers were oriented on perioperative portions of ERP to include: the use of epidurals, limiting the use of narcotics and benzodiazepines, preoperative antibiotics and restricting the use of IV fluids to maintain euvolemia. The postanesthesia care unit was also instructed to minimize narcotic use for pain control and initiation of oral intake. The surgical wards were given the ERP, outlining in detail the postoperative care. After nine months of a series of board committee meetings, group lectures, and countless direct encounters with administrators, physicians, residents, and nurses to educate on the ERP, the protocol was approved. At which point it was converted into an official hospital guideline and the first patient was enrolled. The study included 130 patients undergoing elective colon resections over the study period, and the study population characteristics are shown in Table 1. There were 69 pre-ERP patients (54% male, with a mean age of 68 years) compared with 60 ERP patients (57% female and a mean age of 65 years). Both groups were similar in the most common indication for surgery Address correspondence and reprint requests to Daniel S. Urias, M.D., Conemaugh Memorial Medical Center, 1086 Franklin Street, Johnstown, PA 15905. E-mail: [email protected].