The Journey to Implement Enhanced Recovery After Surgery(ERAS®) Pathways Across the System
Enhanced Recovery After Surgery(ERAS®) pathways for elective colorectal, emergent appendectomy and cholecystectomy were created using Epic® functionality, and initiated within six months across six hospitals at a Pennsylvania health system. A multidisciplinary group implemented the initiative including quality, surgery, nursing, information technology(IT), pharmacy, and leadership. Baseline risk-adjusted data was collected for select measures, not limited to length of stay, readmission and complication rates. Dashboards were developed to determine surgeon and nursing engagement for pathway utilization. Outcomes were evaluated and improvement strategies implemented, with early successes already identified. Committed leaders and reevaluation strategies are key to a successful systemwide process implementation.
Problem: Enhanced Recovery After Surgery (ERAS) pathways were used in only a few hospitals across the system. ERAS has been shown to result in improved patient outcomes such as a decrease in length of stay, complications, readmissions and costs. An initiative was undertaken to implement three ERAS surgical pathways systemwide.
Measurement: Using Premier Quality Advisor, risk-adjusted data for principal procedure codes for emergent appendectomy, emergent cholecystectomy and elective colorectal surgeries were obtained. Outcome measures for all included geometric and arithmetic length of stay, inpatient complication rates, 30-day readmission rate to inpatient setting and geometric cost per case.
Analysis: Baseline outcome measure data were obtained from Premier Quality Advisor. Once the ERAS pathways were in use, data were evaluated and compared to baseline results. If present, statistical significance was identified in the results. System overview dashboards were developed in Epic to determine surgeon and nursing engagement for pathway utilization.
Implementation: ERAS pathways for elective colorectal and emergent appendectomy and cholecystectomy were implemented systemwide. Obstacles included delay in nurse manager/nurse educator involvement, pre-existing workflow variation, IT build limitations and individual utilization scorecard delay. Meetings with surgeons and nursing to provide outcome data, education and sharing of dashboard information for department monitoring.
Results/Discussion: After seven months of data, length of stay improved for appendectomy(1.76-1.51), cholecystectomy(2.70-2.45) and colorectal(3.36-2.49). Inpatient complication rate improved for appendectomy(12.24%-5%), cholecystectomy(13.4%-9.09%) with colorectal(12.3%-0%) showing the greatest improvement. Thirty-day readmissions fell for appendectomies(6.32%-0%) with an increase for cholecystectomy and colorectal (2.61%-6.56% and 3.83%-26.7%) respectively. Continue data monitoring and reevaluation of strategies.
Speakers
Director Quality Improvement Service Lines - WellSpan Health
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