Multicenter Observational Study Examining the Implementation of Enhanced Recovery Within the Virginia Surgical Quality Collaborative in Patients Undergoing Elective Colectomy.

BACKGROUND

The American College of Surgeons (ACS) NSQIP Virginia Surgical Quality Collaborative (VSQC) exists to improve surgical outcomes through multi-institutional collaboration. Enhanced recovery (ER) protocols improve morbidity and reduce length of stay (LOS) after elective surgery. We hypothesized implementation of ER through VSQC would reduce postoperative complications and LOS in patients undergoing elective colectomy. Our objective was to evaluate whether standardization of care based on evidenced-based practices in healthcare settings across multiple institutions improved outcomes.

STUDY DESIGN

In 2013, VSQC incrementally implemented ER for patients undergoing elective colectomy at participating institutions. Institutions shared protocols, order sets, educational materials, and met semi-annually to discuss progress. Risk-adjusted ACS NSQIP data (January 1, 2012 through December 31, 2016) was queried in 4 participating hospitals. The association of ER with surgical outcomes was evaluated with a before and after ER implementation analysis and multivariable logistic regression modeling with a priori selection of clinically relevant variables.

RESULTS

There were 2,438 consecutive colectomies included in analysis (1,035 pre-ER/1,403 post-ER). In the post-ER implementation patient cohort, relatively more patients were treated laparoscopically (68%) compared with the pre-ER cohort (52%) (p < 0.001). Median LOS decreased from 5 to 4 days after ER implementation in patients undergoing open colectomy (p < 0.001), although total complications were similar in frequency (23% vs 22%). Laparoscopic patients had a reduced LOS (4 vs 3 days; p < 0.001), 30-day readmissions (12% vs 8%; p = 0.01), and total complications (16% vs 9%; p < 0.001) after ER implementation. In multivariable models, American Society of Anesthesiologists Physical Status Classification, hypertension, smoking, ER, and laparoscopy were independently associated with complication risk.

CONCLUSIONS

Implementation of ER across VSQC was associated with reduction in LOS and complications in patients undergoing elective laparoscopic colectomy.