Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery

Robert H. Thiele, Kathleen M. Rea, Florence E. Turrentine, Charles M. Friel, Taryn E. Hassinger, Bernadette J. Goudreau, Bindu A. Umapathi, Irving L. Kron, Robert G. Sawyer, Traci L. Hedrick, Timothy L. McMurry

Research output: Contribution to journalArticle

139 Citations (Scopus)

Abstract

Background Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. Study Design A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. Results One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. Conclusions Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.

Original languageEnglish (US)
Pages (from-to)430-443
Number of pages14
JournalJournal of the American College of Surgeons
Volume220
Issue number4
DOIs
StatePublished - Apr 1 2015
Externally publishedYes

Fingerprint

Colorectal Surgery
Length of Stay
Costs and Cost Analysis
Patient Satisfaction
Patient Participation
Cost Savings
Resuscitation
Laparoscopy
Analgesia
Morphine
Opioid Analgesics
Walking
Counseling
Morbidity

ASJC Scopus subject areas

  • Surgery

Cite this

Standardization of care : Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. / Thiele, Robert H.; Rea, Kathleen M.; Turrentine, Florence E.; Friel, Charles M.; Hassinger, Taryn E.; Goudreau, Bernadette J.; Umapathi, Bindu A.; Kron, Irving L.; Sawyer, Robert G.; Hedrick, Traci L.; McMurry, Timothy L.

In: Journal of the American College of Surgeons, Vol. 220, No. 4, 01.04.2015, p. 430-443.

Research output: Contribution to journalArticle

Thiele, RH, Rea, KM, Turrentine, FE, Friel, CM, Hassinger, TE, Goudreau, BJ, Umapathi, BA, Kron, IL, Sawyer, RG, Hedrick, TL & McMurry, TL 2015, 'Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery', Journal of the American College of Surgeons, vol. 220, no. 4, pp. 430-443. https://doi.org/10.1016/j.jamcollsurg.2014.12.042
Thiele, Robert H. ; Rea, Kathleen M. ; Turrentine, Florence E. ; Friel, Charles M. ; Hassinger, Taryn E. ; Goudreau, Bernadette J. ; Umapathi, Bindu A. ; Kron, Irving L. ; Sawyer, Robert G. ; Hedrick, Traci L. ; McMurry, Timothy L. / Standardization of care : Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. In: Journal of the American College of Surgeons. 2015 ; Vol. 220, No. 4. pp. 430-443.
@article{ebbb1299440a4e49bf3ebcbfa87fa636,
title = "Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery",
abstract = "Background Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. Study Design A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. Results One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. Conclusions Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.",
author = "Thiele, {Robert H.} and Rea, {Kathleen M.} and Turrentine, {Florence E.} and Friel, {Charles M.} and Hassinger, {Taryn E.} and Goudreau, {Bernadette J.} and Umapathi, {Bindu A.} and Kron, {Irving L.} and Sawyer, {Robert G.} and Hedrick, {Traci L.} and McMurry, {Timothy L.}",
year = "2015",
month = "4",
day = "1",
doi = "10.1016/j.jamcollsurg.2014.12.042",
language = "English (US)",
volume = "220",
pages = "430--443",
journal = "Journal of the American College of Surgeons",
issn = "1072-7515",
publisher = "Elsevier Inc.",
number = "4",

}

TY - JOUR

T1 - Standardization of care

T2 - Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery

AU - Thiele, Robert H.

AU - Rea, Kathleen M.

AU - Turrentine, Florence E.

AU - Friel, Charles M.

AU - Hassinger, Taryn E.

AU - Goudreau, Bernadette J.

AU - Umapathi, Bindu A.

AU - Kron, Irving L.

AU - Sawyer, Robert G.

AU - Hedrick, Traci L.

AU - McMurry, Timothy L.

PY - 2015/4/1

Y1 - 2015/4/1

N2 - Background Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. Study Design A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. Results One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. Conclusions Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.

AB - Background Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. Study Design A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. Results One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. Conclusions Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.

UR - http://www.scopus.com/inward/record.url?scp=84925651451&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84925651451&partnerID=8YFLogxK

U2 - 10.1016/j.jamcollsurg.2014.12.042

DO - 10.1016/j.jamcollsurg.2014.12.042

M3 - Article

C2 - 25797725

AN - SCOPUS:84925651451

VL - 220

SP - 430

EP - 443

JO - Journal of the American College of Surgeons

JF - Journal of the American College of Surgeons

SN - 1072-7515

IS - 4

ER -