In this study, we prospectively collected and retrospectively analyzed bowel resection patients in a single institution both before and after implementation of an ERAS protocol. Overall, the greatest effect of the Enhanced Recovery interventions was observed in decreased length of stay of 1.8 days on average. This resulted in a net savings of approximately $3,000 per patient at our institution. Notably, there was no statistically significant difference in the rates of any complication nor readmissions pre and post ERAS. Additionally, rates of commonly reported colorectal complications are commensurate with nationally reported rates.14,15 It is unclear why our institution did not see an improvement in complication rates as demonstrated in other meta-analyses of ERAS trials.16,17 However, we did not see an increase in readmission rates either, which is frequently reported in other studies.18
The study was not randomized, and this is a limitation. The intervention (ie/ ERAS protocol) was not blinded, and this is a source of potential bias. However, patient groups pre and post were comparable in demographics and comorbidities. It was necessary to maximize the number of patients subjected to protocol in a short period, and this required a total overhaul in the institutional practice. Our compliance rate for usage of pre-op and post-op order sets was 75.89%, while the rate for usage of pre-op or post-op order sets was 93.75%. These rates are commensurate with other published rates.18,19
One of the most important components was the support of the organization, which permitted the needed devoted meetings with all representatives of pre, trans, and post operative levels of care. Every relevant party was included. The changes hoped for were discussed, and there was consensus. These interventions started in the clinic setting at the network level, and flowed through the perioperative period. The unique, complex nature of implementing these changes may also represent a limitation of generalizability to other organizations.
In retrospect, there were certain ERAS interventions that particularly made a difference in our practice. These included the following: Avoidance of preoperative bowel preparation; Usage of carbohydrate loading; Multimodal pain management (including liposomal bupivacaine); Avoidance of routine intra/post-operative nasogastric decompression; Early removal of urinary catheters; Early cessation of intravenous fluids postoperatively; Usage of Alvimopan; Early regular diet and ambulation. The full order sets can be seen in Appendix 2.++
At the core, the sustainable endpoint of any project implementation requires shifting culture by convincing those involved of the intrinsic benefits. From a patient’s perspective, this may include convincing a patient that carbohydrate loading, early ambulation, and a clear recovery timeline will be best for them. This was accomplished through clear, lay-term pamphlets in clinic and prominent ERAS-educational whiteboards in patient rooms. From a health caregiver-provider perspective, this included in-service training providing convincing data that their patient’s would benefit from the interventions.
We believe this demonstrates that ERAS is feasible for rural hospitals, despite unique challenges in the rural setting. Lack of human labor, poor communication and collaboration, resistance to change, rotating residents, and patient factors (such as comorbidity and socioeconomic disadvantages) have all been listed as barriers in other publications.20,21 Table 3 demonstrates how a “rural-specific barrier” to implementation can be overcome, yielding a sustainable endpoint. Several of these sustainable endpoints are difficult to quantify, such as trusted relationships or lessened burden of opioid addiction on the community. There is opportunity for more research therein.
Table 3
Rural-Specific Barrier
|
Implementation
|
Sustainable Endpoint
|
Patient’s travel distance to hospital
|
Build “hub and spoke” model hospital network
|
Surgery performed at larger hospital but patients are seen closer to home for pre- and post-operative visits
|
Poor patient health literacy
|
Design communicable pre- and post-operative counseling
(pamphlets and posters created, in lay terms) and offer easy access for communication via telephone or internet
|
Trusted relationships develop between patients and providers
|
Relatively low-volume surgical practice
|
Use evidence-based changes in practice
|
Improved outcomes yield change of culture
|
Care staff education challenges in the face of workforce shortages and high turnover
|
Streamline processes, standardized order sets, educate staff about the benefits of ERAS
|
Measurable goals are transparent for all. Intrinsic motivation of caregivers that ERAS is best for patients. Reduce total patient-days on wards.
|
Few financial resources for equipment and medication, higher percent Medicare and Medicaid patients, lower reimbursement
|
Implement accelerated post-operative track with safe discharge. Prioritize stock of ERAS components, multimodal analgesia and justify to payers and administrators
|
Cost-containment through lower LOS, complications and readmission
|