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Enhanced Recovery After Surgery - USA

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Nowai Keleekai-Brapoh, PhD, RN, NPD-BC1 Kirk W. Kerr, PhD2 Florise Altino-Pierre, MSN, RN, NEA-BC3 Nathalie De Leon, MSN, RN3 Lauren Krause, MBA, RN3 Karen Suczewski, MS, BSN, RN-BC3 Christina Agnellino, MSN, APN, AGACNP4 Bridget A. Cassady, PhD, RDN, LD2, Bertram Chinn, MD3
1Penn Medicine Princeton Health 2Abbott Nutrition 3Overlook Medical Center 4NAPA Anesthesia

Overlook Medical Center (OMC), a 504-bed teaching hospital in United States implemented a comprehensive Enhanced Recovery After Surgery (ERASŪ) program for elective colorectal surgery patients in July 2018 (outlined in Figure 1). A unique feature of this program was its pre-operative nutrition assessment, diet recommendations, provision of pre-operative immunonutrition, carbohydrate loading drinks, and post-operative immunonutrition in addition to multimodal pain management, early mobilization and other ERASŪ practices to optimize the overall care of patients undergoing colorectal surgeries. To understand the initial impact of the program, this quality improvement study evaluated patient outcomes during the first year of the ERASŪ program implementation.

Retrospective data for adult patients undergoing pre-defined elective abdominal/pelvic open or laparoscopic colectomies between July 2017 and July 2019 (N=206; n=103 pre-ERASŪ [July 2017-June 2018], n=103 post-ERASŪ [July 2018-July 2019]) were obtained from OMC's electronic health record (EHR) and American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIPŪ) databases post Institutional Review Board approval (Atlantic Health IRB: 1564889-1). Variables of interest included: patient demographics, opioid use measured in morphine milligram equivalents (MME), and post-operative nausea and vomiting (PONV) through post-operative day (POD) 3. All variables were compared between the pre- and post-ERASŪ implementation periods.

Post-ERASŪ patients had significantly a higher mean age (63.7 vs 60.2 years, P=0.04), lower median American Society of Anesthesiology (ASA) score (2 vs 3, P <0.01), but were not different in the share of patients with diabetes (P=0.34), Crohn's disease (P=0.12), and patients who required a stoma as part of surgery (P=0.34). Post-ERASŪ patients received significantly less opioids (45 vs 114 MME, P<0.01) and experienced significantly fewer incidents of PONV requiring unscheduled antiemetics (33 vs 51, P=0.01) through POD-3.

These real-world data suggest that implementation of an ERASŪ program significantly improved management of pain and PONV in colorectal surgery patients. This study was limited in its ability to control for patient-level differences including severity of illness and surgical complexity. Future work should establish better controls for informing comparative analysis supporting assessment of ERASŪ programs' effectiveness. Nonetheless, these initial findings support the use and effectiveness of ERASŪ programs including pre-operative carbohydrate loading and immunonutrition to improve overall quality of care and recovery of colorectal surgery patients.

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