Enhanced Recovery Programs in an Ambulatory Surgical Oncology Center

Abstract

BACKGROUND: We describe the implementation of enhanced recovery after surgery (ERAS) programs designed to minimize postoperative nausea and vomiting (PONV) and pain and reduce opioid use in patients undergoing selected procedures at an ambulatory cancer surgery center. Key components of the ERAS included preoperative patient education regarding the postoperative course, liberal preoperative hydration, standardized PONV prophylaxis, appropriate intraoperative fluid management, and multimodal analgesia at all stages. METHODS: We retrospectively reviewed data on patients who underwent mastectomy with or without immediate reconstruction, minimally invasive hysterectomy, thyroidectomy, or minimally invasive prostatectomy from the opening of our institution on January 2016 to December 2018. Data collected included use of total intravenous anesthesia (TIVA), rate of PONV rescue, time to first oral opioid, and total intraoperative and postoperative opioid consumption. Compliance with ERAS elements was determined for each service. Quality outcomes included time to first ambulation, postoperative length of stay (LOS), rate of reoperation, rate of transfer to acute care hospital, 30-day readmission, and urgent care visits ≤30 days. RESULTS: We analyzed 6781 ambulatory surgery cases (2965 mastectomies, 1099 hysterectomies, 680 thyroidectomies, and 1976 prostatectomies). PONV rescue decreased most appreciably for mastectomy (28% decrease; 95% confidence interval [CI], –36 to –22). TIVA use increased for both mastectomies (28%; 95% CI, 20-40) and hysterectomies (58%; 95% CI, 46-76). Total intraoperative opioid administration decreased over time across all procedures. Time to first oral opioid decreased for all surgeries; decreases ranged from 0.96 hours (95% CI, 2.1-1.4) for thyroidectomies to 3.3 hours (95% CI, 4.5 to –1.7) for hysterectomies. Total postoperative opioid consumption did not change by a clinically meaningful degree for any surgery. Compliance with ERAS measures was generally high but varied among surgeries. CONCLUSIONS: This quality improvement study demonstrates the feasibility of implementing ERAS at an ambulatory surgery center. However, the study did not include either a concurrent or preintervention control so that further studies are needed to assess whether there is an association between implementation of ERAS components and improvements in outcomes. Nevertheless, we provide benchmarking data on postoperative outcomes during the first 3 years of ERAS implementation. Our findings reflect progressive improvement achieved through continuous feedback and education of staff.

Implementation of an enhanced recovery protocol in patients undergoing mastectomies for breast cancer: an interrupted time-series design

“…The initial mastectomy protocol led to an increase in TIVA usage by 28% (95% CI, 20–40). 2 However, despite the known benefits of TIVA, anesthesia providers describe being hesitant to use the technique due to reasons such as an increased setup time, risk of missing drug delivery, and lack of real-time monitoring of propofol concentration. 17 Our study demonstrated a large increase of TIVA usage following the protocol updates.…”

“… 1 We implemented an enhanced recovery protocols (ERP) to standardize and optimize care. 2 One of the primary endpoints of the total breast mastectomy ERP was the reduction of postoperative nausea and vomiting (PONV), which can lead to dehydration, wound dehiscence, pain, immobility, increased length of hospital stays, and decreased patient satisfaction. 3 We initially presented the protocol at a departmental meeting, and then distributed printed copies to each of the operating rooms for reference.…”

“…Between January 4, 2016 and December 31, 2018, our rates of postoperative nausea and vomiting rescue administration dropped by 28% in patients undergoing mastectomies (95% CI, 22–36). 2 …”

Assessing Postoperative Benefits of a Nerve Block: Study Design is Critical [Letter]

“…However, this study did not observe the main quality outcomes of enhanced recovery after surgery protocols, such as the time to first ambulation, length of hospital stay, rates of transfer to acute care hospital, readmission, and others. 7 Because of this limitation, an important issue that this study cannot answer is whether improved postoperative quality of recovery provided by the TPVB can be really translated into the clinical benefits of patient outcomes.…”

Enhanced Recovery Programs in an Ambulatory Surgical Oncology Center: Erratum

“…The article, “Enhanced Recovery Programs in an Ambulatory Surgical Oncology Center,” 1 that appeared in the December 2021 issue on pages 1391-1401 contained an error on page 1398. “Table 3” was incorrectly cited in the following sentence: “Compliance exceeded 90% for the majority of ERAS elements across all programs (Table 3) …”…”