Evaluating variation in enhanced recovery for colorectal surgery: a report from the Surgical Care Outcomes Assessment Program

Abstract

Aim: Robust data demonstrate that enhanced recovery protocols (ERPs) decrease length of stay, complications and cost. However, little is known about the reasons for variation in compliance with ERPs. The aim of this work was to confirm the efficacy of ERPs in a regional network, and to determine factors that are associated with ERP delivery in diverse hospital settings.Method: A prospective cohort of patients was created by recording all elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP). The delivery of 12 ERP components was tracked at all sites, and factors associated with ERP component delivery and affecting outcomes were reported. Results: From 2016 to 2019, 9274 elective colorectal operations were performed at 36 hospitals. Indications were 48% cancer, 23% diverticulitis and 8% inflammatory bowel disease. Minimally invasive surgery was used in 71%. The proportion of cases with six or more ERP components received increased from 23% in 2016 to 50% in 2019. An increase in components was associated with a shorter length of stay and fewer combined adverse events and reinterventions. Further, increasing numbers of ERP components provided an incremental benefit to patients even when delivered in a low-volume centre or by a lowvolume surgeon, and regardless of patient presentation. Conclusion:At SCOAP hospitals, the delivery of increasing numbers of ERP components was associated with improved perioperative outcomes and decreased complications after elective colorectal surgery. The variation in delivery of these evidence-based components in subsets of our cohort indicates an important opportunity for quality improvement initiatives.

The Impact of Prolonged Operative Time Associated with Minimally Invasive Colorectal Surgery: A Report from the Surgical Care Outcomes Assessment Program

“…Prior work from the SCOAP collaborative showed that MIS colorectal operations were more likely to receive more ERAS components perioperatively, but ERAS implementation had benefits in all operations, especially those with an open approach. 39 A fifth limitation is the lack of information surrounding the conversion of MIS operations to open, including the reason for conversion or at what time in the operation the conversion occurred, as these data are not captured in SCOAP. As such, we cannot tell from our data whether an earlier conversion may have sped up an operation.…”

Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter, single-blinded, randomized controlled trial

“…Second, each participating hospital was allowed to use their own site-specific ERP which may have impacted postoperative outcomes. Studies have reported an association between the number of ERP components and risk for postoperative complications [ 20 ]. However, it would have been difficult to ask each site to adhere to a uniform ERP, and this was a pragmatic trial.…”