Study shows postimplementation audits lead to improved enhanced recovery pathway compliance

According to a study in the October 2017 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), use of a novel auditing strategy was useful in identifying outliers among patients undergoing an enhanced recovery pathway (ERP) program.* These audits also aided in the use of care interventions that led to a significant reduction in the average length of stay (LOS) for a resource-intensive patient population.

What are ERPs?

ERPs, including enhanced recovery after surgery (ERAS) programs, were first implemented widely in Europe and have more recently been adopted in the U.S. These programs incorporate a number of evidence-based measures (such as minimizing the use of nasogastric suction and drains, early mobilization, and carbohydrate loading before an operation) that are associated with a more rapid recovery and substantial decreases in the LOS. As these programs became more widely adopted in the U.S., most efforts have been directed at the creation of the pathways, with less attention to enrollment of patients in the pathways, the completion of all processes contained in the pathway, and the postimplementation fate of those pathways.

ERPs are bundled best-practice process measures that are associated with reductions in preventable harm, decreased LOS in health care settings, and increased overall value of care. ERPs can have more than 20 unique elements and cover many care settings. They also are some of the best examples of successful adoption of a systems-based approach in surgery. The study’s authors state ERP teams must work together to engage patients and their families to be partners in their care, adhere to best practices regarding patient care processes, and use Robust Process Improvement methods to optimize implementation and performance.

Study purpose

The author of the study, “Optimizing an enhanced recovery pathway program: Development of a postimplementation audit strategy,” Michael C. Grant, MD, assistant professor of anesthesiology and critical care medicine, Johns Hopkins University School of Medicine, Baltimore, MD, and his coauthors suggest that postimplementation evaluation and continued improvement to pathways is essential to ensure their success. Indeed, recruitment of all patients who qualify and process measure compliance are crucial elements that determine the success of ERPs.

The audit involved the continual use of postimplementation evaluation, which the authors believe fostered improved teamwork, focused on patient engagement, and promoted local and organizational culture shifts.

Although the authors state that “there is mounting evidence to support the technical interventions that are usually included in ERPs,” there hasn’t been much reporting on “strategies using either process implementation or postproduction evaluation and optimization of ERP programs from the frontline provider perspective.” The authors posited they could address these elements by developing an audit strategy that would account for the burden of collecting data while also tapping into the knowledge of frontline providers to improve an ERP program.

Prior to this study, the authors had reported on the development and data provided from a multidisciplinary ERP for colorectal surgery at Johns Hopkins Hospital—a 1,059-bed tertiary care academic medical center. The patients who underwent elective outpatient colorectal surgery—performed by a specific surgeon on the staff—were placed on the ERP.

Study methodology and findings

The ERP factored in 18 process measures, divided into three categories:

  • Prior to surgery (such as preoperative counseling regarding surgery; anesthesia; pain management and recovery; and carbohydrate drink, 20 ounces, two hours before the procedure)
  • Date of surgery (such as preoperative venous thromboembolism prophylaxis administered prior to incision, and prophylactic intravenous antibiotic administration before incision)
  • After surgery (such as early and progressive mobilization, early resumption of oral intake, and minimal or no use of intravenous fluids)

The ERP processes were reviewed by frontline providers to determine how to define compliance and noncompliance. Later, to determine compliance with the key process measures, an ERP form was created to provide structure for data abstraction from the electronic health record and team discussions about ways to improve.

The audit took place over a 12-month period. The year before the ERP was used, 397 patients underwent a “traditional colorectal surgical treatment paradigm.” An average LOS was determined for each procedure subtype, and overall average LOS was 6.9 days. This included averages for operations such as:

  • Open colectomy (7.2 days)
  • Laparoscopic colectomy (5.1 days)
  • Open rectal procedures (7.4 days)
  • Laparoscopic rectal procedures (5.7 days)
  • Open small bowel resections (3.8 days)
  • Laparoscopic small bowel resections (3.2 days)
  • Other procedures (4.9 days)

During the study, the electronic health records for 413 consecutive patients were evaluated. A total of 102 patients (24.7 percent) were defined as outliers, while 311 patients were deemed successes. The LOS for the outliers was significantly longer (12.2 days) than for those cases considered successes (3.6 days).

Overall, LOS was significantly reduced in the quarter following use of the ERP in comparison with both the previous quarter and the previous year. This decrease continued for each quarter through the entirety of the study. The authors note, however, “Following optimization of the ERP, the average LOS for outliers was significantly reduced compared to the prior ERP quarter…as well as compared to all outliers over the prior year.”


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


*Grant MC, Galante DJ, Hobson DB, et al. Optimizing an enhanced recovery pathway program: Development of a postimplementation audit strategy. Jt Comm J Qual Patient Saf. 2017;43(10):524-533.

Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg. 2010;14(1):88-95.

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