The American College of Surgeons (ACS)—in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD—continues to support U.S. hospitals that are adopting enhanced recovery pathways. This enhanced recovery program—the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR)—launched in the fall of 2016 with funding and guidance from AHRQ.
This article looks at the rationale for starting ISCR, where the program has been, where it’s going, and the benefits of participation. It also highlights a new opportunity to join the program and focus on improving the care of patients undergoing emergency general surgery, as well as new program enhancements designed to help hospitals improve opioid stewardship for surgical patients.
In an effort to provide health care providers and other stakeholders with examples of how ISCR is improving patient care, the experiences of three participating hospitals are described in this article.
The relevance of enhanced recovery programs
Enhanced recovery practices foster patient and family engagement, avoidance of prolonged periods of fasting, appropriate use of both multimodal analgesia and intravenous fluids, early mobility, and adherence to best practices for preventing complications, such as surgical site infection (SSI), venous thromboembolism, and urinary tract infections. The surgical community has embraced enhanced recovery techniques because they have been proven to result in better outcomes. Today, enhanced recovery is the standard of care for elective colorectal surgery, with strong evidence in support of adoption in other specialties as well. This approach to perioperative care emphasizes standardized, evidence-based care that incorporates both patients and families, as well as the entire care team. These enhanced recovery pathways have been associated with reduced surgical complications, improved patient experience, and decreased length of stay without increased readmission rates.1-5
Yet, despite the overriding support for the adoption of enhanced recovery, implementation at hospitals has been challenging for myriad reasons, including challenges related to obtaining physician buy-in and leadership support, coordinating electronic health records (EHRs), and limited resources for auditing performance and developing a data-driven improvement program.
Given the importance of ensuring consistent evidence-based perioperative care for our patients, the ISCR program launched in 2016 to accelerate adoption by disseminating easy-to-use materials and providing implementation support to U.S. hospitals that are seeking to implement enhanced recovery practices within the framework of the Comprehensive Unit-based Safety Program (CUSP). CUSP is a well-known model for sustainable safety improvement that has been associated with preventing harm in multiple areas.6-14 Since the start of the first ISCR cohort in July 2017, the program has supported more than 300 hospitals in implementing evidence-based surgical care in four procedure areas including colorectal, orthopaedics (hip and knee repair), and gynecologic surgery. An upcoming cohort is set to start in March with a new focus on emergency general surgery, but hospitals will still be able to join and work on colorectal pathways as well.
Over the last three years, ISCR program administrators have worked closely with hospitals during the implementation stage. In the process, ISCR leaders have learned some valuable lessons. What we discovered from recent site visits conducted at three ISCR hospitals follows.
Lesson one: Regularly meet as a team
Assembling a multidisciplinary perioperative team is one of the first and most critical steps in a hospital’s ISCR journey. ISCR teams at all three sites met at least monthly, providing a structured forum for solving problems, sharing data, and keeping goals front and center. Importantly, these face-to-face meetings also provided an opportunity for team members to form relationships with staff from across the continuum of care who may have had limited opportunities for engagement.
In one hospital, interest in enhanced recovery pathways was cropping up in siloed efforts initiated by small groups of surgeons, with little effort to engage other staff who play an integral role in the pathway. The hospital used the ISCR program and team meetings to centralize enhanced recovery efforts across the hospital to ensure that key stakeholders were involved in all of the enhanced recovery programs in the hospital, foster the spread of best practices (both clinical and implementation), and gain efficiencies in the development of EHR order sets.
Lesson two: Provide multimodal education
A core element of enhanced recovery pathways is the use of multimodal analgesia. A nurse manager at one site noted that implementation of the pathways also requires a multimodal education component; that is, the use of education strategies that are tailored to different audiences. In the early stages of implementation, all sites emphasized the need to present their colleagues with credible evidence of the effectiveness of the pathway (particularly to physician colleagues) and the importance of explaining why the pathway is being implemented (particularly to nurse colleagues). In later stages of the implementation process, one participant described her strategy of using “pearls of wisdom” to distill new information into specific actions that staff could readily absorb. In sustaining the pathway, participants also highlighted the need to regularly provide feedback to frontline staff about their individual performance and to celebrate improvements in patient outcomes. Of interest, at a few sites, the anesthesia providers were not receiving feedback or follow-up on their efforts, and they felt they should be included in the efforts to share both process and outcome data, even if not directly related to their practice.
Lesson three: Be resilient in the face of staff turnover
Staff turnover is, unfortunately, a regular occurrence and can often stifle a project’s momentum. In all three hospitals visited, a champion or project lead left at some point in the implementation process. At one hospital, the loss of a surgeon champion meant putting the enhanced recovery pathway on hold for that surgical specialty and shifting the focus to other surgical specialties that did have an active champion. At another hospital, the departure of the ISCR project lead created an opportunity for other team members to rally around the project, leading to a more decentralized network of staff who were invested in the implementation process.
Staff turnover also can support the implementation process in unexpected ways. For example, at one hospital, an anesthesiologist who resisted the program left the practice, and a new anesthesiologist, who embraced enhanced recovery pathways, was hired. This new anesthesia champion then was able to make significant headway in advancing the pathway’s implementation.
How has the ISCR program helped hospitals?
The two hospitals that were relatively new to implementing enhanced recovery pathways used ISCR program materials extensively—from learning how to structure a multidisciplinary project team to adapting patient education booklets and EHR order sets to match their local needs. The third hospital, which had implemented a pathway several years earlier, found benefit in the structured team meetings to optimize and sustain changes to the pathway, as well as the benchmarking data provided through the ISCR program. As evidenced by this small sample of sites, the ISCR program can support a hospital’s enhanced recovery implementation journey and overall comfort and skills with perioperative quality improvement in many ways.
Introduction of emergency general surgery
Although much of the work in enhanced recovery has focused on the elective colorectal surgery population, hospitals sometimes extend enhanced recovery care pathways to patients undergoing emergency colorectal surgery, as well as an extension of best perioperative practices. Each year, more than 900,000 patients in the U.S. undergo surgery for emergency general surgery conditions.15 Some of the most common procedures include laparotomies to treat diverticulitis, bowel obstructions, perforated ulcers, and incarcerated hernias, as well as cholecystectomies and appendectomies. Overall, emergency general surgery procedures are less studied than the equivalent elective procedures, but, unquestionably, emergency general surgery is performed on complex patients, with up to 50 percent of these individuals having comorbid conditions.15 Postoperative complications, although they vary significantly by type of procedure, can be upward of 50 percent.15
Despite the tremendous potential to improve, the diverse presentation and severity of disease has made systematic quality improvement efforts in emergency general surgery challenging. Although there have been local efforts to develop clinical pathways and standardize clinical care across some emergency general surgery procedures, there are few reports of systematic and scalable efforts. More than 30 percent of ISCR hospitals have organically spread their colorectal enhanced recovery program to patients undergoing emergency colorectal procedures. With the final cohort of the ISCR program, the national project team will offer the chance to be part of a large-scale learning collaborative that will help us begin to understand how to systematically and broadly apply both enhanced recovery principles and standardized care pathways in patients undergoing emergency general surgery procedures.
These pathways—developed in conjunction with leading experts in emergency general surgery and further vetted with a large multidisciplinary group of national stakeholders—will adhere to the same common tenets that are the backbone of enhanced recovery: patient education, early mobility after surgery, reduced periods of fasting, multimodal analgesia, and health care-acquired infection processes. The recommended pathways also will highlight some of the challenges unique to emergency general surgery, including opportunities to improve antimicrobial stewardship, time to the operating room, and understanding the influence of social determinants of health in both process measure adherence and clinical outcomes.
Introduction of discharge opioid prescribing tools
Multimodal analgesia has been a core tenet of enhanced recovery, but discharge prescribing has been included in only a few pathways. In light of the opioid crisis—clear evidence that patients are prescribed more opioids than needed after an operation—and the inconsistent use of nonopioid analgesia, the ISCR program has incorporated evidence-based recommendations for all pathway procedures starting in 2020.16-18 To support implementation of these recommendations, patient-facing education on safe pain control and an opportunity to track and benchmark prescribing over time using the ACS data registry will be available.
Benefits of participation
Participating hospitals receive a ready-to-use pathway developed using the latest evidence reviews, access to education materials on how to implement the pathway, access to experts in performance improvement and education who will help them troubleshoot as they implement, and inclusion in a community of surgeons and perioperative teams rolling out the same pathway. Furthermore, the program has developed an outstanding resource in the vibrant community of surgeons, nurses, and anesthesia providers committed to like-minded work.
Enrolled hospitals also have the opportunity to join monthly coaching calls that focus on learning from peers and sharing best practices, as well as special topic calls presented by national leaders who highlight best practices and encourage participants to ask specific questions about evidence. Coaching calls are conversational and have included discussions on patient and staff education about enhanced recovery and program implementation, leading and coordinating change efforts, best approaches to EHR order sets, and challenges associated with specific clinical practice changes, such as adoption of the mechanical bowel preparation with oral antibiotics for SSI prevention in colorectal surgery or nonsteroidal anti-inflammatory use as part of a comprehensive multimodal analgesia program. National leaders in quality, including Joseph Caprini, MD, FACS (venous thromboembolism); Sanjay Saint, MD (urinary tract infections); and Chad Brumett, MD (opioids), have shared their expertise with program participants. One-on-one support for both program implementation and data collection is available to all participating hospitals.
Collecting process and outcomes data to assess adherence to pathway elements and measure improvements in patient outcomes is a key component in gaining buy-in for this program, optimizing effectiveness, and sustaining the work. All participating hospitals have access to a registry that incorporates the lessons learned from the ACS Quality Programs and is focused on the pathways process measures and key outcomes. Support is available for hospital data abstractors, and all hospitals have access to reports that benchmark their performance against other participating hospitals to help drive local conversations and engagement.
How to enroll
ISCR is especially useful to hospitals that meet the following criteria:
- Have no prior enhanced recovery implementation experience
- Have implemented enhanced recovery in one procedure area and are looking to expand to other areas
- Have attempted to implement enhanced recovery pathways but did not experience significant improvements or were unable to sustain the program
The program team is now recruiting hospitals to participate in the fourth cohort, which will focus on colorectal and emergency general surgery. Hospitals are encouraged to begin enrollment now in order to participate in the 18-month program that starts March 2020.
To enroll or learning more about the program or about participation in any of the cohorts, e-mail ISCR@facs.org.
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- Thiele RH, Rea KM, Turrentine FE, et al. Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430-443.
- Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg. 2014;149(9):955-961.
- Nicholson A, Lowe MC, Parker J, et al. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. BJS. 2014;101(3):172-188.
- Grant MC, Yang D, Wu CL, Makary MA, Wick EC. Impact of enhanced recovery after surgery and fast track surgery pathways on healthcare-associated infections: Results from a systematic review and meta-analysis. Ann Surg. 2017;265(1):68-79.
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related blood stream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
- Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter-related bloodstream infections in Michigan intensive care units: An observational study. BMJ 2010;340:c309.
- Berenholtz SM, Pham JC, Thompson DA, et al. An intervention to reduce ventilator-associated pneumonia in the ICU. Infect Control Hosp Epidemiol. 2011;32(4):305-314.
- Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: Retrospective comparative analysis. BMJ. 2011;342:d219.
- Agency for Healthcare Research and Quality. AHRQ patient safety project reduces bloodstream infections by 40 percent. Available at: https://psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent. Accessed November 7, 2019.
- Waters HR, Korn R Jr, Colantuoni E, et al. The business case for quality: Economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011;26(5):333-339.
- Wick EC, Hobson D, Bennett J, et al. Implementation of a surgical Comprehensive Unit-based Safety Program (CUSP) to reduce surgical site infections. J Am Coll Surg. 2012;215(2):193-200.
- Timmel J, Kent PS, Holzmueller CG, et al. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36(6):252-260.
- Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934-939.
- Gale SC, Shafi S, Dombrovskiy VY, Arumugam D, Crystal JS. The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample—2001 to 2010. J Trauma Acute Care Surg. 2014;77(2):202-208.
- Council of Economic Advisers. The underestimated cost of the opioid crisis. November 2017. Available at: www.whitehouse.gov/search/?s=Underestimated+cost+of+the+opioid+crisis. Accessed November 7, 2019.
- Lev R, Lee O, Petro S, et al. Who is prescribing controlled medications to patients who die of prescription drug abuse? Am J Emerg Med. 2016;34(1):30-35.
- Hill MV, McMahon ML, Stucke RS, Barth RJ, Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2016;265(4):709-714.