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Hip fracture outcomes are the next ERAS improvement goal
ORLANDO – compared with patients treated before the intervention, an investigator reported at the American College of Surgeons Quality and Safety Conference.
These patients had a lower pneumonia rate and were more often discharged to home from acute care after the program was implemented, according to Lila Gottenbos, RN, BSN, of Langley (B.C.) Memorial Hospital.
The intervention incorporated some traditional enhanced recovery after surgery (ERAS) process measures, along with others that were not so traditional, Ms. Gottenbos said. “Implementing ERAS in a fractured hip patient population is possible, and by doing so, more patients go home faster to their previous places of residence with fewer complications.”
A multidisciplinary team at Langley Memorial Hospital, a 200-bed community hospital with approximately 6,000 surgical procedures performed each year, has used ERAS measures in their colorectal patient population since 2013. Those measures have been successful in creating a sustained reduction in morbidity and length of stay, according to Ms. Gottenbos.
The team began searching for other patient populations who might also benefit. They chose to focus on the fractured hip population, which in 2015 had a 9.7% mortality rate, 17% morbidity rate, 5% pneumonia rate, and 19% rate of discharge to home from acute care. “We looked at this data and we realized we had a significant opportunity to do better for our patients,” Ms. Gottenbos told meeting attendees.
The team developed ERAS-based process measures tailored specifically to pre- and postoperative challenges in the fractured hip patient population, Ms. Gottenbos said. Measures included preoperative patient and family education, elimination of prolonged preoperative NPO status, early mobilization, assessment of mentation, and use of standardized order sets. The protocol has been applied to every hip fracture patient who has had surgery from January 2016 to the present. The hospital averages 110 of these procedures per year.
Fractured hip mortality dropped after the modified ERAS process measures were adopted, Ms. Gottenbos reported. Measured to 30 days postoperatively, mortality decreased from 9.7% in 2015 to 4.2% by 2017. Similarly, fractured hip morbidity within 30 days, excluding transfusion, dropped from 17.7% in 2015 to 11.7% in 2017, and fractured hip pneumonia dropped from 5.4% to 2.5%.
Perhaps the most telling evidence of success, according to the presenter, was the increase in the number of patients going home from acute care: “Before ERAS, fractured hip patients were going home to their place of residence less than 20% of the time from the acute care setting, meaning they were languishing in the hospital, in a convalescent unit, in a rehab unit, or worse, residential care,” she said. “We’ve been able to increase that to over 43%.”
The program is ongoing. A multidisciplinary team meets monthly to review outcomes data and devise strategies to improve compliance with the process measures. “It’s an iterative process, and it’s one that’s worked very well for us so far,” Ms. Gottenbos remarked.
The investigator had no disclosures.
ORLANDO – compared with patients treated before the intervention, an investigator reported at the American College of Surgeons Quality and Safety Conference.
These patients had a lower pneumonia rate and were more often discharged to home from acute care after the program was implemented, according to Lila Gottenbos, RN, BSN, of Langley (B.C.) Memorial Hospital.
The intervention incorporated some traditional enhanced recovery after surgery (ERAS) process measures, along with others that were not so traditional, Ms. Gottenbos said. “Implementing ERAS in a fractured hip patient population is possible, and by doing so, more patients go home faster to their previous places of residence with fewer complications.”
A multidisciplinary team at Langley Memorial Hospital, a 200-bed community hospital with approximately 6,000 surgical procedures performed each year, has used ERAS measures in their colorectal patient population since 2013. Those measures have been successful in creating a sustained reduction in morbidity and length of stay, according to Ms. Gottenbos.
The team began searching for other patient populations who might also benefit. They chose to focus on the fractured hip population, which in 2015 had a 9.7% mortality rate, 17% morbidity rate, 5% pneumonia rate, and 19% rate of discharge to home from acute care. “We looked at this data and we realized we had a significant opportunity to do better for our patients,” Ms. Gottenbos told meeting attendees.
The team developed ERAS-based process measures tailored specifically to pre- and postoperative challenges in the fractured hip patient population, Ms. Gottenbos said. Measures included preoperative patient and family education, elimination of prolonged preoperative NPO status, early mobilization, assessment of mentation, and use of standardized order sets. The protocol has been applied to every hip fracture patient who has had surgery from January 2016 to the present. The hospital averages 110 of these procedures per year.
Fractured hip mortality dropped after the modified ERAS process measures were adopted, Ms. Gottenbos reported. Measured to 30 days postoperatively, mortality decreased from 9.7% in 2015 to 4.2% by 2017. Similarly, fractured hip morbidity within 30 days, excluding transfusion, dropped from 17.7% in 2015 to 11.7% in 2017, and fractured hip pneumonia dropped from 5.4% to 2.5%.
Perhaps the most telling evidence of success, according to the presenter, was the increase in the number of patients going home from acute care: “Before ERAS, fractured hip patients were going home to their place of residence less than 20% of the time from the acute care setting, meaning they were languishing in the hospital, in a convalescent unit, in a rehab unit, or worse, residential care,” she said. “We’ve been able to increase that to over 43%.”
The program is ongoing. A multidisciplinary team meets monthly to review outcomes data and devise strategies to improve compliance with the process measures. “It’s an iterative process, and it’s one that’s worked very well for us so far,” Ms. Gottenbos remarked.
The investigator had no disclosures.
ORLANDO – compared with patients treated before the intervention, an investigator reported at the American College of Surgeons Quality and Safety Conference.
These patients had a lower pneumonia rate and were more often discharged to home from acute care after the program was implemented, according to Lila Gottenbos, RN, BSN, of Langley (B.C.) Memorial Hospital.
The intervention incorporated some traditional enhanced recovery after surgery (ERAS) process measures, along with others that were not so traditional, Ms. Gottenbos said. “Implementing ERAS in a fractured hip patient population is possible, and by doing so, more patients go home faster to their previous places of residence with fewer complications.”
A multidisciplinary team at Langley Memorial Hospital, a 200-bed community hospital with approximately 6,000 surgical procedures performed each year, has used ERAS measures in their colorectal patient population since 2013. Those measures have been successful in creating a sustained reduction in morbidity and length of stay, according to Ms. Gottenbos.
The team began searching for other patient populations who might also benefit. They chose to focus on the fractured hip population, which in 2015 had a 9.7% mortality rate, 17% morbidity rate, 5% pneumonia rate, and 19% rate of discharge to home from acute care. “We looked at this data and we realized we had a significant opportunity to do better for our patients,” Ms. Gottenbos told meeting attendees.
The team developed ERAS-based process measures tailored specifically to pre- and postoperative challenges in the fractured hip patient population, Ms. Gottenbos said. Measures included preoperative patient and family education, elimination of prolonged preoperative NPO status, early mobilization, assessment of mentation, and use of standardized order sets. The protocol has been applied to every hip fracture patient who has had surgery from January 2016 to the present. The hospital averages 110 of these procedures per year.
Fractured hip mortality dropped after the modified ERAS process measures were adopted, Ms. Gottenbos reported. Measured to 30 days postoperatively, mortality decreased from 9.7% in 2015 to 4.2% by 2017. Similarly, fractured hip morbidity within 30 days, excluding transfusion, dropped from 17.7% in 2015 to 11.7% in 2017, and fractured hip pneumonia dropped from 5.4% to 2.5%.
Perhaps the most telling evidence of success, according to the presenter, was the increase in the number of patients going home from acute care: “Before ERAS, fractured hip patients were going home to their place of residence less than 20% of the time from the acute care setting, meaning they were languishing in the hospital, in a convalescent unit, in a rehab unit, or worse, residential care,” she said. “We’ve been able to increase that to over 43%.”
The program is ongoing. A multidisciplinary team meets monthly to review outcomes data and devise strategies to improve compliance with the process measures. “It’s an iterative process, and it’s one that’s worked very well for us so far,” Ms. Gottenbos remarked.
The investigator had no disclosures.
REPORTING FROM ACSQSC 2018
Key clinical point: Fractured hip patients managed with the ERAS protocol had improved outcomes.
Major finding: After implementation of the ERAS protocol, 43% of fractured hip patients were discharged to home, which is up from 20% before the project.
Study details: More than 200 patients treated for hip fracture during 2016-2017 at the Langley (B.C.) Memorial Hospital.
Disclosures: The investigator had no disclosures. .
Percutaneous drainage upped morbidity risk in hepatobiliary cancer patients
ORLANDO – In patients with was associated with an increased risk of death or serious morbidity versus endoscopic drainage, results of a recent retrospective study show.
Patients undergoing percutaneous transhepatic biliary drainage did have more preoperative comorbidities, compared with those undergoing endoscopic biliary stenting, according researcher Q. Lina Hu, MD, an American College of Surgeons Clinical Scholar-in-Residence.
“Nevertheless, compared to endoscopic drainage, percutaneous drainage was associated with a significantly increased morbidity and mortality, even after adjustment for measured confounders,” Dr. Hu said a presentation at the American College of Surgeons Quality and Safety Conference.
Patients with resectable hepatobiliary malignancies often present with biliary obstruction, which may increase risk of perioperative morbidity and mortality, said Dr. Hu, a general surgery resident at University of California, Los Angeles.
“Preoperative biliary drainage is thought to reduce this risk by resolving cholestasis and preserving liver function,” she said.
However, the preferred drainage technique is not established, she added.
The endoscopic approach approximates normal physiologic drainage, she said, but is associated with complications including pancreatitis and cholangitis. By contrast, percutaneous drainage has a lower contamination risk and higher rate of success, but involves external catheters and has catheter-related complications.
To evaluate associations between preoperative drainage technique and postoperative outcomes, Dr. Hu and her colleagues queried the ACS National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Hepatectomy Database. They identified 527 patients who underwent preoperative biliary drainage prior to resection between 2014 and 2017, of whom about 80% underwent endoscopic drainage and 20% underwent percutaneous drainage. The primary outcome of their analysis was 30-day death or serious morbidity.
Patients who were selected for percutaneous drainage had significantly more preoperative comorbidities, including higher American Society of Anesthesiologists class, recent weight loss, and lower albumin levels, Dr. Hu said.
Death or serious morbidity occurred in 250 of the patients, or approximately 48% of the cohort.
In unadjusted analysis, the incidence of death or serious morbidity was significantly more frequent in the percutaneous group, compared with endoscopic group. The percutaneous group also had greater odds of surgical site infection, liver failure, bile leakage, and prolonged length of stay.
Those associations remained significant for death or serious morbidity and surgical site infection in both multivariable– and propensity score–adjusted models, Dr. Hu said.
In a propensity score–matched model, 93 patients who received percutaneous drainage were matched one-to-one to 93 patients who received endoscopic drainage based on relevant baseline characteristics. In that rigorous analysis, the odds ratio for death or serious morbidity was 2.17 (95% confidence interval, 1.16-4.09), according to the report.
“Death and serious morbidity was significantly associated with percutaneous drainage across all models, suggesting that patients receiving percutaneous drainage were more likely to experience an adverse event, compared to patients receiving endoscopic drainage,” Dr. Hu said.
However, Dr. Hu acknowledged the limitations of the retrospective study, noting that propensity score adjustment and matching accounts for measured confounders. “It obviously cannot account for any unmeasured confounders,” she said.
Dr. Hu reported funding from the Agency for Healthcare Research and Quality related to her position. She had no disclosures related to her presentation.
ORLANDO – In patients with was associated with an increased risk of death or serious morbidity versus endoscopic drainage, results of a recent retrospective study show.
Patients undergoing percutaneous transhepatic biliary drainage did have more preoperative comorbidities, compared with those undergoing endoscopic biliary stenting, according researcher Q. Lina Hu, MD, an American College of Surgeons Clinical Scholar-in-Residence.
“Nevertheless, compared to endoscopic drainage, percutaneous drainage was associated with a significantly increased morbidity and mortality, even after adjustment for measured confounders,” Dr. Hu said a presentation at the American College of Surgeons Quality and Safety Conference.
Patients with resectable hepatobiliary malignancies often present with biliary obstruction, which may increase risk of perioperative morbidity and mortality, said Dr. Hu, a general surgery resident at University of California, Los Angeles.
“Preoperative biliary drainage is thought to reduce this risk by resolving cholestasis and preserving liver function,” she said.
However, the preferred drainage technique is not established, she added.
The endoscopic approach approximates normal physiologic drainage, she said, but is associated with complications including pancreatitis and cholangitis. By contrast, percutaneous drainage has a lower contamination risk and higher rate of success, but involves external catheters and has catheter-related complications.
To evaluate associations between preoperative drainage technique and postoperative outcomes, Dr. Hu and her colleagues queried the ACS National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Hepatectomy Database. They identified 527 patients who underwent preoperative biliary drainage prior to resection between 2014 and 2017, of whom about 80% underwent endoscopic drainage and 20% underwent percutaneous drainage. The primary outcome of their analysis was 30-day death or serious morbidity.
Patients who were selected for percutaneous drainage had significantly more preoperative comorbidities, including higher American Society of Anesthesiologists class, recent weight loss, and lower albumin levels, Dr. Hu said.
Death or serious morbidity occurred in 250 of the patients, or approximately 48% of the cohort.
In unadjusted analysis, the incidence of death or serious morbidity was significantly more frequent in the percutaneous group, compared with endoscopic group. The percutaneous group also had greater odds of surgical site infection, liver failure, bile leakage, and prolonged length of stay.
Those associations remained significant for death or serious morbidity and surgical site infection in both multivariable– and propensity score–adjusted models, Dr. Hu said.
In a propensity score–matched model, 93 patients who received percutaneous drainage were matched one-to-one to 93 patients who received endoscopic drainage based on relevant baseline characteristics. In that rigorous analysis, the odds ratio for death or serious morbidity was 2.17 (95% confidence interval, 1.16-4.09), according to the report.
“Death and serious morbidity was significantly associated with percutaneous drainage across all models, suggesting that patients receiving percutaneous drainage were more likely to experience an adverse event, compared to patients receiving endoscopic drainage,” Dr. Hu said.
However, Dr. Hu acknowledged the limitations of the retrospective study, noting that propensity score adjustment and matching accounts for measured confounders. “It obviously cannot account for any unmeasured confounders,” she said.
Dr. Hu reported funding from the Agency for Healthcare Research and Quality related to her position. She had no disclosures related to her presentation.
ORLANDO – In patients with was associated with an increased risk of death or serious morbidity versus endoscopic drainage, results of a recent retrospective study show.
Patients undergoing percutaneous transhepatic biliary drainage did have more preoperative comorbidities, compared with those undergoing endoscopic biliary stenting, according researcher Q. Lina Hu, MD, an American College of Surgeons Clinical Scholar-in-Residence.
“Nevertheless, compared to endoscopic drainage, percutaneous drainage was associated with a significantly increased morbidity and mortality, even after adjustment for measured confounders,” Dr. Hu said a presentation at the American College of Surgeons Quality and Safety Conference.
Patients with resectable hepatobiliary malignancies often present with biliary obstruction, which may increase risk of perioperative morbidity and mortality, said Dr. Hu, a general surgery resident at University of California, Los Angeles.
“Preoperative biliary drainage is thought to reduce this risk by resolving cholestasis and preserving liver function,” she said.
However, the preferred drainage technique is not established, she added.
The endoscopic approach approximates normal physiologic drainage, she said, but is associated with complications including pancreatitis and cholangitis. By contrast, percutaneous drainage has a lower contamination risk and higher rate of success, but involves external catheters and has catheter-related complications.
To evaluate associations between preoperative drainage technique and postoperative outcomes, Dr. Hu and her colleagues queried the ACS National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Hepatectomy Database. They identified 527 patients who underwent preoperative biliary drainage prior to resection between 2014 and 2017, of whom about 80% underwent endoscopic drainage and 20% underwent percutaneous drainage. The primary outcome of their analysis was 30-day death or serious morbidity.
Patients who were selected for percutaneous drainage had significantly more preoperative comorbidities, including higher American Society of Anesthesiologists class, recent weight loss, and lower albumin levels, Dr. Hu said.
Death or serious morbidity occurred in 250 of the patients, or approximately 48% of the cohort.
In unadjusted analysis, the incidence of death or serious morbidity was significantly more frequent in the percutaneous group, compared with endoscopic group. The percutaneous group also had greater odds of surgical site infection, liver failure, bile leakage, and prolonged length of stay.
Those associations remained significant for death or serious morbidity and surgical site infection in both multivariable– and propensity score–adjusted models, Dr. Hu said.
In a propensity score–matched model, 93 patients who received percutaneous drainage were matched one-to-one to 93 patients who received endoscopic drainage based on relevant baseline characteristics. In that rigorous analysis, the odds ratio for death or serious morbidity was 2.17 (95% confidence interval, 1.16-4.09), according to the report.
“Death and serious morbidity was significantly associated with percutaneous drainage across all models, suggesting that patients receiving percutaneous drainage were more likely to experience an adverse event, compared to patients receiving endoscopic drainage,” Dr. Hu said.
However, Dr. Hu acknowledged the limitations of the retrospective study, noting that propensity score adjustment and matching accounts for measured confounders. “It obviously cannot account for any unmeasured confounders,” she said.
Dr. Hu reported funding from the Agency for Healthcare Research and Quality related to her position. She had no disclosures related to her presentation.
REPORTING FROM ACSQSC 2018
Key clinical point: Percutaneous biliary drainage for resectable hepatobiliary cancer was associated with an increased risk of death or serious morbidity, compared with endoscopic drainage.
Major finding: For patients having percutaneous biliary drainage, the odds ratio for death or serious morbidity was 2.17 (95% confidence interval, 1.16-4.09).
Study details: Cohort of 327 patients in the ACS NSQIP database who underwent preoperative biliary drainage.
Disclosures: The investigators had no disclosures.
Neoadjuvant-treated N2 rectal cancer linked to PCR failure
Orlando – Clinical an analysis of a large, multicenter database has suggested.
In multivariate regression, pretreatment N2 stage was the only variable significantly associated with failure of achieving pathologic complete response, according to Ebram Salama, MD, of Sir Mortimer B. Davis Jewish General Hospital at McGill University, Montreal.
“We should be reconsidering putting these patients in watch-and-wait protocols,” Dr. Salama said in an oral abstract presentation at the American College of Surgeons Quality and Safety Conference.
The analysis included 369 elective cases of cT2-4 N0-2 rectal cancer that were treated with neoadjuvant chemoradiotherapy during 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) proctectomy-specific database.
Of those cases, 53 (14.4%) achieved PCR, a proportion consistent with what has been reported previously in medical literature, Dr. Salama noted during his presentation.
The multivariate analysis revealed that pretreatment N2 stage was a negative predictor of PCR with an odds ratio of 0.18 (95% confidence interval, 0.04-0.82; P = .026), according to presented data.
By contrast, Dr. Salama said, there were no significant associations between response and other variables, including pretreatment N1 stage, pretreatment T stage, tumor location, gender, or body mass index.
Dr. Salama acknowledged limitations of this retrospective study, including a lack of data on other variables of interest, such as carcinoembryonic antigen, tumor size, imaging characteristics, molecular markers, and the time interval between chemoradiotherapy and surgery.
“We obviously need more data to evaluate other predictive factors in achieving a complete pathological response,” he said, adding that it’s also unclear whether the results of the present study could be generalized to institutions not participating in ACS NSQIP.
Dr. Salama presented the research on behalf of Nathalie Wong-Chong, MD, also of McGill University. He had no conflicts of interest to report for his presentation.
Orlando – Clinical an analysis of a large, multicenter database has suggested.
In multivariate regression, pretreatment N2 stage was the only variable significantly associated with failure of achieving pathologic complete response, according to Ebram Salama, MD, of Sir Mortimer B. Davis Jewish General Hospital at McGill University, Montreal.
“We should be reconsidering putting these patients in watch-and-wait protocols,” Dr. Salama said in an oral abstract presentation at the American College of Surgeons Quality and Safety Conference.
The analysis included 369 elective cases of cT2-4 N0-2 rectal cancer that were treated with neoadjuvant chemoradiotherapy during 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) proctectomy-specific database.
Of those cases, 53 (14.4%) achieved PCR, a proportion consistent with what has been reported previously in medical literature, Dr. Salama noted during his presentation.
The multivariate analysis revealed that pretreatment N2 stage was a negative predictor of PCR with an odds ratio of 0.18 (95% confidence interval, 0.04-0.82; P = .026), according to presented data.
By contrast, Dr. Salama said, there were no significant associations between response and other variables, including pretreatment N1 stage, pretreatment T stage, tumor location, gender, or body mass index.
Dr. Salama acknowledged limitations of this retrospective study, including a lack of data on other variables of interest, such as carcinoembryonic antigen, tumor size, imaging characteristics, molecular markers, and the time interval between chemoradiotherapy and surgery.
“We obviously need more data to evaluate other predictive factors in achieving a complete pathological response,” he said, adding that it’s also unclear whether the results of the present study could be generalized to institutions not participating in ACS NSQIP.
Dr. Salama presented the research on behalf of Nathalie Wong-Chong, MD, also of McGill University. He had no conflicts of interest to report for his presentation.
Orlando – Clinical an analysis of a large, multicenter database has suggested.
In multivariate regression, pretreatment N2 stage was the only variable significantly associated with failure of achieving pathologic complete response, according to Ebram Salama, MD, of Sir Mortimer B. Davis Jewish General Hospital at McGill University, Montreal.
“We should be reconsidering putting these patients in watch-and-wait protocols,” Dr. Salama said in an oral abstract presentation at the American College of Surgeons Quality and Safety Conference.
The analysis included 369 elective cases of cT2-4 N0-2 rectal cancer that were treated with neoadjuvant chemoradiotherapy during 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) proctectomy-specific database.
Of those cases, 53 (14.4%) achieved PCR, a proportion consistent with what has been reported previously in medical literature, Dr. Salama noted during his presentation.
The multivariate analysis revealed that pretreatment N2 stage was a negative predictor of PCR with an odds ratio of 0.18 (95% confidence interval, 0.04-0.82; P = .026), according to presented data.
By contrast, Dr. Salama said, there were no significant associations between response and other variables, including pretreatment N1 stage, pretreatment T stage, tumor location, gender, or body mass index.
Dr. Salama acknowledged limitations of this retrospective study, including a lack of data on other variables of interest, such as carcinoembryonic antigen, tumor size, imaging characteristics, molecular markers, and the time interval between chemoradiotherapy and surgery.
“We obviously need more data to evaluate other predictive factors in achieving a complete pathological response,” he said, adding that it’s also unclear whether the results of the present study could be generalized to institutions not participating in ACS NSQIP.
Dr. Salama presented the research on behalf of Nathalie Wong-Chong, MD, also of McGill University. He had no conflicts of interest to report for his presentation.
REPORTING FROM ACSQSC 2018
Key clinical point: N2 disease may be a negative predictor of pathological complete response after neoadjuvant chemoradiotherapy for rectal cancer.
Major finding: Pretreatment N2 stage was a negative predictor of complete pathological response, with an odds ratio of 0.18 (95% confidence interval, 0.04-0.82; P = .026).
Study details: A study of 369 elective cases of cT2-4 N0-2 rectal cancer treated with neoadjuvant chemoradiotherapy from 2016 in the ACS NSQIP proctectomy-specific database.
Disclosures: Dr. Salama had no conflicts of interest to report for his presentation.
ERAS adoption for colectomy yielded state-wide outcome improvements
ORLANDO – Widespread implementation of an analysis shows.
The benefits were particularly pronounced in the subset of patients undergoing laparoscopic colectomy in the retrospective analysis, which included data for treated at four institutions in the Virginia Surgical Quality Collaborative Workgroup.
While the benefits of enhanced recovery after surgery (ERAS) are well known, most of the published data has come from single-institution experiences, according to investigator Traci L. Hedrick, MD, FACS, of the University of Virginia, Charlottesville.
At the American College of Surgeons Quality and Safety Conference, Dr. Hedrick presented risk-adjusted National Surgical Quality Improvement Program (NSQIP) data for 2,971 consecutive procedures during 2012-2016 at the University of Virginia, Winchester Medical Center, Carilion Clinic, and Inova Fairfax.
“Institutions came and went from the collaborative during this time period, so we focused on those institutions that maintained in the collaborative throughout the entire study protocol,” Dr. Hedrick said in her presentation.
Of the 2,971 procedures, about half (1,460) were performed after implementation of enhanced recovery protocols. Laparoscopic and open procedures were analyzed separately due to a substantial shift toward laparoscopic procedures, mainly during the 2012-2014 period, Dr. Hedrick said.
Among laparoscopic cases, there was a significant 1-day reduction in median length of stay, dropping from 4 days for pre–enhanced recovery protocol cases to 3 days for post–enhanced recovery protocol cases, Dr. Hedrick reported.
Observed morbidity also dropped significantly from 14.8% to 8.9% for the pre– and post–enhanced recovery cases, and the readmission rate fell significantly from 13% to 8.8%.
For open cases, there was a significant 1-day drop in median length of stay, from 4 to 3 days, but no significant differences in observed morbidity or readmission rates, according to Dr. Hedrick.
“As more of the patients were done laparoscopically, that really selected out the more complicated patients that were undergoing open procedures,” she said.
The protocols implemented by institutions in the Virginia collaborative group were generally uniform in important tenants of enhanced recovery, such as opioid minimization and avoidance of fasting, but specific elements were left up to each institution to improve buy-in, according to Dr. Hedrick.
“A lot of our protocols are very similar, particularly with regards to the order set,” Dr. Hedrick explained, “[but] I really am a firm believer in not being very strict about exactly what to use, because it’s so dependent on preference at the local level.”
The Virginia Surgical Quality Collaborative Workgroup is one of 20 regional ACS NSQIP collaboratives with the objective of improving surgical outcomes through multi-institutional collaboration, Dr. Hedrick said.
Dr. Hedrick and her coinvestigators had no relevant disclosures to report.
ORLANDO – Widespread implementation of an analysis shows.
The benefits were particularly pronounced in the subset of patients undergoing laparoscopic colectomy in the retrospective analysis, which included data for treated at four institutions in the Virginia Surgical Quality Collaborative Workgroup.
While the benefits of enhanced recovery after surgery (ERAS) are well known, most of the published data has come from single-institution experiences, according to investigator Traci L. Hedrick, MD, FACS, of the University of Virginia, Charlottesville.
At the American College of Surgeons Quality and Safety Conference, Dr. Hedrick presented risk-adjusted National Surgical Quality Improvement Program (NSQIP) data for 2,971 consecutive procedures during 2012-2016 at the University of Virginia, Winchester Medical Center, Carilion Clinic, and Inova Fairfax.
“Institutions came and went from the collaborative during this time period, so we focused on those institutions that maintained in the collaborative throughout the entire study protocol,” Dr. Hedrick said in her presentation.
Of the 2,971 procedures, about half (1,460) were performed after implementation of enhanced recovery protocols. Laparoscopic and open procedures were analyzed separately due to a substantial shift toward laparoscopic procedures, mainly during the 2012-2014 period, Dr. Hedrick said.
Among laparoscopic cases, there was a significant 1-day reduction in median length of stay, dropping from 4 days for pre–enhanced recovery protocol cases to 3 days for post–enhanced recovery protocol cases, Dr. Hedrick reported.
Observed morbidity also dropped significantly from 14.8% to 8.9% for the pre– and post–enhanced recovery cases, and the readmission rate fell significantly from 13% to 8.8%.
For open cases, there was a significant 1-day drop in median length of stay, from 4 to 3 days, but no significant differences in observed morbidity or readmission rates, according to Dr. Hedrick.
“As more of the patients were done laparoscopically, that really selected out the more complicated patients that were undergoing open procedures,” she said.
The protocols implemented by institutions in the Virginia collaborative group were generally uniform in important tenants of enhanced recovery, such as opioid minimization and avoidance of fasting, but specific elements were left up to each institution to improve buy-in, according to Dr. Hedrick.
“A lot of our protocols are very similar, particularly with regards to the order set,” Dr. Hedrick explained, “[but] I really am a firm believer in not being very strict about exactly what to use, because it’s so dependent on preference at the local level.”
The Virginia Surgical Quality Collaborative Workgroup is one of 20 regional ACS NSQIP collaboratives with the objective of improving surgical outcomes through multi-institutional collaboration, Dr. Hedrick said.
Dr. Hedrick and her coinvestigators had no relevant disclosures to report.
ORLANDO – Widespread implementation of an analysis shows.
The benefits were particularly pronounced in the subset of patients undergoing laparoscopic colectomy in the retrospective analysis, which included data for treated at four institutions in the Virginia Surgical Quality Collaborative Workgroup.
While the benefits of enhanced recovery after surgery (ERAS) are well known, most of the published data has come from single-institution experiences, according to investigator Traci L. Hedrick, MD, FACS, of the University of Virginia, Charlottesville.
At the American College of Surgeons Quality and Safety Conference, Dr. Hedrick presented risk-adjusted National Surgical Quality Improvement Program (NSQIP) data for 2,971 consecutive procedures during 2012-2016 at the University of Virginia, Winchester Medical Center, Carilion Clinic, and Inova Fairfax.
“Institutions came and went from the collaborative during this time period, so we focused on those institutions that maintained in the collaborative throughout the entire study protocol,” Dr. Hedrick said in her presentation.
Of the 2,971 procedures, about half (1,460) were performed after implementation of enhanced recovery protocols. Laparoscopic and open procedures were analyzed separately due to a substantial shift toward laparoscopic procedures, mainly during the 2012-2014 period, Dr. Hedrick said.
Among laparoscopic cases, there was a significant 1-day reduction in median length of stay, dropping from 4 days for pre–enhanced recovery protocol cases to 3 days for post–enhanced recovery protocol cases, Dr. Hedrick reported.
Observed morbidity also dropped significantly from 14.8% to 8.9% for the pre– and post–enhanced recovery cases, and the readmission rate fell significantly from 13% to 8.8%.
For open cases, there was a significant 1-day drop in median length of stay, from 4 to 3 days, but no significant differences in observed morbidity or readmission rates, according to Dr. Hedrick.
“As more of the patients were done laparoscopically, that really selected out the more complicated patients that were undergoing open procedures,” she said.
The protocols implemented by institutions in the Virginia collaborative group were generally uniform in important tenants of enhanced recovery, such as opioid minimization and avoidance of fasting, but specific elements were left up to each institution to improve buy-in, according to Dr. Hedrick.
“A lot of our protocols are very similar, particularly with regards to the order set,” Dr. Hedrick explained, “[but] I really am a firm believer in not being very strict about exactly what to use, because it’s so dependent on preference at the local level.”
The Virginia Surgical Quality Collaborative Workgroup is one of 20 regional ACS NSQIP collaboratives with the objective of improving surgical outcomes through multi-institutional collaboration, Dr. Hedrick said.
Dr. Hedrick and her coinvestigators had no relevant disclosures to report.
REPORTING FROM ACSQSC 2018
Key clinical point: State-wide adoption of ERAS for colectomy yielded state-wide outcome improvements .
Major finding: Morbidity also dropped significantly from 14.8% to 8.9% and the readmission rate fell significantly from 13% to 8.8%.
Study details: Risk adjusted NSQIP data in 2,971 colectomy patients from four hospitals in the Virginia Surgical Quality Collaborative Workgroup.
Disclosures: Dr. Hedrick and coinvestigators had no relevant disclosures to report.
Higher lymph node harvest could improve right-side colon cancer outcomes
ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.
Among patients with right-sided cancers, the rate of survival improved when 22 or more lymph nodes were harvested during operations, according to the study results presented at the American College of Surgeons Quality and Safety Conference.
“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.
This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.
Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.
Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.
In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.
The difference was most pronounced in stage III of the disease, he added.
Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”
Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.
Help your patients better prepare for their colonoscopy by using AGA patient education materials: https://www.gastro.org/practice-guidance/gi-patient-center/topic/colonoscopy.
ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.
Among patients with right-sided cancers, the rate of survival improved when 22 or more lymph nodes were harvested during operations, according to the study results presented at the American College of Surgeons Quality and Safety Conference.
“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.
This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.
Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.
Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.
In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.
The difference was most pronounced in stage III of the disease, he added.
Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”
Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.
Help your patients better prepare for their colonoscopy by using AGA patient education materials: https://www.gastro.org/practice-guidance/gi-patient-center/topic/colonoscopy.
ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.
Among patients with right-sided cancers, the rate of survival improved when 22 or more lymph nodes were harvested during operations, according to the study results presented at the American College of Surgeons Quality and Safety Conference.
“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.
This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.
Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.
Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.
In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.
The difference was most pronounced in stage III of the disease, he added.
Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”
Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.
Help your patients better prepare for their colonoscopy by using AGA patient education materials: https://www.gastro.org/practice-guidance/gi-patient-center/topic/colonoscopy.
REPORTING FROM ACSQSC 2018
Higher lymph node harvest could improve right-side colon cancer outcomes
ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.
“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.
This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.
Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.
Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.
In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.
The difference was most pronounced in stage III of the disease, he added.
Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”
Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.
ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.
“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.
This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.
Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.
Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.
In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.
The difference was most pronounced in stage III of the disease, he added.
Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”
Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.
ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.
“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.
This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.
Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.
Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.
In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.
The difference was most pronounced in stage III of the disease, he added.
Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”
Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.
REPORTING FROM ACSQSC 2018
Pediatric appendectomy fast track reduced LoS, narcotic use
Orlando – A significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.
After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.
Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.
While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.
“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.
In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.
Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.
They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.
The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.
Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.
Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.
Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.
Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.
Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.
“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”
Dr. Kao had no disclosures relevant to her presentation.
Orlando – A significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.
After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.
Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.
While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.
“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.
In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.
Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.
They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.
The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.
Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.
Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.
Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.
Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.
Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.
“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”
Dr. Kao had no disclosures relevant to her presentation.
Orlando – A significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.
After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.
Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.
While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.
“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.
In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.
Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.
They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.
The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.
Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.
Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.
Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.
Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.
Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.
“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”
Dr. Kao had no disclosures relevant to her presentation.
REPORTING FROM ACSQSC 2018
ACS NSQIP project collected patient-reported data on surgery outcomes
ORLANDO – A pilot survey to generate had a high response rate and yielded clinically meaningful data, an investigator reported at the American College of Surgeons Quality and Safety Conference.
The 45-question electronic survey, conducted as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) had 1,300 respondents with a response rate of 20%, according to Jason B. Liu, MD, an ACS Clinical Scholar-in-Residence and general surgery resident at the University of Chicago.
Results to date have demonstrated that in patients undergoing total knee arthroplasty (TKA), pain had a greater impact on daily activities than for other procedures, Dr. Liu said in a general session presentation the conference.
“Overall, the lesson learned is that in the current health care landscape, with its regulations and privacy issues, it is indeed both feasible and acceptable to electronically measure patient-reported outcomes using the ACS NSQIP platform,” Dr. Liu said at the meeting.
Eighteen hospitals in the United States and Canada participated in the pilot survey, which elicited responses from patients with a median age of 63 years, representing more than 340 types of operations.
The survey incorporates measurements from the PROMIS Pain Interference instrument, which measures how much pain hinders daily activities; PROMIS Global Health, which measures physical and mental health; and aspects of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), Dr. Liu said.
The TKA finding is just one example of the data obtained through the pilot, he said. Looking at PROMIS Pain Interference, pain had more impact in TKA patients compared with open GI, breast hernia, and laparoscopic GI procedures. Difference between means ranged from 3.2 to 9.4 for TKA, compared with those procedures.
Conducting the pilot has been an “uphill battle,” according to Dr. Liu, citing critics who wondered if the program would generate meaningful data, whether older patients would respond to an electronic survey, and whether patients would take time to fill out a 45-question survey.
In fact, the average completion time for the survey was just 6.4 minutes, and the median number of items missing was zero, meaning that patients who started the survey tended to finish it, he said.
“We really hope to expand what we’ve learned across all of the [ACS] quality programs so that we can begin to really incorporate the patients’ perspective in improving national surgical quality,” he said.
Dr. Liu had no disclosures to report.
ORLANDO – A pilot survey to generate had a high response rate and yielded clinically meaningful data, an investigator reported at the American College of Surgeons Quality and Safety Conference.
The 45-question electronic survey, conducted as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) had 1,300 respondents with a response rate of 20%, according to Jason B. Liu, MD, an ACS Clinical Scholar-in-Residence and general surgery resident at the University of Chicago.
Results to date have demonstrated that in patients undergoing total knee arthroplasty (TKA), pain had a greater impact on daily activities than for other procedures, Dr. Liu said in a general session presentation the conference.
“Overall, the lesson learned is that in the current health care landscape, with its regulations and privacy issues, it is indeed both feasible and acceptable to electronically measure patient-reported outcomes using the ACS NSQIP platform,” Dr. Liu said at the meeting.
Eighteen hospitals in the United States and Canada participated in the pilot survey, which elicited responses from patients with a median age of 63 years, representing more than 340 types of operations.
The survey incorporates measurements from the PROMIS Pain Interference instrument, which measures how much pain hinders daily activities; PROMIS Global Health, which measures physical and mental health; and aspects of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), Dr. Liu said.
The TKA finding is just one example of the data obtained through the pilot, he said. Looking at PROMIS Pain Interference, pain had more impact in TKA patients compared with open GI, breast hernia, and laparoscopic GI procedures. Difference between means ranged from 3.2 to 9.4 for TKA, compared with those procedures.
Conducting the pilot has been an “uphill battle,” according to Dr. Liu, citing critics who wondered if the program would generate meaningful data, whether older patients would respond to an electronic survey, and whether patients would take time to fill out a 45-question survey.
In fact, the average completion time for the survey was just 6.4 minutes, and the median number of items missing was zero, meaning that patients who started the survey tended to finish it, he said.
“We really hope to expand what we’ve learned across all of the [ACS] quality programs so that we can begin to really incorporate the patients’ perspective in improving national surgical quality,” he said.
Dr. Liu had no disclosures to report.
ORLANDO – A pilot survey to generate had a high response rate and yielded clinically meaningful data, an investigator reported at the American College of Surgeons Quality and Safety Conference.
The 45-question electronic survey, conducted as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) had 1,300 respondents with a response rate of 20%, according to Jason B. Liu, MD, an ACS Clinical Scholar-in-Residence and general surgery resident at the University of Chicago.
Results to date have demonstrated that in patients undergoing total knee arthroplasty (TKA), pain had a greater impact on daily activities than for other procedures, Dr. Liu said in a general session presentation the conference.
“Overall, the lesson learned is that in the current health care landscape, with its regulations and privacy issues, it is indeed both feasible and acceptable to electronically measure patient-reported outcomes using the ACS NSQIP platform,” Dr. Liu said at the meeting.
Eighteen hospitals in the United States and Canada participated in the pilot survey, which elicited responses from patients with a median age of 63 years, representing more than 340 types of operations.
The survey incorporates measurements from the PROMIS Pain Interference instrument, which measures how much pain hinders daily activities; PROMIS Global Health, which measures physical and mental health; and aspects of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), Dr. Liu said.
The TKA finding is just one example of the data obtained through the pilot, he said. Looking at PROMIS Pain Interference, pain had more impact in TKA patients compared with open GI, breast hernia, and laparoscopic GI procedures. Difference between means ranged from 3.2 to 9.4 for TKA, compared with those procedures.
Conducting the pilot has been an “uphill battle,” according to Dr. Liu, citing critics who wondered if the program would generate meaningful data, whether older patients would respond to an electronic survey, and whether patients would take time to fill out a 45-question survey.
In fact, the average completion time for the survey was just 6.4 minutes, and the median number of items missing was zero, meaning that patients who started the survey tended to finish it, he said.
“We really hope to expand what we’ve learned across all of the [ACS] quality programs so that we can begin to really incorporate the patients’ perspective in improving national surgical quality,” he said.
Dr. Liu had no disclosures to report.
REPORTING FROM ACSQSC 2018
Key clinical point: Clinically meaningful data on patient-reported outcomes can be obtained using the ACS NSQIP platform.
Major finding: The average completion time for the survey was 6.4 minutes, and the median number of items missing was zero.
Study details: A 45-question electronic survey of 1,300 patients treated at 18 hospitals for 340 different types of surgical procedures.
Disclosures: Dr. Liu had no disclosures to report.
Enhanced recovery initiative improved bariatric length of stay
ORLANDO – Adopting a 28-point significantly reduced length of stay without significant effects on complications or readmissions, according to interim results of a large, nationwide surgical quality initiative. 
Thirty-six centers participated in this pilot initiative, making it one of the largest national projects focused on enhanced recovery to date, according to Stacy A. Brethauer, MD, FACS, cochair of the Quality and Data Committee of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).
The initiative, known as Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), was developed in light of “huge gaps in literature and knowledge” about what best practices of enhanced recovery should look like for bariatric surgery, Dr. Brethauer said in a podium presentation at the American College of Surgeons Quality and Safety Conference.
“Bariatric surgery is very pathway driven, but the pathway can be very cumbersome and very antiquated if you don’t keep it up to date and evidence based,” said Dr. Brethauer, associate professor of surgery at the Cleveland Clinic.
Invitations to join in the ENERGY pilot were targeted to the 80 or so MBSAQIP-accredited centers in the top decile of programs for length of stay. “That’s the needle that we want to move,” Dr. Brethauer said.
ENERGY includes interventions in the preoperative, perioperative, and postoperative setting for each patient who undergoes a primary band, lap sleeve, or lap bypass procedure.
The 36 participating centers were asked to document 28 discrete process measures, starting with “did the patient stop smoking before surgery?” and ending with “did the patient have a follow-up clinic appointment scheduled?” Each one was entered by a trained clinical reviewer. The program included monthly audits for each participating center.
Data collection started on July 1, 2017, and continued to June 30, 2018, following a 6-month run-up period to allow centers to incorporate the measures.
The interim analysis presented included 4,700 patients who underwent procedures in the first 6 months of the data collection period. Nearly 60% (2,790 patients) had a laparoscopic sleeve gastrectomy, while about 40% (1,896 patients) underwent laparoscopic gastric bypass, and 0.1% (6 patients) had a band procedure.
Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers (P less than .001), Dr. Brethauer reported.
Similarly, the rate of extended length of stay was 4.4% in the first 6 months of the pilot, down from 8.2% in 2016. Extended length of stay decreased with increasing adherence to the protocol, Dr. Brethauer and his colleagues found in their analysis.
Those length-of-stay reductions were accomplished with no increase in bleeding rates, all-cause reoperation rates, or readmissions. “We’re not doing this at the expense of other complications,” Dr. Brethauer said in a comment on the results.
Adherence to the 28 ENERGY measures increased from 26% in the first month of the pilot to 80.2% in March 2017, the latest month included in the interim analysis.
Opioid-sparing pain management strategies are incorporated into ENERGY. Over the first six months of the pilot, the average proportion of patients receiving no opioids postoperatively was 26.8%.
The ultimate goal of ENERGY is a large-scale rollout of enhanced recovery strategies, according to Dr. Brethauer.
ENERGY is the second national quality improvement project of the MBSAQIP. In the first, known as Decreasing Readmissions through Opportunities Provided (DROP), 128 U.S. hospitals implemented a set of standard processes organized into preoperative, inpatient, and postoperative care bundles. Results of a yearlong study of the DROP intervention demonstrated a significant reduction in 30-day all-cause hospital readmissions following sleeve gastrectomy.
“If you look at what’s happened in our specialty, and all the changes and all the work that’s been done, it’s really quite impressive,” Dr. Brethauer told attendees at the meeting. “It’s something that we’re very proud of. “
Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
ORLANDO – Adopting a 28-point significantly reduced length of stay without significant effects on complications or readmissions, according to interim results of a large, nationwide surgical quality initiative.
Thirty-six centers participated in this pilot initiative, making it one of the largest national projects focused on enhanced recovery to date, according to Stacy A. Brethauer, MD, FACS, cochair of the Quality and Data Committee of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).
The initiative, known as Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), was developed in light of “huge gaps in literature and knowledge” about what best practices of enhanced recovery should look like for bariatric surgery, Dr. Brethauer said in a podium presentation at the American College of Surgeons Quality and Safety Conference.
“Bariatric surgery is very pathway driven, but the pathway can be very cumbersome and very antiquated if you don’t keep it up to date and evidence based,” said Dr. Brethauer, associate professor of surgery at the Cleveland Clinic.
Invitations to join in the ENERGY pilot were targeted to the 80 or so MBSAQIP-accredited centers in the top decile of programs for length of stay. “That’s the needle that we want to move,” Dr. Brethauer said.
ENERGY includes interventions in the preoperative, perioperative, and postoperative setting for each patient who undergoes a primary band, lap sleeve, or lap bypass procedure.
The 36 participating centers were asked to document 28 discrete process measures, starting with “did the patient stop smoking before surgery?” and ending with “did the patient have a follow-up clinic appointment scheduled?” Each one was entered by a trained clinical reviewer. The program included monthly audits for each participating center.
Data collection started on July 1, 2017, and continued to June 30, 2018, following a 6-month run-up period to allow centers to incorporate the measures.
The interim analysis presented included 4,700 patients who underwent procedures in the first 6 months of the data collection period. Nearly 60% (2,790 patients) had a laparoscopic sleeve gastrectomy, while about 40% (1,896 patients) underwent laparoscopic gastric bypass, and 0.1% (6 patients) had a band procedure.
Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers (P less than .001), Dr. Brethauer reported.
Similarly, the rate of extended length of stay was 4.4% in the first 6 months of the pilot, down from 8.2% in 2016. Extended length of stay decreased with increasing adherence to the protocol, Dr. Brethauer and his colleagues found in their analysis.
Those length-of-stay reductions were accomplished with no increase in bleeding rates, all-cause reoperation rates, or readmissions. “We’re not doing this at the expense of other complications,” Dr. Brethauer said in a comment on the results.
Adherence to the 28 ENERGY measures increased from 26% in the first month of the pilot to 80.2% in March 2017, the latest month included in the interim analysis.
Opioid-sparing pain management strategies are incorporated into ENERGY. Over the first six months of the pilot, the average proportion of patients receiving no opioids postoperatively was 26.8%.
The ultimate goal of ENERGY is a large-scale rollout of enhanced recovery strategies, according to Dr. Brethauer.
ENERGY is the second national quality improvement project of the MBSAQIP. In the first, known as Decreasing Readmissions through Opportunities Provided (DROP), 128 U.S. hospitals implemented a set of standard processes organized into preoperative, inpatient, and postoperative care bundles. Results of a yearlong study of the DROP intervention demonstrated a significant reduction in 30-day all-cause hospital readmissions following sleeve gastrectomy.
“If you look at what’s happened in our specialty, and all the changes and all the work that’s been done, it’s really quite impressive,” Dr. Brethauer told attendees at the meeting. “It’s something that we’re very proud of. “
Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
ORLANDO – Adopting a 28-point significantly reduced length of stay without significant effects on complications or readmissions, according to interim results of a large, nationwide surgical quality initiative.
Thirty-six centers participated in this pilot initiative, making it one of the largest national projects focused on enhanced recovery to date, according to Stacy A. Brethauer, MD, FACS, cochair of the Quality and Data Committee of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).
The initiative, known as Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), was developed in light of “huge gaps in literature and knowledge” about what best practices of enhanced recovery should look like for bariatric surgery, Dr. Brethauer said in a podium presentation at the American College of Surgeons Quality and Safety Conference.
“Bariatric surgery is very pathway driven, but the pathway can be very cumbersome and very antiquated if you don’t keep it up to date and evidence based,” said Dr. Brethauer, associate professor of surgery at the Cleveland Clinic.
Invitations to join in the ENERGY pilot were targeted to the 80 or so MBSAQIP-accredited centers in the top decile of programs for length of stay. “That’s the needle that we want to move,” Dr. Brethauer said.
ENERGY includes interventions in the preoperative, perioperative, and postoperative setting for each patient who undergoes a primary band, lap sleeve, or lap bypass procedure.
The 36 participating centers were asked to document 28 discrete process measures, starting with “did the patient stop smoking before surgery?” and ending with “did the patient have a follow-up clinic appointment scheduled?” Each one was entered by a trained clinical reviewer. The program included monthly audits for each participating center.
Data collection started on July 1, 2017, and continued to June 30, 2018, following a 6-month run-up period to allow centers to incorporate the measures.
The interim analysis presented included 4,700 patients who underwent procedures in the first 6 months of the data collection period. Nearly 60% (2,790 patients) had a laparoscopic sleeve gastrectomy, while about 40% (1,896 patients) underwent laparoscopic gastric bypass, and 0.1% (6 patients) had a band procedure.
Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers (P less than .001), Dr. Brethauer reported.
Similarly, the rate of extended length of stay was 4.4% in the first 6 months of the pilot, down from 8.2% in 2016. Extended length of stay decreased with increasing adherence to the protocol, Dr. Brethauer and his colleagues found in their analysis.
Those length-of-stay reductions were accomplished with no increase in bleeding rates, all-cause reoperation rates, or readmissions. “We’re not doing this at the expense of other complications,” Dr. Brethauer said in a comment on the results.
Adherence to the 28 ENERGY measures increased from 26% in the first month of the pilot to 80.2% in March 2017, the latest month included in the interim analysis.
Opioid-sparing pain management strategies are incorporated into ENERGY. Over the first six months of the pilot, the average proportion of patients receiving no opioids postoperatively was 26.8%.
The ultimate goal of ENERGY is a large-scale rollout of enhanced recovery strategies, according to Dr. Brethauer.
ENERGY is the second national quality improvement project of the MBSAQIP. In the first, known as Decreasing Readmissions through Opportunities Provided (DROP), 128 U.S. hospitals implemented a set of standard processes organized into preoperative, inpatient, and postoperative care bundles. Results of a yearlong study of the DROP intervention demonstrated a significant reduction in 30-day all-cause hospital readmissions following sleeve gastrectomy.
“If you look at what’s happened in our specialty, and all the changes and all the work that’s been done, it’s really quite impressive,” Dr. Brethauer told attendees at the meeting. “It’s something that we’re very proud of. “
Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
REPORTING FROM ACSQSC 2018
Key clinical point: An evidence-based enhanced recovery protocol reduced length of stay for bariatric surgery patients.
Major finding: Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers.
Study details: Data on 36 bariatric surgery centers and 4,700 patients who underwent procedures in the first 6 months of the data collection period.
Disclosures: Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
Acute care prescriptions can be cut to minimize opioid exposure
ORLANDO – By cutting the number of pills prescribed after a surgical procedure, exposure to opioids can be minimized in a largely opioid-naive patient population at risk of new, persistent use, according to Michael J. Englesbe, MD, FACS, professor of surgery at the University of Michigan, Ann Arbor, who is leading a Michigan initiative to tailor acute care prescribing.
About 90% of surgically patients are opioid-naive, and of those, studies suggest about 6% may become new, persistent opioid users, according to Dr. Englesbe, codirector of the Michigan Opioid Prescribing and Engagement Network (Michigan-OPEN), a state-wide effort to transform acute pain prescribing across all surgical specialties.
“This is a very vulnerable population where their operation can lead to life-changing events way beyond their surgical outcomes,” Dr. Englesbe said in a presentation at the American College of Surgeons Quality and Safety Conference.
“We have to really worry about them,” he added. “It’s hard to identify who they are, and I think minimizing exposure to opioids is the best we have at this point.”
By following evidence-based prescribing guidelines after laparoscopic cholecystectomy, Dr. Englesbe and his colleagues were able to reduce prescription size by 63% with no increase in refills and no change in pain score, according to a research letter recently published in JAMA Surgery.
After adopting the guidelines, median postoperative opioid use dropped from 30 mg to 20 mg (P = .04), they reported.
Laparoscopic cholecystectomy patients could be prescribed as few as 10 5-mg tablets of oxycodone, according to recommendations developed by Michigan-OPEN that are published on opioidprescribing.info. Dr. Englesbe called the website figures “precise prescribing recommendations” that are still relatively generous, meeting or exceeding self-reported use for 75% of patients.
“I think this is an important template for change,” he said. “We’ve found the surgeons in the state very receptive, but more importantly, we’ve been able to partner with other really important stakeholders.” For example, one insurer in the state now aligns some hospital incentive reimbursement based on some of these prescribing methods, he added.
Dr. Englesbe reported no commercial disclosures related to his presentation.
ORLANDO – By cutting the number of pills prescribed after a surgical procedure, exposure to opioids can be minimized in a largely opioid-naive patient population at risk of new, persistent use, according to Michael J. Englesbe, MD, FACS, professor of surgery at the University of Michigan, Ann Arbor, who is leading a Michigan initiative to tailor acute care prescribing.
About 90% of surgically patients are opioid-naive, and of those, studies suggest about 6% may become new, persistent opioid users, according to Dr. Englesbe, codirector of the Michigan Opioid Prescribing and Engagement Network (Michigan-OPEN), a state-wide effort to transform acute pain prescribing across all surgical specialties.
“This is a very vulnerable population where their operation can lead to life-changing events way beyond their surgical outcomes,” Dr. Englesbe said in a presentation at the American College of Surgeons Quality and Safety Conference.
“We have to really worry about them,” he added. “It’s hard to identify who they are, and I think minimizing exposure to opioids is the best we have at this point.”
By following evidence-based prescribing guidelines after laparoscopic cholecystectomy, Dr. Englesbe and his colleagues were able to reduce prescription size by 63% with no increase in refills and no change in pain score, according to a research letter recently published in JAMA Surgery.
After adopting the guidelines, median postoperative opioid use dropped from 30 mg to 20 mg (P = .04), they reported.
Laparoscopic cholecystectomy patients could be prescribed as few as 10 5-mg tablets of oxycodone, according to recommendations developed by Michigan-OPEN that are published on opioidprescribing.info. Dr. Englesbe called the website figures “precise prescribing recommendations” that are still relatively generous, meeting or exceeding self-reported use for 75% of patients.
“I think this is an important template for change,” he said. “We’ve found the surgeons in the state very receptive, but more importantly, we’ve been able to partner with other really important stakeholders.” For example, one insurer in the state now aligns some hospital incentive reimbursement based on some of these prescribing methods, he added.
Dr. Englesbe reported no commercial disclosures related to his presentation.
ORLANDO – By cutting the number of pills prescribed after a surgical procedure, exposure to opioids can be minimized in a largely opioid-naive patient population at risk of new, persistent use, according to Michael J. Englesbe, MD, FACS, professor of surgery at the University of Michigan, Ann Arbor, who is leading a Michigan initiative to tailor acute care prescribing.
About 90% of surgically patients are opioid-naive, and of those, studies suggest about 6% may become new, persistent opioid users, according to Dr. Englesbe, codirector of the Michigan Opioid Prescribing and Engagement Network (Michigan-OPEN), a state-wide effort to transform acute pain prescribing across all surgical specialties.
“This is a very vulnerable population where their operation can lead to life-changing events way beyond their surgical outcomes,” Dr. Englesbe said in a presentation at the American College of Surgeons Quality and Safety Conference.
“We have to really worry about them,” he added. “It’s hard to identify who they are, and I think minimizing exposure to opioids is the best we have at this point.”
By following evidence-based prescribing guidelines after laparoscopic cholecystectomy, Dr. Englesbe and his colleagues were able to reduce prescription size by 63% with no increase in refills and no change in pain score, according to a research letter recently published in JAMA Surgery.
After adopting the guidelines, median postoperative opioid use dropped from 30 mg to 20 mg (P = .04), they reported.
Laparoscopic cholecystectomy patients could be prescribed as few as 10 5-mg tablets of oxycodone, according to recommendations developed by Michigan-OPEN that are published on opioidprescribing.info. Dr. Englesbe called the website figures “precise prescribing recommendations” that are still relatively generous, meeting or exceeding self-reported use for 75% of patients.
“I think this is an important template for change,” he said. “We’ve found the surgeons in the state very receptive, but more importantly, we’ve been able to partner with other really important stakeholders.” For example, one insurer in the state now aligns some hospital incentive reimbursement based on some of these prescribing methods, he added.
Dr. Englesbe reported no commercial disclosures related to his presentation.
EXPERT ANALYSIS FROM ACSQSC 2018