The Impact of Bariatric ERAS Protocol on Patient Outcomes

General Information

Institution Name: Northwell Health North Shore University Hospital

Submitter Name: Charmaine Gentles, DNP, ANP, RNFA

Name of Case Study: The Impact of Bariatric ERAS Protocol on Patient Outcomes

What Was Done?

Global Problem Addressed

Enhanced recovery after surgery (ERAS) protocols are multimodal approaches used during the perioperative period to achieve faster patient rehabilitation.

Significant components of an ERAS protocol include standardized perioperative counseling, nutritional optimization, early ambulation, multimodal analgesia, and anesthetic agents.¹ Multiple specialties, including colorectal, vascular, cardiac, and orthopaedic surgery have demonstrated improved outcomes and shorter length of stay with the use of ERAS protocols.^{2 3}

Identification of Local Problem

Since 2012, the bariatric surgery program at North Shore University Hospital (NSUH) used data collected from their own readmission tracking data spreadsheet and data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) database to identify outliers in terms of length of stay and adverse outcomes. These outliers were used to create internal quality improvement projects, which are reviewed at the program's Bariatric Quarterly Taskforce Committee meetings. In 2014, the MBSAQIP established inaugural standards. In particular, Standard 2.1,"Metabolic and Bariatric Surgery Committee," and Standard 7, "Continuous Quality Improvement," require all accredited centers to establish a committee for continuous quality improvement to share best practices and track outcomes based on the Semiannual Reports (SARs) to identify potential areas of improvement. Throughout this time, using data from MBSAQIP, NSUH's quality improvement projects focused on methods to improve resource and process utilization, and the quality of care delivered. From 2009 to 2011, the average length of stay (LOS) for bariatric surgery patients at NSUH was 1 to 3.5 days, and following ERP LOS was reduced in all patients by an average of 0.5 to 2 days. Median reduction in LOS of 3 days has been reported by programs utilizing ERAS protocols.⁴

How Was the Quality Improvement (QI) Activity Put in Place?

Context of the QI Activity

• NSUH is one of 23 hospitals in the Northwell Health system. It is an 831-bed tertiary hospital located within a Long Island suburb. NSUH is a comprehensive MBSAQIP facility accredited to perform bariatric surgery. It is a referral center for the other nine bariatric programs within the Northwell Health system, as well as for bariatric patients within the community in the tristate area. There are two verified bariatric surgeons on staff at NSUH.
• There has been a nationwide effort to decrease LOS and adverse outcomes, which was bolstered by the change in the American Medical Association's 2013 reimbursement policies. The average NSUH LOS was 1 to 3.5 days following a primary bariatric procedure, which was noted to be longer than the average LOS at programs using ERAS protocols. In 2012, NSUH bariatric surgery targeted LOS and post-op complication rate for developing a QI program and implemented an ERAS protocol.

Planning and Development Process

• Patient data is reviewed with the bariatric surgeons, and any outliers are analyzed to find areas for clinical improvement. Action items are created, which are presented for discussion at the quarterly Bariatric Task Force Committee meeting. The Bariatric Taskforce Committee members include hospital administrators, anesthesiologists, bariatric surgeons, unit directors, NPs, PAs, nurses, pharmacists, dieticians, SCR, the MIS Fellow, care coordinators, and social workers. A consensus is reached at the meeting, which is then incorporated into the patient plan of care. All of the key participants are involved in the Bariatric Taskforce Committee and have the opportunity to weigh in on every issue, which facilitates support for new initiatives.
• The action items that are approved by the committee are then implemented in four different phases: (1) patient and provider education, (2) implementation of ERAS evidence-based order sets, (3) monitoring of adherence to ERAS guidelines, and (4) analysis of patient outcomes to sustaining the process as best practice.
• The planned change came from existing literature on the use of ERAS protocols in various surgical specialties and the significant benefits obtained in clinical outcomes and cost in the practice settings.²

Description of the Quality Improvement Activity

The specific steps (outlined below) that comprised the QI project consisted of providing education and sharing the protocol to all providers.

Step 1: Patient and Provider Education

• Patient education: This involves providing comprehensive counseling on the purpose of ERAS and its benefits. Patients are educated about what to expect before and after surgery. This includes the use of incentive spirometry, early ambulation, CPAP, optimization of nutritional status such as correction of vitamin and mineral deficiencies, optimization of current health status, use of standardized multi-modal analgesia, and anti-emetics.
• Provider education: This involves disseminating the approved ERAS protocol via e-mail and during grand rounds to all providers involved in the care of the bariatric patients.

Step 2: lmplementation of ERAS Evidence-Based Order Sets

• The bariatric quality lead team (consisting of the bariatric surgeon champion and the bariatric NP) collaborates with the IT department to create a computerized ERAS order set as outlined below.

Step 3: Monitoring of Adherence to ERAS Guidelines

• All members of the clinical team worked together to ensure that all parameters of the implemented change are being followed.
• The nurse practitioner and MIS Fellow write all orders for the postoperative care of the bariatric patients to maintain compliance as well as conduct real-time monitoring of this process intraoperatively and postoperatively when the residents provides assistance.

Step 4: Analysis of Patient Outcomes

• The Bariatric Taskforce holds quarterly committee meetings to review patient outcome data to ensure adherence to ERAS protocol.

Team Roles

• Bariatric surgery champions (MBS Director and NP) are responsible for creating ERAS order sets, educating the health care providers, and reviewing outcome data.
• Anesthesia providers are responsible for adhering to ERAS protocol within the operating room. The anesthesia residency program director ensures ERAS adherence among the anesthesia providers.
• The quality improvement project was implemented in 2012 and has been sustained throughout the years.

Resources Used and Skills Needed

Staff

The MBS Surgeon Champion and the bariatric program manager/NP led the QI initiative. There were a total of 10 active members involved in the QI project, which included the surgeons, MIS Fellow, NPs, administrators, hospital surgical quality officer, and anesthesiologists.

Costs

There were no costs beyond normal hospital operations to implement and maintain the QI program.

Funding

No additional funding sources were necessary.

What Were the Results?

The chi-square test was used to examine the association between time periods (pre/post) and each outcome of interest, namely adverse events (yes/no) and readmission (yes/no). Additionally, the Cochrane-Armitage test was used to examine increasing or decreasing trends in adverse events and readmission rates over time (2009-2015). Results were considered significant at a significance level of p<0.05. Analyses were conducted using SAS version 9.4 (SAS Institute, Inc., Cary, NC).

There were a total of 1,140 patients; 401 (35.18%) 2009-2011 (pre) and 739 (64.82%) 2012-2015 (post). Adverse events, hospital length of stay, and readmission rates all trended down over time. Adverse events in the post-ERAS period were significantly lower (2.98%) as compared with adverse events in the pre-ERAS period (8.98%, P < 0.0001). Readmissions in the post-ERAS period were significantly lower (1.76%) as compared with readmissions in the pre-ERAS period (7.48%, P < 0.0001).

Additionally, there was a significant decline in adverse events (P < 0.0001) and readmissions (P < 0.0001) from 2009 to 2015. For gastric bypass patients, length of stay decreased from 4.2 days to 2 days. Average hospital length of stay for gastric band patients decreased from 1.1 days in 2009 to 0.25 in 2015. Sleeve gastrectomy average length of stay decrease from 2. 2 to 1.2 days from 2012 to 2015.

Setbacks

There was hesitation for change in practices by the anesthesia department. However by providing evidence-based education and collaborating, providers were able to update and implement changes in practice.

Cost Savings

There was no money invested in implementing the QI project. Further studies need to be performed on the costs saved by shortening the LOS and improving quality outcomes.

Tips for Others

• "Play well with others." At its core, QI is a team process, so it is important to engage the primary stakeholders as early as possible to avoid pitfalls and barriers. In addition, for QI to be effective, there must be a solid infrastructure with the right leadership, policies, and procedures to support and facilitate the work flow. Having the right infrastructure will not only provide the right tools and resources, but will also set clear goals and expectations to help keep the team on track.
• Focus on the data. Data is the foundation for QI. Use the data to identify what is currently happening and the outcomes when changes are implemented. Document the performance (improvement versus no improvement) and check for benchmark comparisons across other programs.
• "A chain is only as strong as its weakest link." Each individual must contribute and be an active member of the team. Keep the lines of communication open. Have weekly meetings, continuous monitoring, and provide feedback as indicated. Different perspectives from an interprofessional collaboration will sustain improvements.
• "You don't know where you're going until you know where you've been." Establish your baseline so you can track what changes you are implementing and their clinical impact.

Acknowledgements

Achieving the high level of quality outcomes and success at NSUH was based on the dedication and leadership of the bariatric surgeon champion (MBS Director) and the bariatric NP in collaboration with organization leadership, the MBS committee, anesthesiologists, residents, nurses, and the SCR. The MIS Fellow provided great support and deserves acknowledgement as well. Many participated in the quarterly meetings to fulfill the quality plan and integrated the QI changes into the respective clinical areas despite their busy work schedules. Their commitment to the quality plan assisted in delivering safe and quality care, which has ensured that bariatric patients at NSUH achieve excellent outcomes.

References

1. Wick EC, et al. Organizational culture changes result in improvement in patient-centered outcomes: Implementation of an integrated recovery pathway for surgical patients. Journal of the American College of Surgeons. September 2015;221(3) 669-677 
2. Ljungqvist 0, Scott M, Fearon KC. Enhanced Recovery After Surgery. A Review. JAMA Surg. 2017;152(3):292-298. doi:10.1001/jamasurg.2016.4952. 
3. Wu CL, et al. Initiating an enhanced recovery pathway program: An anesthesiology department's perspective. The Joint Commission Journal on Quality and Patient Safety. October 2015;41(10): 447-456. 
4. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, Umapathi BA, McMurry TL. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. Journal of the American College of Surgeons. January 2015;220(4):430-443.