Implementation of an Enhanced Recovery After Surgery (ERAS) Program Improves Outcomes in Patients Undergoing Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy (HIPEC)

General Information 

Institution Name: Mayo Clinic Arizona 

Submitter Name and Title: Nabil Wasif, MD, MPH 

Name of the Case Study: Implementation of an Enhanced Recovery After Surgery (ERAS) Program Improves Outcomes in Patients Undergoing Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy (HIPEC) 

What Was Done? 

Global Problem Addressed 

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have emerged as an acceptable treatment modality for patients with peritoneal surface malignancies. This combined treatment can be considered standard of care for pseudomyxoma peritonei (PMP) and peritoneal mesothelioma as well as for select patients with peritoneal metastasis from colorectal and advanced epithelial ovarian cancers.^1,2 Since the latter part of the late 1990s, it has grown in practice significantly throughout the U.S.³ 

In addition to the normal physiologic responses after CRS, administration of intraabdominal chemotherapy and patient hyperthermia lead to a myriad of biologic responses, including exaggerated fluid and electrolyte shifts, hemodynamic derangements, bone marrow suppression, and inhibition of wound healing.^4,5 Consequently, HIPEC procedures have traditionally seen high rates of postoperative complications.^6-8 Contemporary approaches to perioperative care have been liberal use of intravenous fluids to mitigate against chemotherapy-induced nephrotoxicity, routine use of feeding/nasogastric tubes for anticipated ileus, delayed feeding, transabdominal drains, and use of intensive care units.^9-12 These are all associated with a prolonged length of stay (LOS). 

Identification of Local Problem 

The HIPEC program was implemented at our institution in 2010. Careful monitoring of morbidity, mortality, and LOS was done from the outset. A prospectively maintained database of patients undergoing HIPEC was maintained by the research team as part of a quality monitoring and improvement initiative. Our initial experience of 49 cases had an overall complication rate of 63 percent with a Grade III/IV complication rate of 24 percent. The mean length of stay was 10.3 ± 8.9 days, the rate of unplanned surgical intervention was 12 percent, and the rate of 30-day readmissions was 16 percent. Our group decided to implement an enhanced recovery program (ERP) for patients undergoing HIPEC to try and improve on these outcomes. 

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

Context of the QI Activity 

The Mayo Clinic in Arizona is a 270-bed hospital with 21 operating rooms. The hospital started performing operations in 1998 and employs close to 6,000 people. 

There is considerable institutional focus on quality of care and achieving high- value care. Employees have the option of becoming bronze, silver, or gold certified in quality by participating in quality initiatives and projects within their clinical realm. The hospital already has a robust Enhanced Recovery After Surgery (ERAS) program in place for colorectal surgeries, so implementing a new program was facilitated. 

Planning and Development Process 

Major stakeholders in the HIPEC practice were identified by the physician lead (Dr. Wasif). These included anesthesiologists, nursing staff, operating room (OR) pharmacists, perfusion staff, allied health staff, and general surgery residents. A review of the literature related to perioperative management of patients undergoing CRS and HIPEC was undertaken to identify areas of intervention. Traditional management of HIPEC patients involves large-volume resuscitation, prolonged durations of no per oral intake, and liberal use of narcotic pain medicines. These patients have high rates of morbidity and mortality and prolonged length of hospital stays, leading to significant use of hospital resources and costs of care. 

There were no prior studies on implementation of ERAS principles in HIPEC patients, so our team developed interventions that we felt would be safe and efficacious. We relied heavily on published literature on implementation of ERAS principles in patients undergoing colon surgery.¹³ Relevant interventions were discussed with each stakeholder in turn by the physician lead. Changes to current practice were clearly outlined and written protocols disseminated and placed on the institutional intranet for access. Buy-in was not an issue, as ERAS pathways were well established in the institution and the potential to reduce morbidity, mortality, and length of stay in these patients was readily appreciated by all participants. 

Description of the Quality Improvement Activity 

Table 1 outlines the major interventions made following the implementation of an ERAS pathway in patients undergoing CRS and HIPEC at our institution. 

Traditional management prior to implementation is also shown for comparison. Our program was launched over several months in early 2016. 

Resources Used and Skills Needed

Staff

There is only one surgeon performing CRS and HIPEC procedures, who also served as the project lead. Two anesthesiologists served as the leads for ERAS programs in general and were responsible for training related to preoperative performance of transversus abdominus plane (TAP) blocks under ultrasound guidance.

Costs

There were no additional costs beyond the normal operating expenses associated with clinical care of these patients. No dedicated funding were required for the project.

What Were the Results?

Overall Results 

Our study population consisted of 130 CRS and HIPEC procedures, 49 (38%) in the pre-ERAS and 81 (62%) in the post-ERAS group. There was no significant difference in mean PCI, surgical time, or patient demographics between both groups. 

Our primary outcomes were 30-day morbidity and mortality. Secondary outcomes were length of hospital stay, 30-day rates of unplanned readmission and reoperation, and rates of acute kidney injury. 

1. In the entire cohort, there was one mortality (0.8%) in the ERAS group secondary to respiratory failure. After implementation of ERAS, the rate of serious grade III/IV complications decreased to from 24 to 15 percent, p = 0.243. The rate of all grade I-IV complications fell from 63 percent pre-ERAS to 37 percent post-ERAS, p = 0.004. 
2. Length of hospital stay decreased significantly from a mean of 10.3 ± 8.9 days in the pre-ERAS group to 6.9 ± 5.0 days in the ERAS group (p = 0.007).
3. Rates of 30-day readmission and acute kidney injury did not change significantly. 
4. Total opioid use measured in oral morphine equivalents (OME) decreased from a median of 272.6 to 159.7mg, a difference that was statistically significant in the open but not the laparoscopic group. 
5. Net total hospital fluid balance decreased from a mean of 6.07±16.8 liters to 3.00±6.3 liters. 
6. On multivariable analyses implementation of an ERAS program was associated with a reduction in LOS (β = -2.89 days, 95% CI -0.94 to -4.84) and a reduction in complications (OR 0.22, 95% CI 0.08-0.57).

Setbacks

There were no significant barriers related to implementation. We attribute this to the small size of the team involved and the fact that there was no significant variation in practice, as only one surgeon performed these procedures.

Furthermore, a robust ERAS program for colorectal surgery was already in place at our institution so that existing clinical pathways and electronic health record order sets were easily customizable to suit our needs. The most technical aspect of our program, the TAP blocks, required little training, as these were already being used by the anesthesiologists on the team.

Cost Savings

A formal cost analysis was not part of this current analysis but is being planned for the future. As a ballpark estimate, we cut our mean length of stay from 10 to 7 days. The average cost for a one-day length of stay in the state of Arizona for a not-for-profit hospital is $2,675.¹⁴ That translates to an average saving of $9,095 per CRS and HIPEC performed. This does not take into account the 38 percent reduction in complication rates.

Tips for Others 

1. Sell as a quality improvement project with potential for significant cost savings and decreased resource utilization.
2. Find a physician lead who is motivated and invested in taking care of this group of patients.
3. Keep the core implementation team small, with one representative from each stakeholder.
4. Start with interventions that can be easily implanted and do not require training (for example, decreasing intraoperative and post-operative fluids).
5. Move on to more difficult interventions after successful baseline implementation (for example, intraoperative TAP blocks).
6. Monitor outcomes closely and implement or maintain a database.
7. Develop and disseminate a patient information booklet setting expectations early of what to expect. Most patients will obtain outdated or incorrect information from the Internet.

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3. Dehal A, Smith JJ, Nash GM. Cytoreductive surgery and intraperitoneal chemotherapy: an evidence-based review-past, present and future. Journal of Gastrointestinal Oncology. 2016;7:143-157. 
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14. Average hospital expenses per inpatient day across 50 states. Available at https://www.beckershospitalreview.com/ finance/average-hospital-expenses-per-inpatient-day-across-50-states.html. Accessed June 12, 2019.