A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay Afte
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ORIGINAL SCIENTIFIC REPORT
A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery Ben E. Byrne1,2
•
Omar D. Faiz3 • Alex Bottle4 • Paul Aylin4 • Charles A. Vincent5
Accepted: 5 September 2020 Ó The Author(s) 2020
Abstract Background Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. Methods A cross-sectional questionnaire was administered to surgeons and nurses in August–October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013–15. Results 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. Conclusions Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00268-020-05810-w) contains supplementary material, which is available to authorized users. & Ben E. Byrne [email protected] 1
2
Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK Department of Surgery and Cancer, Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
3
Surgical Epidemiology, Trials and Outcome Centre, St Marks Hospital, Harrow, UK
4
Dr. Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
5
Department of Experimental Psychology, University of Oxford, Oxford, UK
123
World J Surg
Abbreviations CT Computed tomography ERP Enhanced Recovery Program NHS National Health Service NIHR National Institute for Health Research NGT Nasogastric tube USS Ul
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