How can lean thinking improve ERAS program in bariatric surgery?
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and Other Interventional Techniques
How can lean thinking improve ERAS program in bariatric surgery? Giovanni Fantola1 · Marina Agus1 · Matteo Runfola1 · Cinzia Podda2 · Daniela Sanna1 · Federica Fortunato1 · Stefano Pintus1 · Roberto Moroni1 Received: 4 May 2020 / Accepted: 17 August 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Introduction Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols. Methods Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time. Results 471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p 2 h for clear liquid and carbohydrate drink loading since 2 h before surgery Premedication (paracetamol and H2 pump inhibitors) Parallel team work Awake patient position Standardized anesthesia and multimodal analgesia opioid-sparing Noninvasive monitoring Prophylactic antibiotics before surgery Compression stocking and pneumatic stocking Hypothermia prevention Goal directed fluid management PONV prevention (preoperative dexamethasone injection) Laparoscopy Avoiding nasogastric tube Avoiding urinary catheter Avoiding abdominal drain Early mobilization Early oral fluid Venous thromboembolism prophylaxis (BMI-adjusted dose) Discharge planning
96.8% 52.1% 100% 100% 100%
CPAS use in OSA patients at least 2 weeks before surgery, diabetes optimization (glycemic control and glycated hemoglobin 50 kg/m2; a weight gain led to an adjournment of the surgery. A bland diet was recommended the night before surgery and clear liquid with carbohydrate drink loading was recommended 2 h before surgery.
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98.9% 100% 96.8% 91.34% 100% 100% 100% 100%
Intraoperative All patients wear compression and pneumatic stockings which are positioned before surgery. Cephalosporin 2 or 3 g according to the weight was given 1 h before skin incision and it was r
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