Rural context, single institution prospective outcomes after enhanced recovery colorectal surgery protocol implementatio
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(2020) 20:1120
RESEARCH ARTICLE
Open Access
Rural context, single institution prospective outcomes after enhanced recovery colorectal surgery protocol implementation Levi Smucker* , Jennifer Victory, Melissa Scribani, Luis Oceguera and Raul Monzon
Abstract Background: Rural hospitals face unique challenges to adopting Enhanced Recovery protocols after colorectal surgical procedures. There are few examples of successful implementation in the United States, and fewer yet of prospective, outcomes-based trials. Methods: This study drew data from elective bowel resection prospectively collected, retrospectively analyzed cases 2 years prior (n = 214) and 3 years after (n = 224) implementing an ERAS protocol at a small, rural health network in upstate New York. Primary outcomes were cost, length-of-stay, readmission rate, and complications. Results: The implementation required changes and buy-in at multiple levels of the institution. There was a statistically significant reduction in mean length of stay (6.9 versus 5.1 days) and per-patient savings to hospital ($3000) after implementation of ERAS protocol. There was no significant change in rate of 30-day readmissions or complications. Conclusions: The authors conclude that for rural-specific barriers to implementation of Enhanced Recovery protocols there are specific organizational strategies that can ultimately yield sustainable endpoints. Keywords: Enhanced recovery, ERAS, Colorectal surgery, Rural, Organizational change
Background Rural hospitals face relative challenges in the adoption of Enhanced Recovery After Surgery (ERAS) protocols for their patients. When the ERAS Study Group published consensus guidelines in 2005, the protocols had primarily been developed and used in urban and academic centers in Europe [1]. Eventually, the ERAS Society --- established in 2010 --- began to create accessible education materials and audit systems to disseminate and encourage early adoption of best perioperative practices throughout the world [2]. Early adoption in North America began soon thereafter. Since then, ERAS protocols have ballooned to encompass multiple surgical specialties beyond colorectal * Correspondence: [email protected] Bassett Medical Center, Cooperstown, NY, USA
surgery, and can refer to many forms of multi-modal, comprehensive, peri-operative frameworks. ERAS protocols rely on a multitude of practices which invariably include detailed preoperative education and counseling, medical optimization, tight glycemic control, maintenance of normothermia, multimodal analgesia, opioid reduction, early feeding, early mobilization, and early catheter removal. However, academic and urban hospitals have implemented ERAS at much greater rates than rural hospitals. There are unique challenges to ERAS feasibility in rural practice including patient factors, geographic limitations, high staff turnover and shortages, fewer resources, and lower case volume. Some other barriers cited include patient education and the notion that ERAS principles may not be intuitiv
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