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01-05-2013

Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands

Authors: Freek Gillissen, Christiaan Hoff, José M. C. Maessen, Bjorn Winkens, Jitske H. F. A. Teeuwen, Maarten F. von Meyenfeldt, Cornelis H. C. Dejong

Published in: World Journal of Surgery | Issue 5/2013

Abstract

Background

It has been clearly shown that after elective colorectal surgery patients benefit from multimodal perioperative care programs. The Dutch Institute for Health Care Improvement started a breakthrough project to implement a multimodal perioperative care program of enhanced recovery after surgery (ERAS). This pre/post noncontrolled study evaluated the success of large-scale implementation of the ERAS program for elective colonic surgery using the breakthrough series.

Methods

A total of 33 hospitals participated in this breakthrough project during 2005–2009. Each hospital performed a retrospective chart review to gather information on traditionally treated patients (pre-ERAS group, n = 1,451). During the subsequent year patients were treated according to the ERAS program (ERAS group, n = 1 034). Outcomes were length of stay (LOS), functional recovery, adherence to the protocol, and determinants of reduced LOS.

Results

Median LOS decreased significantly from 9 to 6 days (p < 0.001). In the ERAS group, functional recovery was reached within 3 days. Adherence to the protocol elements was high during the preoperative and perioperative phases but slightly lower during the postoperative phase. Younger age, female sex, American Society of Anesthesiologists grades I/II, and laparoscopic surgery were associated with decreased LOS. Care elements that positively influenced LOS were cessation of intravenous fluids and mobilization on postoperative day 1 and administration of laxatives postoperatively.

Conclusions

The ERAS program was successfully implemented in one-third of all Dutch hospitals using the breakthrough series. Participating hospitals reduced the LOS by a median 3 days and were able to improve their standard of care in elective colonic surgery.

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Schoetz DJ Jr, Bockler M, Rosenblatt MS et al (1997) “Ideal” length of stay after colectomy: whose ideal? Dis Colon Rectum 40:806–810PubMedCrossRef

Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation program. Br J Surg 86:227–230PubMedCrossRef

Basse L, Hjort Jakobsen D, Billesbolle P et al (2000) A clinical pathway to accelerate recovery after colonic resection. Ann Surg 232:51–57PubMedCrossRef

Basse L, Raskov HH, Hjort Jakobsen D et al (2002) Accelerated postoperative recovery program after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 89:446–453PubMedCrossRef

Basse L, Thorbol JE, Lossl K et al (2004) Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 47:271–277 discussion 277–278PubMedCrossRef

Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606–617PubMedCrossRef

Kehlet H (2000) Manipulation of the metabolic response in clinical practice. World J Surg 24:690–695PubMedCrossRef

Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183:630–641PubMedCrossRef

Varadhan KK, Neal KR, Dejong CH et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440PubMedCrossRef

10.

Bradshaw BG, Liu SS, Thirlby RC (1998) Standardized perioperative care protocols and reduced length of stay after colon surgery. J Am Coll Surg 186:501–506PubMedCrossRef

11.

Schwenk W (2001) Perioperative management influences the results of laparoscopic colonis surgery: arguments for a fast track program. Presented at the 1st hvidovre symposium on perioperative care—colorectal surgery, Copenhagen

12.

Henriksen MG, Hansen HV, Hessov I (2002) Early oral nutrition after elective colorectal surgery: influence of balanced analgesia and enforced mobilization. Nutrition 18:263–267PubMedCrossRef

13.

Anderson AD, McNaught CE, MacFie J et al (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90:1497–1504PubMedCrossRef

14.

Delaney CP, Zutshi M, Senagore AJ et al (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859PubMedCrossRef

15.

Soop M, Carlson GL, Hopkinson J et al (2004) Randomized clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg 91:1138–1145PubMedCrossRef

16.

Gatt M, Anderson AD, Reddy BS et al (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362PubMedCrossRef

17.

Maessen J, Dejong CH, Hausel J et al (2007) A protocol is not enough to implement an enhanced recovery program for colorectal resection. Br J Surg 94:224–231PubMedCrossRef

18.

Lassen K, Soop M, Nygren J et al (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS) group recommendations. Arch Surg 144:961–969PubMedCrossRef

19.

Lassen K, Hannemann P, Ljungqvist O et al (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 330:1420–1421PubMedCrossRef

20.

Nygren J, Hausel J, Kehlet H et al (2005) A comparison in five European centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr 24:455–461PubMedCrossRef

21.

Hannemann P, Lassen K, Hausel J et al (2006) Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northern-European countries. Acta Anaesthesiol Scand 50:1152–1160PubMedCrossRef

22.

Polle SW, Wind J, Fuhring JW et al (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24:441–449PubMedCrossRef

23.

Grimshaw JM, Eccles MP, Walker AE et al (2002) Changing physicians’ behavior: what works and thoughts on getting more things to work. J Contin Educ Health Prof 22:237–243PubMedCrossRef

24.

Grol R, Wensing M (2004) What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 180(6 Suppl):S57–S60PubMed

25.

Wilson KD, Kurz RS (2008) Bridging implementation and institutionalization within organizations: proposed employment of continuous quality improvement to further dissemination. J Public Health Manag Pract 14:109–116PubMed

26.

Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477PubMedCrossRef

27.

Kilo CM (1998) A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement’s Breakthrough Series. Qual Manag Health Care 6:1–13PubMed

28.

Schouten LM, Hulscher ME, van Everdingen JJ et al (2008) Evidence for the impact of quality improvement collaboratives: systematic review. BMJ 336:1491–1494PubMedCrossRef

29.

Maessen JM, Dejong CH, Kessels AG et al (2008) Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg 32:971–975PubMedCrossRef

30.

Tjeerdsma HC, Smout AJ, Akkermans LM (1993) Voluntary suppression of defecation delays gastric emptying. Dig Dis Sci 38:832–836PubMedCrossRef

31.

Hansen CT, Sorensen M, Moller C et al (2007) Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study. Am J Obstet Gynecol 196:e311–e317CrossRef

32.

Hendry PO, van Dam RM, Bukkems SF et al (2010) Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection. Br J Surg 97:1198–1206PubMedCrossRef

33.

Andersen J, Christensen H, Pachler JH et al (2011) Effect of the laxative magnesium oxide on gastrointestinal functional recovery in fast-track colonic resection: a double-blind, placebo-controlled randomized study. Colorectal Dis 14:776–782CrossRef

34.

Zingg U, Miskovic D, Pasternak I et al (2008) Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial. Int J Colorectal Dis 23:1175–1183PubMedCrossRef

35.

Van Bree S, Vlug M, Bemelman W et al (2011) Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology 141(872–880):e871–e874

36.

Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254:868–875PubMedCrossRef

Title: Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands
Authors: Freek Gillissen
Christiaan Hoff
José M. C. Maessen
Bjorn Winkens
Jitske H. F. A. Teeuwen
Maarten F. von Meyenfeldt
Cornelis H. C. Dejong
Publication date: 01-05-2013
Publisher: Springer-Verlag
Published in: World Journal of Surgery / Issue 5/2013
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-013-1938-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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