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. 2019 Feb 1;62(1):25-32.
doi: 10.1503/cjs.015617.

Impact of sequential implementation of multimodal perioperative care pathways on colorectal surgical outcomes

Karan D’Souza  1 , Jung-In Choi  1 , Julie Wootton  1 , Thomas Wallace  1
Affiliations

Impact of sequential implementation of multimodal perioperative care pathways on colorectal surgical outcomes

Karan D’Souza et al. Can J Surg. .

Abstract
in English, French

Background: Standardized care protocols offer the potential to reduce postoperative complication rates. The purpose of this study was to determine whether there was an additive benefit associated with the sequential implementation of the evidence-based surgical site infection bundle (SSIB) and enhanced recovery after surgery (ERAS) protocols for patients undergoing colorectal surgery in a community hospital.

Methods: Patients at a single institution who underwent elective colorectal surgery between Apr. 1, 2011, and Dec. 31, 2015, were identified by means of American College of Surgeons National Surgical Quality Improvement Program data. Patients were stratified into 3 groups according to the protocol implementation dates: pre-SSIB/pre-ERAS (control), post-SSIB/pre-ERAS and post-SSIB/post-ERAS. Primary outcomes assessed were length of stay and wound complication rates. We used inverse proportional weighting to control for possible differences between the groups.

Results: There were 368 patients included: 94 in the control group, 95 in the post-SSIB/pre-ERAS group and 179 in the post-SSIB/post-ERAS group. In the adjusted analyses, mean length of stay (control group 7.6 d, post-SSIB/post-ERAS group 5.5 d, p = 0.04) and overall wound complication rates (14.7% and 6.5%, respectively, p = 0.049) were reduced after sequential implementation of the protocols.

Conclusion: Sequential implementation of quality-improvement initiatives yielded additive benefit for patients undergoing colorectal surgery in a community hospital, with a decrease in length of stay and wound complication rates. The amount of improvement attributable to either initiative is difficult to define as they were implemented sequentially. The improved outcomes were realized after the introduction of the ERAS protocol in adjusted analyses.

Contexte: Les protocoles de soins standardisés offrent la possibilité de réduire les taux de complications postopératoires. Le but de cette étude était de déterminer s’il y a un avantage additif associé à l’application séquentielle des protocoles fondés sur des données probantes SSIB (surgical site infection bundle) et ERAS (enhanced recovery after surgery) chez des patients soumis à une chirurgie colorectale dans un hôpital communautaire.

Méthodes: Les patients d’un seul établissement ayant subi une chirurgie colorectale non urgente entre le 1er avril 2011 et le 31 décembre 2015 ont été recensés à partir des données du Programme national d’amélioration de la qualité chirurgicale de l’American College of Surgeons. Les patients ont été stratifiés en 3 groupes selon les dates d’application des protocoles : pré-SSIB/pré-ERAS (témoin), post-SSIB/pré-ERAS et post-SSIB/post-ERAS. Les paramètres principaux évalués étaient la durée du séjour hospitalier et les taux de complications de plaies. Nous avons utilisé une pondération proportionnelle inverse pour tenir compte des possibles différences entre les groupes.

Résultats: Nous avons inclus 368 patients, 94 dans le groupe témoin, 95 dans le groupe post-SSIB/pré-ERAS et 179 dans le groupe post-SSIB/post-ERAS. Dans les analyses ajustées, la durée moyenne des séjours (groupe témoin 7,6 j, groupe post-SSIB/post-ERAS 5,5 j, p = 0,04) et les taux globaux de complications de plaies (14,7 % et 6,5 % respectivement, p = 0,049) ont diminué après l’application séquentielle des protocoles.

Conclusion: L’application séquentielle des initiatives d’amélioration de la qualité a donné lieu à des bienfaits additifs chez les patients soumis à une chirurgie colorectale dans un hôpital communautaire, avec abrègement du séjour hospitalier et diminution du taux de complications de plaies. Le degré d’amélioration attribuable à chacune des initiatives est difficile à préciser puisqu’elles ont été appliquées séquentiellement. L’amélioration des paramètres a été obtenue après l’introduction du protocole ERAS dans des analyses ajustées.

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Conflict of interest statement

None declared.

References

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