Hospitals Face Challenges When Implementing Enhanced Recovery Programs for Surgery

Key takeaways

• Striving to improve patient care: Enhanced recovery programs (ERPs) provide hospitals with patient-centered protocols and standards to improve the safety and quality of care for patients undergoing surgery.
• Understanding barriers to compliance: Although previous studies have shown substantial improvements when hospitals implement ERPs, some hospitals have reported difficulties successfully implementing these programs.
• ERPs are not always easily implemented: This study found that out of 151 hospitals that implemented an ERP for colorectal surgery, most of them (85%) had difficulty improving compliance with a national protocol.

Newswise — CHICAGO: Enhanced recovery programs (ERPs) provide hospitals with the highest-quality resources to improve patient care for surgery, but many hospitals still struggle to successfully implement these programs and may need more structured resources to boost compliance rates, according to findings published in the Journal of the American College of Surgeons (JACS). 

“Enhanced recovery programs have been instrumental in promoting evidence-based, standardized perioperative care that focuses on engaging patients from the moment it’s decided they will have surgery, all the way to their transition back into the community,” said Elizabeth Wick, MD, FACS, a professor of surgery at the University of California, San Francisco (UCSF) and a study co-author. “While some previous studies have reported substantial improvements when hospitals implement these programs, the goal of this study was to take a deep dive into process compliance and understand how successful these hospitals were at implementing enhanced recovery programs.”

The research stems from the Improving Surgical Care and Recovery Collaborative (ISCR), a partnership between the American College of Surgeons (ACS), the Agency for Healthcare Research and Quality, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. That collaboration began in 2016 with the goal of helping hospitals implement ERPs, also known as enhanced recovery after surgery, around the country by providing them with centralized support and tools for standardizing patient care — from guidelines on infection control to optimal nutrition. The program ran until 2022 and assisted about 300 hospitals in initiating and spreading ERPs across multiple surgical specialties, according to Dr. Wick.

“Another principle we try to emphasize through the program is the importance of multidisciplinary or collaborative surgical care with surgeons, anesthesiologists, hospitals, and nurses,” Dr. Wick explained. “All members of the team need to come together to provide the best surgical care for patients and their families.”

For this study, researchers analyzed data from 151 hospitals enrolled in an ISCR protocol for colorectal surgery to determine if they got better or worse at complying with ERP process measures — and by how much — over an 18-month period. Participating hospitals, which were located throughout the country but were mostly teaching hospitals in urban areas, entered data on process measure compliance and 30-day patient outcomes into a customized registry through the ACS National Surgical Quality Improvement Program^® (ACS NSQIP^®).

The researchers looked at six common components of an ERP protocol for colorectal surgery:

• Oral antibiotics: Did the patient receive oral antibiotics within 24 hours of the operation?
• Mechanical bowel preparation: Did the patient complete a mechanical bowel preparation (oral medication used to cleanse the large bowel of fecal matter) before the operation?
• Multimodal pain control: Did the patient use scheduled, nonopioid pain medication in addition to, or in place of, opioid pain medication within 24 hours of the operation?
• Early mobilization: Was the patient mobile (able to walk and stand) within 24 hours of the operation?
• Early liquid intake: Did the patient receive liquid within 24 hours of the operation?
• Early solid intake: Did the patient receive solid food within 48 hours of the operation?

Looking at changes in process measure compliance from the start of the program to the end, the team divided compliance rate changes into three categories: worsening (<0%), minimal improvement (0-20% change in compliance), and substantial improvement (greater than 20% change in compliance).

Researchers looked at each of the six process measures separately as an individual opportunity for improvement and looked at a composite measure of all six process measures by the hospital.

Key findings

• Out of 151 hospitals studied, only 15% of the hospitals achieved substantial improvements in compliance across the entire protocol.
• The researchers identified 663 individual opportunities available for improvement; of these opportunities, substantial improvement in compliance only occurred 20% of the time.
• Process measures that involved simple interventions, such as pain control or oral antibiotics, improved the most by 23% and 16%, respectively. In contrast, early mobilization improved the least, by 2%.
• On average, the individual components of the ERP were implemented for patients less than 70% of the time across all the hospitals.

The research focused on a national ERP for colorectal surgery, but the authors note that the results may be generalizable across many surgical specialties.

“I think these findings suggest that there’s a significant opportunity available to improve compliance with enhanced recovery programs, and in turn, improve patient outcomes, because prior studies have shown that high compliance leads to better outcomes,” said Tejen Shah, MD, a general surgery resident at Ohio State University Wexner Medical Center and lead author of the study.

Addressing barriers

Though the study only included data from hospitals that participated in the ISCR collaborative, which could cause selection bias, the trends reflected in the study paint a larger picture of barriers to implementing ERPs, the researchers said. When implementing ERPs, inadequate resources or limited leadership support may hinder progress, for example, or there may be ineffective collaboration and communication among team members.

In their journal article, the researchers identified the ACS Quality Verification Program^™ (ACS QVP) as one program that may offer hospitals a more structured approach to achieving quality improvement measures. The ACS QVP provides hospitals with customized, actionable recommendations on improving surgical quality, such as leadership and safety culture, based on the framework of 12 evidence-based standards vetted by the ACS. The program may help hospitals and providers break down each component of the ERP into manageable items, the researchers noted.

“The overall structure of the ACS QVP may also be advantageous to hospitals. It really helps surgeons engage with hospital leadership at a very high level,” Dr. Wick said.

“Lower compliance rates didn’t occur because of a lack of effort. People were passionate about trying to implement the enhanced recovery program. But it was challenging,” she added. “I think this study highlights the fact that we need to collectively figure out how to address those barriers and make this work easier. We have the opportunity to improve prioritization and access to resources, whether it’s project management or expertise in data skills, and then ultimately hold people accountable for doing the work.”

“This research confirms what we as surgeons know — the work of improvement is challenging. It takes tremendous focus and determination,” Dr. Wick said. “The good news is that the ACS has exceptional expertise in how to improve surgical quality. With more than 17 surgical quality programs, the ACS is a valuable resource for every hospital’s quality journey.”

Study coauthors are Leandra Knapp, MS; Mark E. Cohen, PhD; Stacy A. Brethauer, MD, MBA, FACS; and Clifford Y. Ko MD, MS, MSHS, FACS. All authors are affiliated with the Division of Research and Optimal Patient Care, the American College of Surgeons, Ohio State University Wexner Medical Center, the University of California, San Francisco (UCSF), or the University of California, Los Angeles (UCLA).

The study authors have no relevant disclosures to report. This research was supported by funding from the Agency for Healthcare Research and Quality (AHRQ). Ms. Knapp is supported by funding from the U.S. Department of Health and Human Services and is employed by the American College of Surgeons, subcontracted under Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality for Improving Surgical Care and Recovery contract with the AHRQ. Dr. Wick is supported by funding from the National Institutes of Health.

This research was also presented at the Southern Surgical Association 134^th Annual Meeting in Palm Beach, Florida, December 2022. This study is published as an article in press on the JACS website.

Citation: Shah T, Knapp L, Cohen M, et al. Truth of Colorectal Enhanced Recovery Programs: Process Measure Compliance in 151 Hospitals. Journal of American College of Surgeons. DOI: 10.1097/XCS.0000000000000562.

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About the American College of Surgeons 

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates a surgeon is a Fellow of the American College of Surgeons.  

The Journal of the American College of Surgeons (JACS) is the official scientific journal of ACS. Each month, JACS publishes peer-reviewed original contributions on all aspects of surgery, with the goal of providing its readership the highest quality rapid retrieval of information relevant to surgeons.