Improving Outcomes in Oesophagectomy Patients

Introduction: Aberdeen Royal Infirmary is a low volume centre carrying out approximately 13 oesophagectomies per annum. Due to minimal exposure to post-operative oesophagectomy patients, staff had low perceived confidence in their management within the Intensive Care Unit (ICU). After an initial pause due to the COVID-19 pandemic, oesophagectomy service provision restarted in June 2020. Prior to this project, no standardised care pathway existed for post-operative oesophagectomy patients. A protocol driven management pathway was implemented within the ICU setting in October 2020. Objective(s): 1. Standardise the first 5 days of post-operative care for oesophagectamies 2. Improve 30 day mortality rate 3. Reduce opiate use on step down to High Dependency Unit (HDU) 4. Improve ICU Medical and Nursing staff perceived confidence in the management of oesophagectomy patients. Method(s): A multi-disciplinary approach was taken, with input from ICU, Surgical, Anaesthetic, Physiotherapy, Nursing, Pain and HDU teams. Standards of care for post-operative oesophagectomy patients were identified and a protocol was subsequently produced for use within ICU with reference to current Enhanced Recovery After Surgery (ERAS) guidelines.1 The protocol covered the first 5 days of post-operative care. It identified tasks to be completed each day and highlighted which staff group was responsible for performing each task. Additionally, an information sheet was distributed to Medical and Nursing ICU staff to educate them on oesophagectomy patients and recognition of potential complications that arise when caring for this patient group. Data on 30 day mortality and opiate use at step down to HDU was collected from electronic notes. This was collected retrospectively prior to implementation of the protocol from January 2019 - July 2020 and prospectively following its implementation, from October 2020 - December 2021. ICU staff perceived confidence in managing post-operative oesophagectomy patients was measured using a combined quiz and survey. It was completed by staff prior to introduction of the protocol. Following implementation of the protocol and distribution of the information sheet, the quiz and survey was repeated to evaluate improvement in staff confidence. Result(s): A total of 38 oesophagectomy cases were identified. 21 cases were reviewed prior to implementation of the protocol, with 1 mortality at 30 days. 17 cases were reviewed following implementation of the protocol, with 0 mortalities at 30 days. Qualitative scoring showed a 20% increase in staff confidence to manage this patient group. Review of drug prescription charts revealed a reduction in dose of modified release opiates at step down to HDU. Conclusion(s): Oesophagectomy is major surgery and causes significant staff anxiety in low volume centres. This protocol has successfully standardised care for this patient group and allowed continuation of this essential service provision during the COVID-19 pandemic. This protocol improved 30 day mortality, reduced opiate use at step down to HDU and improved ICU staff perceived confidence in caring for post-operative oseophagectomy patients.

Enhanced Recovery After Cleft Lip Repair: Protocol Development and Implementation in Outreach Settings.

INTRODUCTION: Clefts of the lip are of the most common congenital craniofacial anomalies. The development and implementation of an enhanced recovery after surgery (ERAS) protocol among patients undergoing cleft lip repair may decrease postoperative complications, accelerate recovery, and result in earlier postoperative discharge. METHODS: A modified ERAS program was developed and applied through Global Smile Foundation outreach craniofacial programs. The main components of this protocol include: (1) preoperative patient education, (2) nutrition screening, (3) smoking cessation when applicable, (4) use of topical anesthetic adjuncts, (5) facial nerve blocks, (6) postoperative analgesia, (7) preferential use of short-acting narcotics, (8) antibiotic administration, (9) use of elbow restraints, (10) early postoperative oral feeding and hydration, and (11) discharge planning. RESULTS: Between April 2019 and March 2020, GSF operated on 126 patients with cleft lip from different age groups and 58.8% of them were less than 1 year of age. Three patients (2.4%) had delayed wound healing and one (0.8%) had postoperative bleeding. There were no cases of mortality, length of hospital stay did not exceed 1 postoperative day, and patients were able to tolerate fluids intake at discharge. CONCLUSION: The implementation of an ERAS protocol among patients undergoing cleft lip repair has shown to be highly effective in minimizing postoperative discomfort while reducing opioids use, decreasing the length of stay in hospital, and leading to early oral feeding resumption. The ERAS principles described carry increased relevance in the context of the ongoing COVID-19 pandemic and opioid crisis and can be safely applied in resource-constrained settings.

"Postoperative Analgesia in Enhanced Recovery After Surgery Protocols: Trends and Updates".

Multimodal analgesia is an effective strategy to decrease opioid use after surgery and has been a mainstay of the surgical contribution to combat the opioid epidemic. Postoperative multimodal analgesia in Enhanced Recovery After Surgery (ERAS) continues to evolve as different adjuncts are added and removed based on the most up to date literature. This review examines recent trends in ERAS analgesia and what current evidence and research supports as well as those adjuncts that may not be as beneficial as once thought.

A national survey on enhanced recovery for renal transplant recipients: current practices and trends in the UK.

INTRODUCTION: Enhanced recovery after surgery (ERAS) is well established in many specialties but has not been widely adopted in renal transplantation. The aim of this survey was to understand current national practices and sentiment concerning ERAS for renal transplant recipients in the UK. METHODOLOGY: A national web-based survey was sent to consultant surgeons at all 23 UK adult renal transplant units. Completed questionnaires were collected between May and July 2020. Data were analysed according to individual responses and grouped according to the existence of formal ERAS pathways within units. RESULTS: All transplant units were represented in this survey. Three units had a formal ERAS pathway for all recipients. Of the remaining units, 65.9% considered implementing an ERAS pathway in the near future. The most commonly perceived barrier to ERAS implementation was 'embedded culture within transplant units' (54.8% of respondents). A fifth of respondents insert surgical drains selectively and 11.7% routinely discontinue patient-controlled analgesia on postoperative day 1. Most respondents routinely remove urinary catheters on day 5 (70%) and ureteric stents 4-6 weeks post-transplantation (81.7%). Median length of stay for deceased donor kidney transplant recipients was lower in units with ERAS programmes (5-7 days versus 8-10 days, respectively). The main cited barriers for discharge were 'suboptimal fluid balance' and 'requirement of treatment for rejection'. CONCLUSIONS: Despite slow uptake of ERAS in kidney transplantation, appetite appears to be increasing, particularly in the post-COVID-19 era. The current practice and opinions of transplant specialists highlighted in this survey may help to establish nationally agreed ERAS guidelines in this field.

Impact of the COVID-19 pandemic in patients who underwent radical cystectomy during the first wave, one-year follow-up

Objectives: During the onset of the COVID-19 pandemic, surgical activity decreased due to an overload of the health system and to reduce SARS-COV-2 transmission. The objective of our study was to evaluate characteristics, analyze complications and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1 to May 31, 2020 (period of the first wave of the COVID-19 pandemic in Spain). We also compared the results with cystectomized patients enrolled in an ERAS program but outside the pandemic period. Method(s): Retrospective, single-center cohort study of patients scheduled for radical cystectomy from March 1, 2020 to May 31, 2020;they were matched with previously operated patients through propensity matching score 1:2. The matching variables were demographic data, preoperative and intraoperative clinical conditions. Result(s): A total of 23 radical cystectomies with urinary diversion were performed in the period described. The minimally invasive approach was more frequent in the pandemic group. Three patients were diagnosed with COVID-19 during their admission. We did not find statistically significant differences in postoperative complications or in mortality up to one year of follow-up. Conclusion(s): The first wave effect of the COVID-19 pandemic did not increase complications or mortality in patients who underwent radical cystectomy in our hospital, although a clear tendency was observed to have more and more severe complications. Performing the SARS-CoV-2 PCR test preoperatively was critical to control in-hospital transmission. The correct selection of surgical patients during the first wave was essential to optimize their evolution. References: 1. Guan W.J.Ni Z.Y,Hu Y.et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382: 1708-1720. 2. Ministerio de la Presidencia, Relaciones con las Cortes y Memoria Democratica. Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestion de la situacion de crisis sanitaria ocasionada por el COVID-19. BOE no 67 de 14 de marzo de 2020. 2020;67(I):25390-400. 3. Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol. 2020;77:663-6. Disclosure of Interest: None declared Copyright © 2022

Ongoing ERAS program monitoring: Does adherence improve clinical outcomes?

Objectives: This study was designed to evaluate compliance with the goals provided by the Enhanced Recovery After Surgery (ERAS) program and how this affects patient outcomes. Method(s): We relied on the surgical case history of the Operative Unit of General Surgery of the Hospital of Fidenza, we retrospectively analysed the data related to patients included in the ERAS program and undergoing elective surgery of the colon-rectal district from July 2019 to September 2021. The time considered was characterized by the appearance of the global pandemic for the SarsCoV-2 virus. During the study period, 54 patients were selected and divided into two macro groups: PreCov19 and PostCov19, corresponding respectively to the initial and final period of application of the ERAS protocol. We made a comparative evaluation between the two groups taking as evaluation criteria the three macro-indicators of the effectiveness of the ERAS protocol: Length of hospitalization (LOS), postoperative complications (POC), and re-hospitalization within 30 days of discharge (RHD). We analysed for each macro group the compliance with the goals in the ERAS protocol divided into the three categories: preoperative, intraoperative, and postoperative. Result(s): Firstly, we observed the presence of a trend of improvement, for LOS and RHD, in the patients of the PostCov19 group. The POC as well as the characteristics of the patients admitted to the study were unchanged in the two periods. We focused on the analysis of the single items of the protocol. We found that compliance with preoperative and intraoperative goals in the two groups was substantially identical. We have shown improvement in complying with the postoperative items with a particular attention to the precocity of NG Tube removal, suspension of postoperative intravenous fluid therapy and start of early oral nutrition (p < 0.05). Conclusion(s): We highlighted how the low number of patients enrolled in the study affect the possibility of obtaining large statistically relevant data. However, the achievement of postoperative items improved in a statistically significant manner, which may partially explain the positive trend of LOS and RHD. The impact of the SarsCov2 pandemic and the subsequent reorganization of the hospital on the ability of the multidisciplinary team to follow the indications of the ERAS protocol remains to be evaluated. Disclosure of Interest: None declared Copyright © 2022

Enhanced recovery after radical cystectomy: Outcomes of implementation after 80 cases

Objectives: To evaluate the effect of implementing Enhanced Recovery After Surgery (ERAS) and compliance to protocol in patients undergoing radical cystectomy (RC) and urinary diversion during the COVID-19 pandemic. Method(s): Since February 2020, a 14-point multimodal ERAS protocol has been implemented for patients undergoing elective CR and urinary diversion at our institution. We retrospectively evaluated 80 patients who underwent CR between February 2020 and February 2022. The effects of ERAS implantation for CR during the COVID-19 pandemic were validated. Result(s): With a mean age of 68.5 years [CI: 66.4-70.7], 80 patients who underwent RC were included in the analysis, 69 men (86%) and 11 women (14%). Main indication for surgery was muscle-invasive bladder cancer and laparoscopic or robot-assisted RC was performed in most cases (86%). Regarding urinary diversion, in 66 patients (82.5%) an ileal conduit was done and an orthotopic neobladder in 14 cases (17.5%). The attached table shows the percentage of compliance with each parameter of the 14-point ERAS protocol. Most of the compliance rates are above 80%, except for early mobilization. Efficiency item assesses whether the expected days of hospital admission are met. In this way, the median length of hospital stay (LOS) was 5 days [IQR 2.5]. In terms of follow-up, the hospital readmission rate one month after surgery was 6%. Before the application of the ERAS program this rate was 9.1%, thus it represents a significant reduction (p<0.05). [Formula presented] Conclusion(s): Our initial experience with the implementation of a 14-point enhanced recovery protocol after RC has been satisfactory achieving a 85% compliance rate and promising results regarding reduction of LOS and hospital readmission. Further cases and analysis are required to draw definitive conclusions. Disclosure of Interest: None declared Copyright © 2022

Overnight joint replacement surgery: a pilot Australian study.

BACKGROUND: With a stretched healthcare system and elective surgery backlog, measures to improve efficiency and decrease costs associated with surgical procedures need to be prioritized. This study compares the benefits of multi-disciplinary involvement in an enhanced recovery after surgery (ERAS) protocol-led overnight model following total hip replacement (THR) and total knee replacement (TKR). METHODS: Patients in each of two private hospitals undergoing THR or TKR were prospectively enrolled. One hospital (Overnight) was fully committed to the ERAS protocol implementation on all levels and formed the treatment group while in the other hospital (control), patients only had the anaesthetic and operative procedure as part of the ERAS protocol but did not follow the perioperative measures of the protocol. Outcomes on hospital length of stay (LOS), inpatient rehabilitation, functional outcomes, satisfaction, adverse events and readmission rates were investigated. RESULTS: Median LOS in the Overnight group was significantly smaller than in the control group (1 vs. 3 days, P < 0.0001). The Overnight group had lower rates of inpatient rehabilitation utilization (4% vs. 41.2%, P < 0.0001), similar improvements in functional hip and knee scores and no increased rate of adverse events or readmission. All patients in both groups were satisfied with their treatment. CONCLUSION: Overnight THR and TKR can safely be performed in the majority of patients, with a multi-disciplinary approach protocol and involvement of all perioperative stakeholders.

Recruitment in the Digital Age: The Implications of Social Media for Physical Medicine and Rehabiliation Applicants

Objective: To investigate the influence of social media interactions with medical students applying to Physical Medicine and Rehabilitation residency programs. Design(s): A cross-sectional online survey of Physical Medicine and Rehabilitation applicants recruited to a single university applicant pool that was generally representative of the nationwide applicant pool. Setting(s): Anonymous, voluntary, electronic questionnaire. Participant(s): United States medical students (31.2% female 67.5% male 1.3% prefer not to disclose) who applied to a Physical Medicine and Rehabilitation residency program. Intervention(s): None. Main Outcome Measure(s): Participant-reported measures by an electronic questionnaire. Result(s): Of the 77 applicants that responded to the survey, 53 (68.8%) followed residency program accounts on social media platforms. Of the social media platforms, Instagram was the most used at 86.8%, followed by Twitter at 56.6%. 86.8% of social media users (SMUs) interacted with residencies on social media platforms (e.g., commenting, liking, direct messaging), which 67.9% reported very positively or positively impacted their perception of residency programs. Overall, 81.1% of SMUs felt more connected to programs that they followed on social media platforms. Around half of SMUs rated that interactions were extremely helpful or very helpful in understanding local culture as well as residency program culture. In fact, 75.5% SMUs agreed that social media is either very important or important in the era of remote/zoom interviews. Interestingly, only a minority of SMUs (24.5%) agreed that interaction with residency programs on social media platforms was extremely or very influential in their ERAS rankings. Conclusion(s): As virtual interviews in Physical Medicine and Rehabilitation residency programs continue in the COVID era, this research indicates that social media plays a large role in program-to-applicant relations during recruitment season and should prompt more programs to foster a stronger connection with applicants through social media.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation.

BACKGROUND: As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. METHODS: Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes. RESULTS: Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing. CONCLUSIONS: The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

Implementation of Enhanced Recovery After Surgery (ERAS) in Total Laryngectomies

Aim: The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients. Method: 22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured. Results: 19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12-14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively. Conclusion: Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.

NARROWING INEQUITY GAP ON WOMEN UNDERGOING HYSTERECTOMY: ERAS HOME DELIVERY KIT

Introduction: The enhanced recovery after surgery (ERAS) pathway comprises a series of evidence-based interventions accelerating recovery after surgery. COVID-19 disrupted perioperative processes, and vulnerable populations were at exceptionally high risk. Objective: To facilitate and improve adherence to preoperative ERAS pathways, preoperative chlorhexidine (CHG) and prenutritional drinks were mailed directly to patients (ERAS kit). We hypothesized that shipping kits direct to women undergoing gynecological surgery would increase adherence and provide more equitable care. Methods: This study is a retrospective cohort study of all adult cis-gender female patients undergoing gynecological surgery at a large tertiary hospital from October to November of 2021. Adherence and access to the pathway at the time of surgery were compared between White patients and other racial minority groups in October and November 2019, 2020, and 2021 (before COVID-19, during COVID-19, and intervention period). Patient demographics were described using frequency and percent for categorical variables and mean and standard deviation for continuous variables. SPC 3-sigma p-charts were used to evaluate changes in the utilization of pre-surgical ERAS interventions. Results: Compared to White patients, women from racial minority groups undergoing hysterectomy were less likely to adhere to ERAS pre-surgical interventions such as pre-surgery carbohydrate hydration (20.9 vs. 42.9%, P = 0.005) or use the preoperative CHG soap (60.4% vs. 77.6%, P = 0185). From October 1st to November 30th of 2021, a total of 127 patients that had a hysterectomy received an ERAS pre-surgery kit at home. White patients had a 91.9% adherence to pre-surgical nutrition, while other racial minority groups had 96.4% adherence (P = 0.713). During the study period, White patients had 98.0% adherence to the CHG portion of the pathway, and other racial minorities groups had 96.3% (P = 0.188). Conclusions: t baseline, non-White patients undergoing hysterectomy were less likely to adhere to ERAS pre-surgical interventions such as pre-surgery carbohydrate hydration and CHG use. Delivering ERAS pre-surgical kits directly to the patients' homes is associated with large increases in utilization of the ERAS pathway among both White patients and patients of color.

THE IMPACT OF ERAS ON FPMRS OUTCOMES AT A PUBLIC TEACHING HOSPITAL DURING THE COVID-19 PANDEMIC

Introduction: Enhanced recovery after surgery (ERAS) protocols have decreased hospital length of stay (LOS) and increased the rate of same-day discharge in patients undergoing minimally invasive surgery, including in female pelvic medicine and reconstructive surgery (FPMRS). In October of 2019, our hospital implemented an ERAS protocol;however, the onset of the COVID-19 epidemic accelerated the need to adopt a same day discharge policy. Given the rapid implementation of this policy, it was important to determine its effect on FPMRS surgical outcomes in a public teaching hospital serving predominantly uninsured and underinsured patients. Objective: The primary objective of this study was to evaluate perioperative management and postoperative outcomes for FPMRS patients after implementation of an ERAS protocol in a public teaching hospital. Methods: A single-center review was performed of FPMRS patients undergoing surgery prior to introduction of the ERAS protocol from January 2019 to June 2019 compared to those undergoing surgery after its implementation from January 2021 to June 2021. Demographic and surgical details were collected for all patients. A retrospective analysis was performed comparing outcomes, including percentage of outpatient surgery, emergency department visits within 30 days of surgery, and opioid use pre- and post-ERAS implementation Results: 29 patients were included in the pre-implementation group and 19 patients were included in the post-ERAS implementation group. Procedure types and patient demographics are seen in table 1. Ninety-three percent of patients self-described as Hispanic/Latino ethnicity. The percentage of outpatient surgeries increased from 17% to 90% (p < 0.01). Preoperative acetaminophen use increased from 3% to 74% of patients (p < 0.01), while mean perioperative morphine milligram equivalents decreased from 57 mg to 42 mg (p < 0.01). Mean opioid pills prescribed was not different after implementation of ERAS. Thirty-day emergency department (ED) returns increased from 0% to 11% (P = 0.15). These two ED returns included one visit for a urinary tract infection and the other for nephrolithiasis. Conclusions: ERAS implementation for FPMRS patients at a public hospital led to a significant decrease in LOS, inpatient admission, and perioperative morphine milligram equivalents used without a significant increase in 30-day ED returns. While the COVID-19 epidemic resulted in an accelerated adoption of ERAS protocol, it was found to be safe and effective in our underserved FPMRS patient population.

COST ANALYSIS OF MINIMALLY-INVASIVE SACROCOLPOPEXY COMPARED TO NATIVE TISSUE VAGINAL REPAIR IN THE ERA OF ERAS

Introduction: Minimally invasive sacrocolpopexy (SCP) is the gold-standard treatment for patients with apical prolapse and is increasingly used as a primary intervention in women with uterovaginal prolapse. There is a lack of comparative data evaluating costs between SCP versus native tissue vaginal repair in the post-ERAS implementation era. Objective: The primary aim was to determine the cost difference between performing hysterectomy and minimally-invasive sacrocolpopexy as compared to vaginal hysterectomy with native tissue vaginal repair for uterovaginal prolapse. We hypothesized that minimally-invasive sacral colpopexy has a higher cost when compared to native tissue repair but when failure rates of native tissue repair approach 15%, costs equilibrate. Methods: This was a retrospective cohort study at a tertiary care center. The electronic medical record system was queried for women who underwent native tissue vaginal repair or minimally invasive SCP with concomitant hysterectomy for uterovaginal prolapse in calendar year 2021 (post-COVID enhanced recovery after surgery implementation). We excluded all patients who had concomitant colorectal procedures and where billing was not complete or re-imbursement was not received. Hospital charges, direct and indirect costs and operating margin (net revenue minus all costs) were obtained from Strata Jazz and were compared using R statistical program. Net revenue (reimbursement) was directly obtained from the record as the total payment received by the hospital from the payor. Results: A total of 81 women were included, (33 SCP (25 robotic and 8 laparoscopic) versus 48 native tissue). Payor mix included 27% Medicare, 5% medicaid, 61% employer-based and 7% private insurance. Demographic and surgical data is presented in Table 1. The mean total charge per case for services was higher in the SCP group compared to the vaginal repair group ($119,863 vs. $82,205, P < 0.01). Cost of supplies was more in the SCP group ($4429 vs. $2108, P < 0.01), but the cost of operating room time and staff was similar ($7926 vs. $7216, P = 0.06). Controlling for surgeon, age and BMI, the direct and indirect costs were also higher in the SCP group ($13,649 vs. $10,168, P < 0.01 and $5068 vs. $3685, P < 0.01, respectively). Net revenue was lower for the vaginal repair group compared to the SCP group ($14,614 vs. $31,618, P < 0.01). The operating margin was significantly higher in the SCP group ($11,770 vs. $ 517, P < 0.01). Additionally, there were no significant differences in the net revenue between different payors (P = 0.8997). Same-day discharge and EBL were similar among both groups with operative time being higher in the SCP group (204 vs. 161, P < 0.01). Using the means of the direct costs between groups, a re-operation rate of 25.5% would be needed for the native tissue repair costs to equilibrate to the SCP group. From a hospital perspective, due to the low operating margins experienced with native tissue vaginal repair, 227 native tissue vaginal repairs would need to be performed for the same net return as 10 minimally-invasive SCP's. Conclusions: Vaginal hysterectomy with native tissue repair had lower direct and indirect costs compared to minimally-invasive SCP. However, operating margins are significantly higher for SC P due to net revenue received. (Table Presented).

Development of a universal thoracic enhanced recover after surgery protocol for implementation across a diverse multi-hospital health system.

Background: Implementation of enhanced recovery after surgery (ERAS) pathways for patients undergoing anatomic lung resection have been reported at individual institutions. We hypothesized that an ERAS pathway can be successfully implemented across a large healthcare system including different types of hospital settings (academic, academic-affiliated, community). Methods: An expert panel with representation from each hospital within a healthcare system was convened to establish a thoracic ERAS pathway for patients undergoing anatomic lung resection and to develop tools and analytics to ensure consistent application. The protocol was translated into an order set and pathway within the electronic health record (EHR). Iterative implementation was performed with recording of the processes involved. Barriers and facilitators to implementation were recorded. Results: Development and implementation of the protocol took 13 months from conception to rollout. Considerable change management was needed for consensus and incorporation into practice. Facilitators of change included peer accountability, incorporating ERAS care elements into the EHR, and conducting case reviews with timely feedback on protocol deviations. Barriers included institutional cultural differences, agreement in defining mindful deviation from the ERAS protocol, lack of access to specific coded data, and resource scarcity caused by the COVID-19 pandemic. Support from the hospital system's executive leadership and institutional commitment to quality improvement helped overcome barriers and maintain momentum. Conclusions: Development and implementation of a health-system wide thoracic ERAS protocol for anatomic lung resections across a six-hospital health system requires a multidisciplinary team approach. Barriers can be overcome though multidisciplinary team engagement and executive leadership support.

Impact of Enhanced Recovery After Surgery Implementation and COVID-19 on Hysterectomy Outcomes at a Public Hospital

INTRODUCTION: Immediately prior to the COVID-19 pandemic, our public hospital implemented an enhanced recovery after surgery (ERAS) protocol. The purpose of this study was to evaluate ERAS outcomes for hysterectomy patients at our public hospital, given concerns about barriers to care in our underserved population. METHODS: A retrospective analysis was performed comparing outcomes (percent of outpatient cases, length of stay, perioperative opioids, percent of emergency department [ED] return) for hysterectomy patients for pre- and post-intervention periods (January to June in 2019 and 2021). Outcomes were compared using the Fisher exact test or t-test. RESULTS: A total of 192 preintervention and 120 post-intervention hysterectomy cases were analyzed. The majority of patients were Hispanic/Latinx in both groups (82% vs. 76%;P=.25). There was no significant change in the percentage of minimally-invasive procedures (71% vs 72%;P=1.0). The percentage of outpatient hysterectomies increased from 0% to 53% (P<.0001), and the mean length of stay (LOS) decreased from 1.6 days to 0.9 days (P<.0001). Peri-operative mean morphine milligram equivalents (MME) decreased from 78 to 54 (P≤.02). Mean post anesthesia care unit stay increased from 186 to 229 minutes (P<.01). There was no significant increase in returns to the ED <30 days (10% vs 13%;P=.36) or mean number of opioid pills prescribed (13 vs 13;P=.21). CONCLUSION: ERAS implementation for hysterectomy patients at a public hospital decreased LOS and peri-operative opioids without significantly increasing ED returns. The COVID-19 pandemic likely helped to expedite the adoption of outpatient management, which was feasible and safe in our underserved patient population.

Framework, component, and implementation of enhanced recovery pathways.

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss 'special cases' in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic.

PURPOSE: Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage. METHODS: A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions. RESULTS: Thirty-seven patients met the highly selective eligibility criteria for "healthy patient, healthy anastomosis." SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores. CONCLUSIONS: In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.

QUALITY IMPROVEMENT STUDIES ARE FEASIBLE IN AUSTERE PERIODS OF RESOURCE ALLOCATION SUCH AS THE COVID-19 PANDEMIC: IMPLEMENTATION OF A NOVEL AGGRESSIVE POSTOPERATIVE AMBULATION PROTOCOL

Purpose/Background: Quality improvement (QI) and enhanced recovery after surgery (ERAS) protocols are effective in reducing length of stay and complications after colorectal surgery. The COVID-19 pandemic's strain on hospital personnel and resources called into question the feasibility of implementation of QI studies. Hypothesis/Aim: We aimed to successfully implement of a novel, structured postoperative ambulation protocol in colorectal surgery patients and determine its effect on patient outcomes in a time of strained personnel. Methods/Interventions: This prospective non-randomized study included all patient who underwent elective inpatient abdominal colorectal procedures at a single quaternary care center. All patients were already undergoing a standard ERAS protocol at baseline. A structured, aggressive postoperative ambulation protocol was developed. An erasable poster (Figure) was placed in patient rooms which allowed the nursing staff and patient to track progress towards specific ambulation goals. The protocol measured specific metrics such as out-of-bed to chair and the number and extent of daily ambulation relative to postoperative day. The protocol was initiated on post-operative day 0, and increased in duration and distance daily. Nursing staff was educated on the protocol prior to initiation and a standard process was created to outline the documentation requirements. The primary outcome measured was hospital length of stay. Secondary outcomes were return of bowel function, 30-day postoperative DVT/PE rate, and 30-day readmission rate. A change in these outcomes metrics over time compared to historical controls was noted. Results/Outcome(s): The protocol was implemented in February 2020, with improvements in outcomes beginning in July 2020 following extensive re-education for nursing staff. Adherence to the post-operative ambulation regimen increased from 36% at baseline to 75%. This was associated with an improvement in postoperative return of bowel function (2.13 days vs 1.44 days), post-operative length of stay (6.36 days vs 3.33 days), postop VTE/PE rates (1.64% vs 0%) and readmission rate (6.56% vs 0%) over a period of 12 months. Limitations: The outcomes of this study may have been influenced by other uncontrolled measures during the COVID crisis but most if not all led to decreased personnel and resources making success of such a project difficult. A standard ERAS protocol was in place with good compliance (>95%) for over 2 years prior to the initiation of this study. Conclusions/Discussion: A novel, structured, aggressive early postoperative ambulation protocol is feasible during times of strained personnel resources such as the COVID-19 pandemic, and leads to improvement in postoperative outcomes such as postoperative length of hospital stay, return of bowel function, VTE/PE rates, and postoperative ambulation without an increase in the readmission rate.

OPIOID-FREE SURGERY: IMPLEMENTATION OF SUCCESSFUL NON- OPIATE COLECTOMY AT COMMUNITY TEACHING CENTER

Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.