System-wide implementation of ERAS+ in Greater Manchester

ABSTRACT

With the damaging impact of COVID-19 on elective surgery globally, it is vital that we deliver major surgical care that supports patients, minimises complications and reduces hospital length of stay (LOS). Enhanced Recovery After Surgery (ERAS) processes [1] provide a means of doing this and the UK ERAS+ peri-operative pathway (www.erasplus.co.uk), which includes a particular emphasis on patient preparation using the surgery school education tool and pre-habilitation elements, has been shown in a single centre to reduce peri-operative pulmonary complications (PPC) and improve hospital LOS [2]. Methods In 2017, ERAS+ Greater Manchester (GM), was awarded Health Foundation Scaling Up funding for the implementation of ERAS+ in six NHS hospitals across GM. Beginning in January 2018, quality improvement and operational partners alongside an expert ERAS+ team worked with site teams in two overlapping phases (three hospitals in each) to support the integration of ERAS+ into colorectal surgical oncological pathways in all six sites, and ERAS+ into lung and upper GI cancer surgical oncological pathways in two of the hospitals. The site ERAS+ team consisted of peri-operative anaesthetist, surgeon, ERAS nurse, allied health professionals and a health foundation funded data audit clerk. Results Fig. 1 shows the results of aggregate LOS data for colorectal cancer resection surgery for five of the hospital sites (A, C, D, E and F), which undertook ERAS+ from 2018 onwards (no. of patients = 1328) and for which Trust historical LOS data were available. The completion points for the initial two phases of implementation of ERAS+ are demonstrated. For the five-sites shown, the baseline mean LOS was 12.1 days. There was an aggregate reduction in LOS to 9.0 days, a reduction of 3.1 days, associated with a reduction in PPC. Patient measured satisfaction with ERAS+ was excellent and there was no increase in re-admission rates associated with LOS reduction. Factorial design methodology was used to compare combinations of process measures patients received against LOS. Generally, a lower LOS occurred where patients (1) were mobilised within 24 h post-surgery, (2) started an oral diet within 24 h after surgery and (3) attended Surgery School before admission. Discussion ERAS+ has been implemented successfully at a system level in GM for colorectal cancer patients, with an aggregate LOS reduction of over 3 days, which was associated with reduced rate of PPC.