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Process Control to Measure Process Improvement in Colorectal Surgery: Modifications to an Established Enhanced Recovery Pathway

Keller, Deborah S. M.S., M.D.1; Stulberg, Jonah J. M.D., Ph.D., M.P.H.2; Lawrence, Justin K. M.D.1; Delaney, Conor P. M.D., M.Ch., Ph.D., F.R.C.S.I.1

Diseases of the Colon & Rectum:
doi: 10.1097/DCR.0b013e3182a62c91
Original Contributions: Benign Colorectal Disease
Abstract

BACKGROUND: After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use.

OBJECTIVE: The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes.

DESIGN: This was a case-matched study.

METHODS: After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex.

SETTINGS: This study was performed at a tertiary referral center.

PATIENTS: Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included.

MAIN OUTCOME MEASURES: The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway.

RESULTS: Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen.

LIMITATIONS: The single-surgeon, single-institution design was a limitation of this study.

CONCLUSIONS: The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

Author Information

1Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Cleveland, Ohio

2Department of Surgery, University Hospitals-Case Medical Center, Cleveland, Ohio

Financial Disclosure: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013.

Correspondence: Conor P. Delaney, M.D., M.Ch., Ph.D, F.R.C.S.I., Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106–5047. E-mail: Conor.Delaney@uhhospitals.org

© 2014 The American Society of Colon and Rectal Surgeons