Patient Satisfaction of Enhanced Recovery after Surgery (ERAS) Protocol in Gynecologic Oncology Surgery
Shaina H. Long DO, Ramsey Ugarte, Morgan Merriman MD, Dylan Solise MD,Jeffery Elder MD and Larry Puls MD
Department of Obstetrics and Gynecology, Prisma Health - Upstate
Greenville, SC
Disclosure
I have no meaningful conflicts of interest to declare.
“Enhanced Recovery after Surgery”
(ERAS)
Reduce stress and return the body to its normal function.
Background
Background
Four components of ERAS care:
1. Preoperative
2. Perioperative
3. Intraoperative
4. Postoperative care
Background
• Preoperative education
• Minimize fasting
• Limit intraoperative fluids
• Encourage early patient mobilization
• Limit drains
• Multi-modal pain management
BackgroundWhy is this important?
• Decreased LOS
• Improved outcomes
• Decreased narcotic usage
• Quicker return to baseline function
ERAS care standard in gynecologic surgery • Landmark recommendations• Society of Gynecologic Oncology 2016
Background
Published April 2019
Background
What do patients think?
• Few published studies evaluating patient satisfaction of ERAS across all specialties.
• Colorectal surgery: Thiele et al utilized Press Ganey surveys. Overall improvement in survey patient satisfaction percentiles.
BackgroundHow satisfied are patients with ERAS protocols in Gynecologic surgery?
• 2013 Mayo Clinic
• 2014 Australia
• 2014 London
• 2016 University of Virginia
What about specific to the Gynecologic Oncology patient???
Objective
• Standardized ERAS protocol adopted by the Gynecologic Oncology service on January 1, 2017.
• Patient satisfaction before and after the implementation of this ERAS protocol Open gynecologic oncology abdominal cases with use of voluntary Press Ganey® surveys.
Hypothesis
• Standardized ERAS protocol demonstrates no difference in patient satisfaction before and after implementation.
Methods
Methods
• Retrospective Cohort Study
• Inclusion Criteria:• GYN-Oncology
• Scheduled Open laparotomy
• Exploratory laparotomy, Abdominal hysterectomy, Abdominal myomectomy or Laparotomy for any other reasons
Methods
Pre-Eras Cohort
Jan 1, 2016 - Nov 1, 2016
(10 months)
4-month washoutERAS Cohort
Mar 1, 2017 – May 30, 2018
(13 months)
Time
Retrospective Study Start
ERAS StartJan 1, 2017
• Ketamine/Lidocaine Intra-op• Limit fluids• Limit drains
• Patient Education
• Clear liquid (3 hr before case)
• High carb drink
• Lyrica/Celebrex/Tylenol
• Ketamine POD 1-2• Early Mobilization• Lyrica/Tylenol/Celebrex• Foley out 8 hr post-op
Pre-Op
Intra-Op
Post-Op
Methods• Surgery date cross-matched to the survey to confirm correct procedure.
• Press Ganey® surveys voluntary & anonymous.
• Mean scores tallied and percentiles compared to similar sized 600-bed plus hospitals.
• Focused on clinically useful questions:• Perception of pain management• Understanding of care• Interactions with nurses and physicians• Discharge process• Overall rating/likelihood of recommending hospital.
Methods• Continuous variables reported as mean ± standard deviation or median interquartile-range (IQR)
• Differences between groups using Student's t-test or Wilcoxon rank-sum.
• Discrete variables are reported as N (%) and tested using Chi-square test or Fisher’s exact test for small sample sizes (n < 5).
• Analyzed using R statistical software (R Foundation for Statistical Computing, version 3.4.3, Vienna Austria).
Results
Results
• 562 cases available • 179 cases pre-ERAS
• 383 cases ERAS
• Survey response rate: 19.4% (109/562 cases).• 30 cases (30 patients) pre-ERAS cohort
• 79 cases (73 patients) ERAS cohort
Results
• Diabetes (10% pre-ERAS vs 16.64% ERAS, p-value 0.386)
Demographics & Comorbidities similar between cohorts:
• Hypertension (43.33% pre-ERAS vs 39.24% ERAS, p-value 1.000)
• Tobacco use (36.67% pre-ERAS vs 22.78% ERAS, p-value 0.177)
0
20
40
60
Case Type
Pre-ERAS ERAS
p-Value 1.00
0
10
20
30
40
50
60
70
80
90
100
Caucasian African American Hispanic Other
Ethnicity
Pre-Eras ERAS
p-Value 0.427
0
5
10
15
20
25
30
35
<18.5 18.5-24.9 25.0-29.9 30.0-34.9
BMI
Pre-ERAS ERAS
p-Value 0.455
Results
Trend towards a one-day shorter length of stay in ERAS cohort (median IQR).
Day of discharge:- (2 vs 3 days, p-value = 0.065)
Time of Admission & Discharge:- (2.4 vs 3.5 days, p-value = 0.057)
ResultsSurvey Question No ERAS ERAS p-value
Need Medicine for Pain 26/28 (92.9) 51/57 (89.5) 1.000
Pain Well controlled, N (%) n=27 n=56 0.571
Sometimes 0 (0) 3 (5.36)
Usually 7 (25.9) 16 (28.57)
Always 20 (74.1) 37 (66.07)
Staff did everything to help with pain, N (%) n=27 n=53 0.657
Sometimes 0 (0) 1 (1.89)
Usually 4 (14.8) 5 (9.43)
Always 23 (85.2) 47 (88.68)
• No difference in perception of pain
• “Pain was well controlled” & “Staff did everything to help with pain”, most common answer was “always”.
Results
No ERAS ERAS p-value
Likelihood of recommending hospital 23/26 (88.5) 67/73 (91.8) 0.694
Overall rating of care given 24/25 (96.0) 69/71 (97.2) 1.000
No difference in patient perception of:
• Understanding of health, purpose of taking meds, skill of the nurses/physicians, discharge speed, and readiness for discharge
• Likelihood in recommending hospital or overall rating of care
Results
Trend towards a more positive perception of patients toward
physician care in the ERAS cohort.
No ERAS ERAS p-value
Time physician spent with you 24/28 (86.2) 71/77 (92.2) 0.541
Physician concern questions 25/28 (89.3) 74/77 (94.9) 0.377
Physician kept you informed 25/28 (89.3) 75/76 (98.7) 0.059
Friendliness/courtesy of physician 26/28 (92.9) 77/77(100) 0.069
Skill of physician 27/28 (96.4) 78/78 (100) 0.264
Results
No difference in national benchmark(percentile rankings) of similar sized teaching hospitals with 600-plus beds.
Pre-ERAS ERAS p-value
Recommend the hospital 26.5 24 0.778
Communication with Doctors 34.75 47.25 0.295
Doctors treat with courtesy/respect 29.25 49 0.261
Doctors listen carefully to you 37.25 41.25 0.731
Doctors explained in way you understand 39 47.75 0.403
Pain management 50.75 36.25 0.391
Pain well controlled 54.5 36.25 0.260
Staff did everything to help with pain 46.25 43.5 0.871
Discussion
Discussion
Primary outcome:
• GYN-Oncology patients do not perceive ERAS perioperative care as inferior to historical, pre-ERAS care.
Discussion
1. Positive trends in patient perception of interactions with physician.
• Not noted in previously published studies.
• Speculate that there is improved relationship building and trust development with implementation of ERAS protocol.
2. Trend towards shorter length of stay.
3. National Press Ganey® response rate 19%. This study, showed a response rate of 19.3%
DiscussionLimitations:
• Larger patient numbers needed
• Retrospective data collection limited
• Retrospective cohort study design
• Inherent biases with self-selection of survey completion
Strengths:• Large number of total cases
reviewed - 562 open laparotomy cases
• Consistency in providers giving care and preoperative education.
• Four-month washout period leading up to implementation of the ERAS protocol
DiscussionImplementation of a standardized ERAS protocol does not negatively impact the GYN-Oncology patient’s perception of care.
• Trends toward a shorter hospital length of stay.
• Improved trends in patient perception of physician interactions.
In this era of value-driven care, the findings observed in this study supports the growing use of standardized ERAS protocols in the gynecologic oncology surgical patient.
AcknowledgementsFaculty Mentors:
• Dr. Larry Puls, MD
• Dr. Jeffery Elder, MD
Co-Authors:
• Ramsey Ugarte, Dr. Morgan Merriman, MD and Dr. Dylan Solise, MD
Biostatistics Department Prisma Health:
• Dr. Alex Ewing, PhD
Prisma Health Departments:
• Obstetrics and Gynecology
• Anesthesia
References1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997 May;78(5):606-17.
2. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008 Aug;248(2):189-98.
3. WijK L, Franzen K, Jungqvist O, Nilsson K. Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy. 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica. 93(2014) 749–756.
4. Scheib S, Thomassee M, Kenner JL. Enhanced Recovery after Surgery in Gynecology: A Review of the Literature. Journal of Minimally Invasive Gynecology. Jan 2019;26(2): 327-343.
5. de Groot JJ, Ament SM, Maessen JM, Dejong CH, Kleijnen JM. Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis. Slangen BFActa Obstet Gynecol Scand. 2016 Apr;95(4):382-95.
6. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, Trabuco E, Lovely JK, Dhanorker S, Grubbs PL, Weaver AL, Haas LR, Borah BJ, Bursiek AA, Walsh MT, Cliby WA, Dowdy SC. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.
7. Mukhopadhyay D. Enhanced recovery programme in gynaecology: outcomes of a hysterectomy care pathway. BMJ Qual Improv Rep. 2015; 4(1): u206142.w2524.
8. Nelson G, Kalogera E, Dwdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecologic Oncology. Dec 2014;135(3): 586–594.
9. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations--Part I. Gynecol Oncol. 2016 Feb;140(2):313-22.
10. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS). Society Recommendations Part II. Gynecology Oncology. Feb 2016;140: 323-332.
11. Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer. 2019. Published online first: Mar 15. doi: 10.1136/ijgc-2019-000356.
12. Miralpeix E, Nick AM, Meyer LA, et al. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol. 2016;141(2):371–378.
13. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, McMurry TL, Goudreau BJ, Umapathi BA, Kron IL, Sawyer RG, Hedrick TL. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015 Apr;220(4):430-43.
14. Philip S, Carter J, Pather S, Barnett C, D'Abrew N, White K Eur J Cancer Care (Engl). Patients' satisfaction with fast-track surgery in gynaecological oncology 2015 Jul;24(4):567-73.
15. Archer S, Montague J, Bali A. Exploring the experience of an enhanced recovery programme for gynaecological cancer patients: a qualitative study. Perioper Med (Lond). 2014;3(1):2
16. Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH, Tiouririne M, Hedrick TL. Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization. Obstet Gynecol.2016 Sep;128(3):457-66.