Internal Audit of an Enhanced Recovery after Surgery Protocol for Radical Cystectomy - Beyond the Abstract

The foundational origin of enhanced recovery after surgery (ERAS®) protocols can be traced back to the late 1990s when the pathophysiology of postsurgical stress and recovery was being characterized and newly featured in colorectal literature. Earlier works suggested that while a single intervention or technique felt unlikely to redirect the postoperative course, perhaps multimodal perioperative interventions could improve patient outcomes.1


Radical cystectomy and urinary diversion are the gold standard treatment for muscle-invasive bladder cancer, a noninvasive disease with a high risk of progression or refractory to intravesical therapy, and after failure of trimodal therapy.2,3 Historically, radical cystectomy has been recognized as among the most complex urologic operations with lengthy hospitalization and significant morbidity.

In 2012, our institution introduced an ERAS® protocol in an effort to reduce the adversities faced by patients undergoing radical cystectomy. Our protocol included evidence-based pre, intra, and postoperative modifications. The first studies from our institution found a shortening of median hospital stay to four days without an increase in readmission rates.4

Over the years, we have evaluated many facets of our ERAS® protocol to identify any impact on patient outcomes and to elucidate areas for improvement. For instance, extended hospital stays among patients enrolled in ERAS® were found to be associated with advanced age, operative time, postoperative transfusions, and ileus.5 We have since become increasingly more mindful of the importance of opioid-sparing analgesia and following transfusion-restricted guidelines. In 2019, we ruled out minimally invasive surgical approach as a determinant of readmission or major complications following radical cystectomy with ERAS®.6 Adherence to ERAS® protocol by both patients and providers has previously been evaluated and shown to be an integral component for such a protocol to be successful.7-10 In this study, we ran an internal audit to understand the tangible impact of our ERAS® protocol by metricizing how successful our institution has been with compliance to these perioperative interventions. We compiled all provider-driven perioperative interventions and generated a composite compliance score (CCS). Our goal in creating the CCS was to utilize a quantitative metric that could help us compare patient outcomes within our ERAS®8 protocol. 

We found that reaching and maintaining a high level of protocol compliance (median CCS = 88%) was attainable within a year of protocol advent. Greater compliance was achieved in younger and healthier patients. Nonetheless, with the use of multivariable regression, we found more compliant CCS to be independently associated with decreased length of stay by at least one day and reduced odds of 30-day readmissions (overall results [OR] 0.58, 95% confidence interval [CI] 0.35-0.96) (Figure 1). No individual perioperative intervention was associated with any primary or secondary outcome. This finding may indicate that CCS represents the sum of the parts, which manifests as a preferred outcome when more compliance is achieved.

Despite recent advancements with ERAS®, universal adoption of the protocol as the standard of care has not yet been fully acknowledged. The recent audit at our institution further strengthens the evidence for ERAS® by tracking the rate of compliance over the years and comparing perioperative outcomes amongst ERAS® protocol participants.

figure 1 patient outcomes
Figure 1. Patient outcomes — more protocol compliance vs less protocol compliance

Written by: Aurash Naser-Tavakolian, MD, Twitter: @antavakolian, Saum Ghodoussipour, MD, Twitter: @saumyg, Hooman Djaladat, MD, Twitter: @HoomandjaladatUSC, Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California

References:

  1. Kehlet, Henrik. "Multimodal approach to control postoperative pathophysiology and rehabilitation." British journal of anaesthesia 78, no. 5 (1997): 606-617.
  2. Woldu, Solomon L., Aditya Bagrodia, and Yair Lotan. "Guideline of guidelines: non‐muscle‐invasive bladder cancer." BJU international 119, no. 3 (2017): 371-380.
  3. Clark, Peter E., Philippe E. Spiess, Neeraj Agarwal, Rick Bangs, Stephen A. Boorjian, Mark K. Buyyounouski, Jason A. Efstathiou et al. "NCCN guidelines insights: bladder cancer, version 2.2016." Journal of the National Comprehensive Cancer Network 14, no. 10 (2016): 1213-1224.
  4. Daneshmand, Siamak, Hamed Ahmadi, Anne K. Schuckman, Anirban P. Mitra, Jie Cai, Gus Miranda, and Hooman Djaladat. "Enhanced recovery protocol after radical cystectomy for bladder cancer." The Journal of urology 192, no. 1 (2014): 50-56.
  5. Thaker, Hatim, Saum Ghodoussipour, Mateen Saffarian, Akbar Ashrafi, Gus Miranda, Jie Cai, Anne K. Schuckman et al. "Extended hospital stay after radical cystectomy with enhanced recovery protocol." The Canadian journal of urology 26, no. 1 (2019): 9654-9659.
  6. Chen, Jian, Hooman Djaladat, Anne K. Schuckman, Monish Aron, Mihir Desai, Inderbir S. Gill, Thomas G. Clifford et al. "Surgical approach as a determinant factor of clinical outcome following radical cystectomy: Does Enhanced Recovery After Surgery (ERAS) level the playing field?." In Urologic Oncology: Seminars and Original Investigations, vol. 37, no. 10, pp. 765-773. Elsevier, 2019.
  7. Feroci, Francesco, Elisa Lenzi, Maddalena Baraghini, Alessia Garzi, Andrea Vannucchi, Stefano Cantafio, and Marco Scatizzi. "Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery." Surgical Laparoscopy Endoscopy & Percutaneous Techniques 23, no. 3 (2013): 259-265.
  8. Gustafsson, Ulf O., Jonatan Hausel, Anders Thorell, Olle Ljungqvist, Mattias Soop, and Jonas Nygren. "Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery." Archives of surgery 146, no. 5 (2011): 571-577.
  9. Feroci, Francesco, Elisa Lenzi, Maddalena Baraghini, Alessia Garzi, Andrea Vannucchi, Stefano Cantafio, and Marco Scatizzi. "Fast-track colorectal surgery: protocol adherence influences postoperative outcomes." International journal of colorectal disease 28, no. 1 (2013): 103-109.
  10. Gustafsson, Ulf O., Henrik Oppelstrup, Anders Thorell, Jonas Nygren, and Olle Ljungqvist. "Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study." World journal of surgery 40, no. 7 (2016): 1741-1747.
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