Implementation Program Improves Bariatric Surgery Outcomes

Researchers report that extended hospital stays afteroperations were reduced by almost half at 36 participating accredited bariatricsurgery centers.

A large-scale implementation of a protocol to improverecovery of patients after weight-loss operations was found to reduce rates ofextended hospitalization by almost half at 36 participating accreditedbariatric surgery centers nationwide, according to a study published onlineahead of print in the current issue of the journal Surgery for Obesity andRelated Diseases. The initiative, titled ENERGY – for Employing EnhancedRecovery Goals in Bariatric Surgery – compared outcomes of 8,946 bariatricoperations before with 9,102 operations that occurred after implementation ofthe protocol, known as an enhanced recovery program (ERP).

For this study, ERP measured 26 different process measuresaimed at improving outcomes after weight-loss operations. “The key finding ofthis study is that the more adherent a program was to all of the processmeasures of the protocol, the greater the reduction their patients experiencedin their extended length of stay,” said lead author Stacy A. Brethauer, MD,FACS, professor of surgery at The Ohio State University, Columbus. Theresearchers defined extended length of stay (LOS) as any hospitalization ofmore than four days after the operation. Before the ERP, 8.1 percent ofoperations resulted in an extended LOS; after ERP, the rate declined to 4.5percent. “This result was accomplished without increasing readmission rates,”Dr. Brethauer said. At centers that complied with 23 or more of the 26 ERPprocess measures, the rate of extended LOS was 2.3 percent versus 5.4 percentat those that complied with 19 or 20.

ERPs have been around for nearly two decades, first adoptedin the United States by colorectal and orthopedic surgery and anesthesiologyunits in hospitals. The goal is to maintain a patient’s normal physiologicalstate as much as possible throughout the operation and recovery process, Dr.Brethauer explained. “This goal is accomplished by allowing patients to arrivefor surgery in a physiologically ‘fed’ state after drinking a carbohydratedrink two hours prior to surgery, minimizing fluid overload during and aftersurgery, maintaining tight blood sugar control, implementing opioid-sparingmultimodal pain management strategies, and minimizing emotional and physicalstress that can accompany a major operation,” Dr. Brethauer said. The protocolalso eliminates the use of drains and urinary catheters, encourages early mobilizationafter operations, and the use of regional anesthetic blocks and non-opioids asfirst- and second-line pain management treatments.

“Patient education is critical to a successful enhancedrecovery program,” he said. “Setting expectations and describing theopioid-sparing pain management strategies to patients before their operationsis important and helps patients understand their role in their recovery.”

The Metabolic and Bariatric Surgery Accreditation andQuality Improvement Program (MBSAQIP) launched this quality improvement projectto implement a prescriptive ERP. The researchers invited 80 MBSAQIP centersidentified as outliers for extended LOS in the MBSAQIP database, and 36enrolled after reviewing the protocol and the commitment required.“Implementation of the protocol required multiple stakeholders – anesthesia,nursing, pharmacy, administration, surgical team – at each site to commit tothe protocol,” Dr. Brethauer said.

As a result of the study, MBSAQIP is encouraging all of itsaccredited centers to adopt enhanced recovery protocols into their surgicalpractice, Dr. Brethauer said. The published study includes the ENERGY protocolas an appendix. Furthermore, MBSAQIP is developing an implementation toolkitfor its accredited centers to use in furthering ERP efforts.

The next national quality improvement project will focusspecifically on opioid prescribing after bariatric surgery, Dr. Brethaueradded.

Study Coauthors

Arielle Grieco, MPH, Teresa Fraker, MS, RN, and Kimberly Evans-Labok, BA, of the American College of Surgeons, Chicago, Ill.; April Smith, PharmD, BCPS, of Creighton University department of pharmacy, Omaha, Neb.; Matthew D. McEvoy, MD, of Vanderbilt University Medical Center department of anesthesiology, Nashville, Tenn.; Alan A. Saber, MBBch, FACS, of Newark Beth Israel Medical Center, Newark, N.J.; John M. Morton, MD, of Yale University department of surgery, New Haven, Conn.; and Anthony Petrick, MD, FACS, of Geisinger Health System department of surgery, Danville, Pa.

Source

Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY): A National Quality Improvement Project Utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program —Surgery for Obesity and Related Diseases DOI: https://doi.org/10.1016/j.soard.2019.08.024(.)

“FACS” designates that a surgeon is a Fellow of the AmericanCollege of Surgeons.