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.