“The problem that emerges when we start to track outcomes after surgery is that there is substantial variation in the way perioperative care is delivered, and this leads to substantial variation in patient outcomes,” said Chelsea Fischer, MD, American College of Surgeons (ACS) 2019–2021 Clinical Scholar in Residence, Chicago, IL, when introducing a session on the ACS and Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR) at Clinical Congress 2019 on Monday, October 28.
The use of standardized enhanced recovery protocols has been shown to decrease rates of complications, such as surgical site infection (SSI), and reduce patient length-of-stay. “The real question is, how do we provide these best practices across the country?” Dr. Fischer said. That question led to the development of ISCR, a free program that provides hospitals with resources, a centralized support team, access to leaders in the field, and the ability to track data over time.
Benjamin C. DuBois, MD, FACS, surgical quality director, Christus Saint Michael Hospital, and operations chief, Christus Trinity Clinic, Texarkana, TX, offered a “boots on the ground perspective” of running an ISCR program. A surgeon needs to put together an ISCR team with members from all phases of surgical care, he said. Dr. Dubois offered an overview of how the ISCR program assists hospitals in implementing an enhanced recovery program, including providing adaptable pathway models on the website, educational material, and access to an ACS-based data collection platform, among other resources.
The ISCR program is a true multiphase program and its effects are felt from the beginning of the surgery process. “The scheduler will note on the OR schedule that the surgery is taking place under an enhanced recovery program, and that will initiate a sequence of events across the phases of care to make sure particular components of the enhanced recovery are followed through,” Dr. DuBois said. His team’s implementation of the ISCR program has led to less perioperative opioid use, less crystalloid fluid use, more patient education, and smoother recovery.
Deborah Yokoe, MD, MPH, medical director, hospital epidemiology and infection prevention, University of California San Francisco, gave an infectious disease expert’s view of some of the techniques that an enhanced recovery program can incorporate to minimize SSIs, including adding basic practices, such as optimizing antimicrobial prophylaxis and controlling perioperative blood glucose. She also spoke of some promising techniques that require additional research.
“There are a number of evidence-based SSI prevention strategies that, if consistently integrated into perioperative practices, have the potential to improve postoperative outcomes,” said Dr. Yokoe, noting that the multidisciplinary teams the ISCR program encourages are a key to success.
Michael Engelsbe, MD, FACS, professor of surgery, University of Michigan, Ann Arbor, reiterated the importance of providing care from standardized protocols, and spoke of his and his Michigan colleagues’ successful work addressing prescription opioids. “Everyone within a hospital should get care within a pathway, and the ISCR program provides exactly that,” he said.
Dr. Englesbe and colleagues in the Michigan Opioid Prescribing Engagement Network developed their own opioid prescribing pathways based on research from select hospitals that showed setting patient pain expectations before surgery, using multimodal analgesia, and blanketly reducing opioid pill prescriptions led to no decrease in patient satisfaction or increase in reported pain. Reducing the number of prescribed pills is important because “these opioid prescriptions, many of which originate from surgeons, feed the epidemic,” he said.
Derrick C. Lee, MD, an anesthesiologist at San Leandro Medical Center, CA, offered his perspective on the Kaiser Permanente experience practice pathways. Kaiser wanted to address high surgical complication rates across the system and developed multiple pathways for seven different procedures. “As we kept expanding, we started to run into barriers—procedural variation started to appear across practices,” he said.
“Then we had a thought,” Dr. Lee continued. “What if we could design a common pathway across procedures that was simple and spreadable, and consolidated into a single ‘adult’ pathway?”
The group participants decided on common items for all surgical patients, such as patient education, elimination of unnecessary fasting, minimal line/tube insertions, and early ambulation after surgery. After implementing the common pathway, “harm-free surgery” increased markedly, Dr. Lee noted, with fewer complication and quicker recovery.
The ISCR program is an opportunity to begin implementing common pathways across the country, and based on the experience from Kaiser, the result will be enhanced recovery for patients.