Improved recovery path for bariatric operations halves hospital stays – ScienceDaily

The goal of implementing the new treatment regimen, called ERAS protocol (Enhanced Recovery After Surgery), was to reduce the number of days of hospitalization of patients after their operation and to prescribe less pain medication opioids, said Charles K. Mitchell Jr., MD, FACS, FASMBS, of Roper St. Francis Bariatric and Metabolic Services, who presented the results of the conference on safety and quality organized by the American College of Surgeons (ACS) in 2019, which will end today in Washington, DC

"My concern was that patients were going back to the emergency room and needed to be seen again because we were sending them home too quickly or we were not controlling their pain properly, but the opposite was true," he said. said Dr. Mitchell. "Our readmission rates have actually dropped by almost 40% with the implementation of this protocol."

More specifically, the rate of readmission to the hospital has increased from 5% before the implementation of ERAS to 3.1% thereafter. Similarly, the average length of stay in the hospital after a bariatric operation has gone from 3.3 to 1.5 days, and the average morphine equivalents to the hospital per patient, which is a measure administered pain medication, has 89.1 to 4 mg. The study evaluated the results for patients in the year prior to and following the adoption of the ERAS protocol by the facility in December 2016.

Roper St. Francis has been invited to adopt the ENERGY project (Employing New Recovery Enhanced Goals) because it is one of the outliers in terms of length of stay in the accreditation program and improving the quality of metabolic and bariatric surgery (MBSAQIP). MBSAQIP is a joint national initiative of the ACS and the American Society of Metabolic and Bariatric Surgery (ASMBS) that tracks results in bariatric surgery centers with the goal of identifying best practices and best practices. improve poor performance centers.

"The cost implications are rather positive," said Dr. Mitchell, not only because of shorter hospital stays, the number of readmissions and the number of pain medications, but also because the type of medicine used. "Some programs will implement these protocols and will use very expensive painkillers, such as the intravenous suspension of Tylenol (acetaminophen) or Exparel," Dr. Mitchell said. The suspension of exparel is liposomal bupivacaine, a local anesthetic that, once injected, can last at least 24 hours. "We decided that this strategy was very expensive, so we administered 0.25% bupivacaine as local anesthetic and Tylenol tablets." The cost of this combination at Dr. Mitchell's facility was $ 6.24 for the first 24 hours postoperatively, compared to about $ 672 for three doses of Tylenol IV and one vial of Exparel, Dr. Mitchell said.

The implementation of the program involved more than the adoption of new practices. "Whenever you start an improved recovery after the surgical protocol, the first thing to make people understand is that it's not just an order, but a state." of completely different spirit, "said Dr. Mitchell.

The ERAS protocol involves intense preoperative patient education on a pain management plan that eliminates the patient-controlled badgesia pump (PCA) and avoids the routine administration of opioids, which can lead to constipation or nausea. It also involves training nurses to administer multimodal pain medications in accordance with the protocol rather than providing opioids to relieve the patient's pain on demand.

"Prior to the protocol, 96% of our surgical patients had received opioids during induction of anesthesia or during treatment.This number is now zero," said Dr. Mitchell. . "One hundred percent of patients received opioids after their operation with a PCA pump with morphine or dilaudid before the start of this protocol, and now, depending on the month, between 55 and 70% do not receive any opioids for their stay at the hospital … stay. "

Obese patients usually take painkillers for the treatment of arthritis before undergoing a bariatric operation, but in this study population, Dr. Mitchell said: "Almost all of these patients were no longer receiving narcotics at their return after their intervention. " Their postoperative care for pain management is not different from the protocol and all patients have resumed their pain management regimen at home on discharge.

Beyond pain management, the ERAS protocol also requires patients to get up, get up and walk, and take fluids by mouth, within six hours of operation. Since the bariatric surgical team has adopted the ENERGY ERAS protocol, other surgical departments of the health system have expressed interest in adopting an ERAS protocol, said Dr. Mitchell .

Dr. Mitchell's co-authors are Bryan K. Thomas, MD; and Ginny Ledbetter, MSN, APRIN, ACNS-BC, CBn; also from St. Francis Bariatric Roper and Metabolic Services.

Quote: Reduced length of stay and reduced opioid consumption during inpatient experience: positive impact on 30-day readmission rates – yes, it's possible! Conference on Quality and Safety of the American College of Surgeons, 2019.