Implementation of Enhanced Recovery in Gynecologic Surgery to Improve Outcomes at an Urban Safety-Net Hospital

Mary Louise Fowler, Lizette Mendez, Shawn Whitehead, Bhavesh Shah, Kristen E. Rizza, Melissa Schapero, Elise P. Memmo, Paul M. Hendessi, Ronald E. Iverson, Mallika Anand


Background: This study aims to implement an enhanced recovery pathway (ERP) for patients undergoing gynecologic surgery and to track clinical outcomes, including perioperative opioid use and adverse events.

Methods: Patients undergoing gynecologic surgery with a planned overnight stay were eligible. The primary outcome measure was perioperative opioid use in oral morphine milligram equivalents. Secondary outcome measures included bundle completion and length of stay. Balancing measures included rates of total and specific adverse events. Data were stratified by route of surgery and univariate analyses were performed between pre- and post-ERP groups to compare demographic factors and outcome measures. Linear regression analyses were run to assess mean differences in perioperative opioid use and length of stay when adjusting for route of surgery, age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, surgical subspecialty, and postoperative hemoglobin change, and/or bundle completion score.

Results: The ERP was implemented in 16 weeks and selected in 63 eligible patients from February 1 to April 30, 2017. ERP bundle completion was significantly higher for all surgical categories following formal pathway implementation. Compared to the pre-ERP cohort, the ERP cohort demonstrated significantly decreased total opioid use in laparotomies (175.5 mg vs. 209.8 mg, P = 0.03) and minimally invasive surgeries (125 mg vs. 170.3 mg, P = 0.018). Additionally, significantly decreased intraoperative opioids were used in both laparotomies (95 mg vs. 105 mg, P = 0.03) and minimally invasive surgeries (75 mg vs. 108.5 mg, P < 0.0001), as well as significantly decreased postoperative opioid use in minimally invasive surgeries (15 mg vs. 45 mg, P = 0.04). A one-point increase in ERP bundle completion score was associated with a 9.2 mg decrease in total opioid used (P = 0.0375) as well as a 4.8 h decrease in length of stay (P < 0.0001) when adjusting for route of surgery, age, BMI, ASA status, surgical subspecialty, and case length. There were no significant differences in adverse events when ERP was used.

Conclusions: ERP implementation was rapidly accomplished at our urban, safety-net hospital. The pathway reduced perioperative opioid use without increasing adverse events. Continued monitoring of enhanced recovery quality improvement measures, including bundle completion, is essential to ensure adherence, safety, and effectiveness.

J Clin Gynecol Obstet. 2020;9(3):43-52


Enhanced recovery pathway; Gynecologic surgery; Opioid reduction

Full Text: HTML PDF

Browse  Journals  


Journal of Clinical Medicine Research

Journal of Endocrinology and Metabolism

Journal of Clinical Gynecology and Obstetrics

World Journal of Oncology

Gastroenterology Research

Journal of Hematology

Journal of Medical Cases

Journal of Current Surgery

Clinical Infection and Immunity

Cardiology Research

World Journal of Nephrology and Urology

Cellular and Molecular Medicine Research

Journal of Neurology Research

International Journal of Clinical Pediatrics






Journal of Clinical Gynecology & Obstetrics, quarterly, ISSN 1927-1271 (print), 1927-128X (online), published by Elmer Press Inc.                     
The content of this site is intended for health care professionals.
This is an open-access journal, the authors retain the copyright, the journal is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International
License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)

This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website:   editorial contact:
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada

© Elmer Press Inc. All Rights Reserved.

Disclaimer: The views and opinions expressed in the published articles are those of the authors and do not necessarily reflect the views or opinions of the editors and Elmer Press Inc. This website is provided for medical research and informational purposes only and does not constitute any medical advice or professional services. The information provided in this journal should not be used for diagnosis and treatment, those seeking medical advice should always consult with a licensed physician.