Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc
Journal website https://www.jcgo.org

Original Article

Volume 9, Number 3, September 2020, pages 43-52

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

Figures

Figure 1.
Figure 1. Implementation timeline for an enhanced recovery pathway in gynecologic surgery. In this implementation timeline, tasks are listed on the horizontal axis in chronologic order, and roles are listed on the vertical axis. The roles are fulfilled by members of the ERP steering committee and stakeholders to whom tasks apply. An ERP steering committee would typically meet every 1 - 4 weeks as full group or subgroup, and consists of the hospital-wide project manager, department project manager, and a representative for each division listed in the task role. A modification of this figure has previously been published. ERP: enhanced recovery pathway.
Figure 2.
Figure 2. Opioid use by phase of care, before and after ERP implementation. Opioid use is depicted for each perioperative phase of care before and after ERP implementation. The red arrow at the top of the figure denotes the date of ERP implementation (February 1, 2017). ERP: enhanced recovery pathway.

Tables

Table 1. Baseline Characteristics of Patients Undergoing Gynecologic Surgery With a Planned Overnight Stay
 
Open surgeryMinimally invasive surgeryVaginal surgery
Pre-ERP cohort (n = 42)ERP Protocol (n = 19)P valuePre-ERP cohort (n = 32)ERP Protocol (n = 25)P valuePre-ERP cohort (n = 22)ERP protocol (n = 19)P value
ERP: enhanced recovery pathway; BMI: body mass index; ASA: American Society of Anesthesiologists.
Age (year)48 (40 - 52)49 (40 - 59)0.8647 (41 - 57)49 (40 - 57)0.9758 (44 - 64)60 (43 - 62)0.55
BMI (kg/m2)28.8 (25.5 - 32.1)29.4 (26.1 - 32.7)0.7832.4 (26.8 - 36.8)29.3 (25.7 - 33.6)0.1329.4 (25.4 - 31.8)27.8 (23.2 - 33.9)0.90
ASA > 36 (14.3)7 (36.8)0.046**4 (12.5)4 (16.0)0.726 (27.3)6 (31.6)0.76

 

Table 2. Intraoperative and PACU Outcomes of Patients Undergoing Gynecologic Surgery With a Planned Overnight Stay
 
Open surgeryMinimally invasive surgeryVaginal surgery
Pre-ERP cohort (n= 42)ERP protocol (n = 19)P valuePre-ERP cohort (n = 32)ERP protocol (n = 25)P valuePre-ERP cohort (n = 22)ERP protocol (n = 19)P value
The two-sample Student’s t-test and Wilcoxon’s rank sum test were used for continuous variables. Chi-square test and Fisher’s exact test were used for categorical variables. Data are presented as n (%) or median (interquartile range). *Statistical significance (P value < 0.05). ERP: enhanced recovery pathway; PACU: post-anesthesia care unit; TAP: transversus abdominis plane; h: hours.
Bupivacaine injection of surgical site (yes)17 (40.5)6 (31.6)0.5132 (100)23 (92)0.192 (9.1)4 (21.1)0.39
TAP block if open2 (4.8)4 (21.1)0.69N/AN/AN/AN/AN/AN/A
Nonopioids used (yes)
  Intraoperative21 (50)13 (68.4)0.1820 (62.5)17 (68)0.676 (27.3)11 (57.9)0.047*
  PACU31 (73.8)6 (31.6)0.001*20 (62.5)7 (28%)0.009*13 (59.1)9 (47.4)0.45
Anesthesia time (h)4.1 (3.3, 4.6)4.1 (3.1, 5.9)0.655.4 (4.3, 6.6)4.6 (4.0, 5.6)0.153.9 (3.3, 4.7)5.2 (4.5, 5.7)< 0.0001*

 

Table 3. Postoperative Outcomes and Perioperative Opioid Use Among Patients Undergoing Gynecologic Surgery With a Planned Overnight Stay
 
Open surgeryMinimally invasive surgeryVaginal surgery
Pre-ERP cohort (n = 42)ERP Protocol (n = 19)P valuePre-ERP cohort (n = 32)ERP protocol (n = 25)P valuePre-ERP cohort (n = 22)ERP protocol (n = 19)P value
The two-sample Student’s t-test and Wilcoxon’s rank sum test were used for continuous variables. The Chi-square test and Fisher’s exact test were used for categorical variables. Data are presented as n (%) or median (interquartile range). *Statistical significance (P value < 0.05). ED: emergency department; IV: intravenous; PACU: post-anesthesia care unit; UTI: urinary tract infection; ERP: enhanced recovery pathway.
Change in hemoglobin (g/dL)-1.8 (-2.7, -0.7)-1.1 (-1.9, -0.8)0.24-1.8 (-2.2, -1.4)-1.5 (-2.3, -0.6)0.36-1.9 (-2.3, -1.4)-1.4 (-3.2, -0.7)0.85
Total opioid use (mg)209.8 (170.5, 264)175.5 (75, 256.9)0.03*170.3 (125.5, 222.5)125 (105, 150)0.018*135.3 (112.5, 194)147 (123.8, 195)0.69
  Intraoperative105 (85, 135)95 (45, 120)0.03*108.5 (89.5, 117.5)75 (60, 90)< 0.0001*77.5 (60, 105)75 (60, 105)0.67
  PACU28.5 (8.0, 46.5)30.0 (7.5, 37.5)0.3915 (0, 25)15 (0, 52.5)0.3622.5 (15, 50.5)27 (15, 60)0.86
  Postoperative67.5 (48, 91.5)52.5 (15, 108.5)0.1945 (15, 73.8)15 (0, 45)0.04*35.8 (15, 45)15 (7.5, 45)0.20
IV opioid used on inpatient floor (yes)30 (71.4)8 (42.1)0.03*4 (12.5)0 (0)0.123 (13.6)4 (21.1)0.68
Day 0 + 1 opioid use (mg)185.5 (154, 228.5)134.5 (75, 219.5)0.016*146.5 (125.3, 195)125 (105, 142.5)0.02*135.3 (110, 179)135 (123.8, 190)0.88
Length of hospital stay (h)54 (50.3, 57)57 (52, 101)0.1229.1 (27.3, 31.8)31 (27, 34)0.4131.4 (29, 36.3)29 (26, 31)0.04*
Adverse events
  30-day readmission3 (7.1)0 (0)0.551 (3.1)2 (8)0.583 (13.6)0 (0)0.24
  ED visits5 (11.9)1 (5.3)0.661 (3.1)5 (20)0.085 (22.7)2 (10.5)0.42
  UTIs3 (38)0 (0)0.094 (36)2 (17)0.914 (18.2)3 (15.8)1.0
Clavien-Dindo
  Grade I2 (15.4)1 (50)0 (0)1 (14.3)2 (16.7)0 (0)
  Grade II3 (37.5)1 (50)0.446 (85.7)5 (71.4)0.589 (75)3 (100)0.63
  Grade III+4 (30.8)0 (0)1 (14.3)1 (14.3)1 (8.3)0 (0)