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Achieving Highly Reliable Perioperative Care: How Do We Get There?
*Chelsea P Fischer1, *Leandra Knapp2, *Mark E. Cohen2, Clifford Y Ko3, *Elizabeth Wick4
1Loyola University Medical Center, Chicago, IL;2American College of Surgeons, CHICAGO, IL;3UCLA, Los Angeles, CA;4UCSF, San Francisco, CA

Objectives: Variation in Enhanced Recovery Pathway(ERP) implementation can hinder improvement in patient outcomes. We sought to identify and characterize institutions with high reliability ERP implementation from a contemporary quality improvement program.
Methods: A national colorectal ERP quality improvement program was evaluated with quantitative (patient-level process and outcome) and qualitative (survey and semi-structured interviews with hospital teams) data between 2017-2019. All program hospitals were characterized as high reliability ERP hospitals(HRE) (80% of elective colorectal surgery patients compliant with > 6/8 process measures) or low reliability ERP hospitals(LRE). Differences in 30-day outcomes between HRE and LRE were evaluated with chi-square tests.
Results: Of 248 hospitals, 65 (26.2%) were HREs, representing 13,276 colorectal surgery patients. Most HREs were academic(83%), mid-size(480 beds), with moderate colorectal volume(median 60 cases/year). The majority (84.6%) joined the program in 2017 (early adopters), initiated colorectal ERP prior to joining (72.3%), and had previous quality improvement program participation (81.5%). HREs had improved outcomes vs LREs [SSI (3.9 vs 4.4%, p=0.02), VTE (0.7 vs 1.0%, p=0.007), 30-day readmission (9.7 vs 10.5%, p=0.015), ileus (9.6 vs 13.8%, p<0.001), and prolonged length of stay (14.9 vs 17.3%, p<0.001)]. On qualitative evaluation of the local environment, stakeholder buy-in, financial support, teamwork, and QI skills were self-identified strengths of HREs.
Conclusions: In a national ERP quality improvement program, only 1 in 4 hospitals achieved highly reliable ERP implementation. Characteristics of the local environment indicate that effort in ERPs needs to be dedicated to resources, culture, and sustaining program longevity to maximize impact on patient outcomes.


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