Implementation of an Enhanced Recovery Program for Lower Extremity Bypass

Abstract Importance Enhanced Recovery Programs (ERP) have gained wide acceptance across multiple surgical disciplines to improve postoperative outcomes and decrease hospital length of stay. However, there is limited information in the existing literature for vascular patients. Objective We describe the implementation, early results, and barriers to implementation of an ERP for lower extremity bypass (LEB) surgery. Our intention is to provide a framework to assist with implementation of similar ERPs. Methods Using the Plan-Do-Check Adjust methodology, a multidisciplinary team was assembled. A database was used to collect information on patient, procedure, and ERP specific metrics. We then retrospectively analyzed patient demographics and outcomes. Results Over nine months, an ERP (n=57) was successfully developed and implemented spanning pre-operative, intra-operative, and post-operative phases. ERP and non-ERP patient demographics were statistically similar. Early successes include 97% utilization of fascia iliaca block and multimodal analgesia administration in 81%. Barriers included only 47% of patients achieving day of surgery mobilization and 19% receiving celecoxib pre-operatively. ERP patients had decreased total and postoperative LOS compared with non-ERP patients (n=190) with a mean (SD) total LOS of 8.32 (8.4) vs 11.14 (10.1) days, p=0.056 and 6.12 (6.02) vs 7.98 (7.52) days postoperative LOS, p=0.089. There was significant decrease in observed to expected post-operative LOS (1.28 (0.66) vs 1.82 (1.38), p=0.005). Variable and total cost for ERP patients was significantly reduced ($13,208 ($9,930) vs $18,777 ($19,118), p Conclusions Successful implementation of ERP for LEB carries notable challenges but can significantly impact practice patterns. Further adjustment of our current protocol is anticipated, but early results are promising. Implementation of a vascular surgery ERP reduced variable and total costs, and decreased total and postoperative LOS. We believe this protocol can easily be implemented at other institutions using the pathway outlined.