title: Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway.
abstract: BACKGROUND
  After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use.
  
  
  OBJECTIVE
  The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes.
  
  
  METHODS
  This was a case-matched study.
  
  
  METHODS
  After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex.
  
  
  METHODS
  This study was performed at a tertiary referral center.
  
  
  METHODS
  Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included.
  
  
  METHODS
  The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway.
  
  
  RESULTS
  Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen.
  
  
  CONCLUSIONS
  The single-surgeon, single-institution design was a limitation of this study.
  
  
  CONCLUSIONS
  The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.
authors.affiliation: 1Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Cleveland, Ohio 2Department of Surgery, University Hospitals-Case Medical Center, Cleveland, Ohio.
authors.forename: Deborah S
authors.initials: DS
authors.lastname: Keller
authors.forename: Jonah J
authors.initials: JJ
authors.lastname: Stulberg
authors.forename: Justin K
authors.initials: JK
authors.lastname: Lawrence
authors.forename: Conor P
authors.initials: CP
authors.lastname: Delaney
mesh_terms: D000009:Abdominal Muscles; D000082:Acetaminophen / Q000008:administration & dosage; D000328:Adult; D000368:Aged; D018712:Analgesics, Non-Narcotic / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage; D002045:Bupivacaine / Q000008:administration & dosage; D003108:Colonic Diseases / Q000601:surgery*; D019091:Critical Pathways / Q000458:organization & administration*; D005260:Female; D017048:Health Care Costs; D006760:Hospitalization; D006801:Humans; D007262:Infusions, Intravenous; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009407:Nerve Block; D059408:Pain Management; D017064:Process Assessment, Health Care; D012002:Rectal Diseases / Q000601:surgery*; D012189:Retrospective Studies
chemical_list: D018712:Analgesics, Non-Narcotic; D000779:Anesthetics, Local; D000082:Acetaminophen; D002045:Bupivacaine