title: Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery.
abstract: BACKGROUND
  Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution.
  
  
  METHODS
  A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables.
  
  
  RESULTS
  One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period.
  
  
  CONCLUSIONS
  Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.
authors: Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA.
authors: Robert H
authors: RH
authors: Thiele
authors: University of Virginia Health System, Charlottesville, VA.
authors: Kathleen M
authors: KM
authors: Rea
authors: University of Virginia Health System, Charlottesville, VA.
authors: Florence E
authors: FE
authors: Turrentine
authors: Department of Surgery, University of Virginia Health System, Charlottesville, VA.
authors: Charles M
authors: CM
authors: Friel
authors: Department of Surgery, University of Virginia Health System, Charlottesville, VA; University of Virginia Health System, Charlottesville, VA.
authors: Taryn E
authors: TE
authors: Hassinger
authors: Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA.
authors: Timothy L
authors: TL
authors: McMurry
authors: University of Virginia Health System, Charlottesville, VA.
authors: Bernadette J
authors: BJ
authors: Goudreau
authors: Department of Surgery, University of Virginia Health System, Charlottesville, VA; University of Virginia Health System, Charlottesville, VA.
authors: Bindu A
authors: BA
authors: Umapathi
authors: Department of Surgery, University of Virginia Health System, Charlottesville, VA.
authors: Irving L
authors: IL
authors: Kron
authors: Department of Surgery, University of Virginia Health System, Charlottesville, VA.
authors: Robert G
authors: RG
authors: Sawyer
authors: Department of Surgery, University of Virginia Health System, Charlottesville, VA. Electronic address: th8q@virginia.edu.
authors: Traci L
authors: TL
authors: Hedrick
mesh_terms: D002985:Clinical Protocols / Q000592:standards*; D003107:Colorectal Surgery / Q000191:economics / Q000592:standards*; D017046:Cost Savings; D003695:Delivery of Health Care / Q000191:economics / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000639:trends*; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D010351:Patient Discharge / Q000191:economics / Q000639:trends*; D019990:Perioperative Care / Q000379:methods; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology