title: Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs.
abstract: BACKGROUND
  The purpose of this study was to examine the impact of the sequential implementation of the enhanced recovery program (ERP) and surgical site infection bundle (SSIB) on short-term outcomes in colorectal surgery (CRS) to determine if the presence of multiple standardized care programs provides additive benefit.
  
  
  METHODS
  Institutional ACS-NSQIP data were used to identify patients who underwent elective CRS from September 2006 to March 2013. The cohort was stratified into 3 groups relative to implementation of the ERP (February 1, 2010) and SSIB (July 1, 2011). Unadjusted characteristics and 30-day outcomes were assessed, and inverse proportional weighting was then used to determine the adjusted effect of these programs.
  
  
  RESULTS
  There were 787 patients included: 337, 165, and 285 in the pre-ERP/SSIB, post-ERP/pre-SSIB, and post-ERP/SSIB periods, respectively. After inverse probability weighting (IPW) adjustment, groups were balanced with respect to patient and procedural characteristics considered. Compared with the pre-ERP/SSIB group, the post-ERP/pre-SSIB group had significantly reduced length of hospitalization (8.3 vs 6.6 days, p = 0.01) but did not differ with respect to postoperative wound complications and sepsis. Subsequent introduction of the SSIB then resulted in a significant decrease in superficial SSI (16.1% vs 6.3%, p < 0.01) and postoperative sepsis (11.2% vs 1.8%, p < 0.01). Finally, inflation-adjusted mean hospital cost for a CRS admission fell from $31,926 in 2008 to $22,044 in 2013 (p < 0.01).
  
  
  CONCLUSIONS
  Sequential implementation of the ERP and SSIB provided incremental improvements in CRS outcomes while controlling hospital costs, supporting their combined use as an effective strategy toward improving the quality of patient care.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Keenan
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Nussbaum
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Mohamed Abdelgadir
authors.initials: MA
authors.lastname: Adam
authors.affiliation: Department of Anesthesiology, Duke University Medical Center, Durham, NC.
authors.forename: Timothy E
authors.initials: TE
authors.lastname: Miller
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Mantyh
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: julie.thacker@dm.duke.edu.
authors.forename: Julie K M
authors.initials: JK
authors.lastname: Thacker
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003107:Colorectal Surgery; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D019990:Perioperative Care / Q000379:methods* / Q000592:standards; D058996:Quality Improvement; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000517:prevention & control*