title: Initiating an Enhanced Recovery Pathway Program: An Anesthesiology Department's Perspective.
abstract: BACKGROUND
  Enhanced recovery pathways (ERPs) for surgical patients may reduce variation in care and improve perioperative outcomes. Mainstays of ERPs are standardized perioperative pathways. At The Johns Hopkins Hospital (Baltimore), an integrated ERP was proposed to further reduce the surgical site infection rate and the longer-than-expected hospital length of stay in colorectal surgery patients.
  
  
  METHODS
  To develop the technical components of the anesthesia pathway, evidence on enhanced recovery was reviewed and the limitations of the hospital infrastructure and policies were considered. The goals of the perioperative anesthesiology pathway were achieving superior analgesia, minimizing postoperative nausea and vomiting, facilitating patient recovery, and preserving perioperative immune function. ERP was implemented in phases during a 30-day period, starting with the anesthesiology elements and followed by the pre- and postoperative surgical team processes. The perioperative anesthetic regimen was tailored to meet the goal of preservation of perioperative immune function (in an attempt to decrease surgical site infection and cancer recurrence), in part by minimizing perioperative opioid use.
  
  
  RESULTS
  After six months of exposure to all ERP elements, a 45% reduction in length of stay was observed among colorectal surgery patients. In addition, patient satisfaction scores for this cohort of patients improved from the 37th percentile preimplementation to >97th percentile postimplementation.
  
  
  CONCLUSIONS
  Development of an ERP requires collaboration among surgeons, anesthesiologists, and nurses. Thoughtful, collaborative pathway development and implementation, with recognition of the strengths and weakness of the existing surgical health care delivery system, should lead to realization of early improvement in outcomes.
authors.affiliation: The Johns Hopkins University, Baltimore, USA.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wu
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Benson
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Hobson
authors.forename: Claro Pio
authors.initials: CP
authors.lastname: Roda
authors.forename: Renee
authors.initials: R
authors.lastname: Demski
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Galante
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Page
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Wick
mesh_terms: D000776:Anesthesiology / Q000458:organization & administration*; D015142:Baltimore; D019091:Critical Pathways / Q000191:economics / Q000458:organization & administration*; D013505:Digestive System Surgical Procedures / Q000191:economics / Q000379:methods; D006785:Hospitals, University; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D059408:Pain Management / Q000379:methods; D017060:Patient Satisfaction; D019990:Perioperative Care / Q000191:economics* / Q000379:methods*