title: Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection.
abstract: BACKGROUND
  Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery.
  
  
  METHODS
  An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire.
  
  
  RESULTS
  There were no differences in patient or disease characteristics between pre-ERAS (42 patients) and post-ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P < 0·001). Duration of hospital stay was shorter in the post-ERAS group (median 5 (i.q.r. 4-7) days versus 6 (5-7) days in the pre-ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (-US $333; -€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (-US $394; -€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation.
  
  
  CONCLUSIONS
  The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers.
authors: Departments of Surgery, Johns Hopkins University School of Medicine, Maryland, USA.
authors: A J
authors: AJ
authors: Page
authors: Departments of Surgery, Johns Hopkins University School of Medicine, Maryland, USA.
authors: F
authors: F
authors: Gani
authors: Armstrong Institute of Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland, USA.
authors: K T
authors: KT
authors: Crowley
authors: Armstrong Institute of Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland, USA.
authors: K H K
authors: KH
authors: Lee
authors: Departments of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Maryland, USA.
authors: M C
authors: MC
authors: Grant
authors: Departments of Surgery, Johns Hopkins University School of Medicine, Maryland, USA.
authors: T L
authors: TL
authors: Zavadsky
authors: Departments of Surgery, Johns Hopkins University School of Medicine, Maryland, USA.
authors: D
authors: D
authors: Hobson
authors: Departments of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Maryland, USA.
authors: C
authors: C
authors: Wu
authors: Departments of Surgery, Johns Hopkins University School of Medicine, Maryland, USA.
authors: E C
authors: EC
authors: Wick
authors: Departments of Surgery, Johns Hopkins University School of Medicine, Maryland, USA.
authors: T M
authors: TM
authors: Pawlik
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D005260:Female; D006498:Hepatectomy / Q000191:economics / Q000379:methods; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D008396:Maryland; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D019990:Perioperative Care / Q000191:economics / Q000379:methods / Q000592:standards*; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D011446:Prospective Studies