title: Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program.
abstract: Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection.
  
  
  
  Prospectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0-100). Regression analyses were adjusted for potential confounders.
  
  
  
  A total of 347 patients were included in the study. Median primary LOS was 4 days (IQR 3-7). Patients were adherent to median 18 (IQR 16-20) elements. A total of 156 (45 %) patients had successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0-22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, p < 0.001), LOS (11 % reduction for every additional element, p < 0.001), 30-day postoperative morbidity (OR 0.78, p < 0.001), and the CCI (17 % reduction, p < 0.001). Laparoscopy (OR 4.32, p < 0.001), early mobilization out of bed (OR 2.25, p = 0.021), and early termination of IV fluid infusion (OR 2.00, p = 0.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity.
  
  
  
  Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.
authors.affiliation: Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada.
authors.forename: Nicolò
authors.initials: N
authors.lastname: Pecorelli
authors.affiliation: Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada.
authors.forename: Olivia
authors.initials: O
authors.lastname: Hershorn
authors.affiliation: Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Baldini
authors.affiliation: Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada.
authors.forename: Julio F
authors.initials: JF
authors.lastname: Fiore
authors.affiliation: Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.
authors.forename: Barry L
authors.initials: BL
authors.lastname: Stein
authors.affiliation: Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.
authors.forename: A Sender
authors.initials: AS
authors.lastname: Liberman
authors.affiliation: Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.
authors.forename: Patrick
authors.initials: P
authors.lastname: Charlebois
authors.affiliation: Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada.
authors.forename: Franco
authors.initials: F
authors.lastname: Carli
authors.affiliation: Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada. liane.feldman@mcgill.ca.|Department of Surgery, McGill University Health Centre, Montreal, QC, Canada. liane.feldman@mcgill.ca.
authors.forename: Liane S
authors.initials: LS
authors.lastname: Feldman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways; D017558:Elective Surgical Procedures; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007422:Intestines / Q000601:surgery*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D019990:Perioperative Care / Q000379:methods / Q000592:standards*; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D020127:Recovery of Function; D012042:Registries; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Colorectal surgery; Laparoscopy; Length of stay; Outcome and process assessment (health care); Postoperative complications; Postoperative recovery