ERAS Society 2019: Internal Audit of an Enhanced Recovery After Surgery for Radical Cystectomy
Benefits have previously been shown of an Enhanced Recovery After Surgery (ERAS®) protocol for patients undergoing radical cystectomy. Since its initial implementation 6 years ago, ERAS® protocol has become a standard of care at the University of Texas Medical Branch, Galveston. In this study, an internal audit of UT Galveston’s protocol is performed and investigations into the importance of compliance to the protocol on outcomes were observed.
Using an Institutional Review Board approved and prospectively maintained database, 434 consecutive patients were identified who underwent open or robotic radical cystectomy with ERAS® from July 2013 to July 2017. Compliance was measured by a Composite Compliance Score (CCS) generated as a percentage of 16 interventions. Median CCS was determined and patients with higher compliance were grouped and compared to patients with lower compliance.
In 2013, median CCS was 81% and subsequent years ranged from 88-93%. Five-year median CCS was 88%, subsequently distributing 262 patients into the higher compliance group (CCS >= 88%) and 172 patients into the lower compliance group (CCS < 88%). Patients in the more compliant group were younger (median 70.2 vs 73.0 years, p < 0.009), more likely to have orthotopic urinary diversion (58.8% vs 39.0%, p < 0.0001), and less likely to undergo robotic surgery (20.6% vs 38.4%, p < 0.0001). For the entire cohort, median length of stay (LOS) was 4 days. On univariate analysis, more compliant patients experienced shorter hospital stays (4 vs 5 days, p < 0.0001) and lower 90-day mortality (1.5 vs 10.5%, p<0.0001). Patients with higher CCS had a lower, though not significant, rate of high-grade complications at 30 and 90 days (9.5 vs 13.4%, p=0.065 and 17.6 vs 22.6%, p=0.064 respectively) as well as 30-day readmissions (13.7 vs 20.9%, p=0.064). Multivariable analysis showed that higher compliance was independently associated with shorter hospital stays (β = -0.91, 95% CI -1.74 - -0.07) and decreased 90-day mortality (OR = 0.16, 95% CI: 0.05 to 0.44).
In conclusion, reaching and maintaining a high level of compliance to an ERAS® protocol was feasible within a year of implementation. Patients with more ERAS® protocol compliance, CCS >= 88%, have a decreased length of stay by one day and reduced odds of 90-day mortality compared to those with lower protocol compliance. This study highlights the critical importance of performing audits to ensure accurate ERAS® implementation and dissemination as well as data reporting are performed consistently. The ERAS® Society has an excellent, comprehensive audit system available for purchase which directly links with existing electronic medical record systems.
Presented by: Siamak Daneshmand, MD, Associate Professor of Urology (Clinical Scholar), Director of Clinical Research, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California
Written by: Written by: Stephen B. Williams, MD, Associate Professor, Division of Urology, The University of Texas Medical Branch, Galveston, Texas at the 7th ERAS World Congress, Liverpool, UK, 1-3 May 2019