Objectives: To describe a process change and evaluate compliance with use of preventive analgesia and deep venous thromboembolic (DVT) prophylaxis in an ...
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Abstracts / Clinical Nutrition ESPEN 12 (2016) e30ee59
P030. IMPLEMENTATION OF AN ENHANCED SURGICAL RECOVERY PROGRAMME (ESRP) IN GYNAECOLOGIC ONCOLOGY: HAS THE DEVELOPMENT OF A PREOPERATIVE ORDER SET IMPROVED COMPLIANCE FOR PREVENTIVE ANALGESIA AND DEEP VENOUS THROMBOEMBOLIC (DVT) PROPHYLAXIS? Javier D. Lasala 1, Jagtar Singh Heir 1,*, Gabriel E. Mena 1, Alpa M. Nick 2, Larissa A. Meyer 2, Maria D. Iniesta 2, Mark F. Munsell 3, Gloria Salvo 2, Juan P. Cata 1, Ifeyinwa Ifeanyi 1, Vijaya Gottumukkala 1, Katherine E. Cain 4, Pedro T. Ramirez 2. 1 Anaesthesiology, University of Texas MD Anderson Cancer Center, Houston, United States; 2 Gyn Onc & Reproductive Med, University of Texas MD Anderson Cancer Center, Houston, United States; 3 Biostatistics, University of Texas MD Anderson Cancer Center, Houston, United States; 4 Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, United States Objectives: To describe a process change and evaluate compliance with use of preventive analgesia and deep venous thromboembolic (DVT) prophylaxis in an ESRP pathway following implementation of order set. Methods: The ESRP at MD Anderson was initiated in the Department of Gynaecologic Oncology in November 2014. We used the following medications for preventive analgesia; pregabalin (neuropathic pain), celecoxib (non-steroidal anti-inflammatory), and tramadol (mu-opioid receptor, synthetic opioid). An order set was developed to include these medications in all patients undergoing gynaecologic surgery provided there were no contraindications. All patients were also written in the order set to receive subcutaneous heparin 5,000 units administered subcutaneously on arrival to the holding area. Medications were administered upon arrival in the preoperative holding area by the nursing staff. Training on the new order set was provided prior to ESRP rollout in November 2014 to members of the gynaecologic oncology team as well as to the nurses in the preoperative holding area. To improve adherence to the process change, a repeat training was performed for the clinic staff 6 weeks after implementation. Attending anaesthesiologist for the case had final say on the medications to be administered to the patients. Statistical analyses with Wilcoxon ranksum, Fisher’s exact, and unpaired t test were used for comparisons. Results: All 272 patients on our ESRP pathway had order set completion at the time of arrival to the surgical holding area for preventive analgesia and DVT prophylaxis. The rate of administration of each of the pre-medications found in the order set were as follows: heparin 262 (96.3%), celecoxib 251 (92.3%), pregabalin 254 (93.4%), and tramadol 257 (94.5%), respectively. The reasons for failure to achieve full compliance in these were: contraindications or allergic reactions. Conclusion: Development of a specific order set in ESRP gynaecologic surgery programme demonstrated excellent compliance with order completion. However, as with any new process change, audits of process flow can identify areas for improvement. Disclosure of interest: None declared. P031. THE INTERDEPARTMENTAL SPREAD OF ENHANCED RECOVERY AFTER SURGERY PROGRAMMES: A MULTICENTRE OBSERVATIONAL STUDY M. Maessen 1, 3, Brigitte F. Slangen 2, Trudy van Jeanny J. De Groot 1, 2, *, Jose der Weijden 1. 1 Department of Family Medicine, Maastricht University, Netherlands; 2 Department of Obstetrics and Gynaecology, Netherlands; 3 Department of Quality and Safety, Maastricht University Medical Center, Maastricht, Netherlands Objectives: Generalisability of enhanced recovery after surgery (ERAS) programmes has been widely demonstrated. Spread of ERAS from colorectal surgery towards other intra-organisational settings could be expected, particularly after running a quality improvement collaborative (QIC). To examine the influence of QICs on interdepartmental spread, we examined spread of ERAS from colorectal towards gynaecologic surgery. Methods: A retrospective observational multicentre study was performed in 23 Dutch hospitals. Data of a consecutive sample of gynaecologic oncology patients who underwent open surgery in 2012-2013 were collected per hospital. Hospitals of which colorectal surgical teams
participated in a breakthrough project were included in the intervention group (n¼10). The hospitals that did not have followed this project acted as controls (n¼13). The breakthrough project was a multidisciplinary programme to implement ERAS in colorectal surgery and was launched in the Netherlands in 2006. Multilevel mixed methods were used for analysis of length of recovery (LOR) and total length of postoperative hospital stay (TLOS). Models were adjusted for clustering and baseline demographics. The uptake of selected ERAS items was evaluated at hospital level. Results: A total of 684 records were audited. Multilevel modeling showed a standardised mean difference of 0.3 days (95% CI -1.3 to 0.8) in LOR and -0.2 days (95% CI -1.3 to 0.8) in TLOS between the control and intervention group. Model estimated marginal means are presented in table 1. Postoperative items were barely adopted in both study groups. The percentage of hospitals that implemented at least half of the items in daily practice was similar between the intervention and control group (10% vs. 23%, p¼0.604).
Table 1 Model estimated marginal means and 95% CI in days
LOR TLOS
Control group
Intervention group
P value
4.2 [3.4-5.0] 5.8 [4.4-7.2]
3.9 [3.1-4.8] 6.1 [4.6-7.5]
0.319 0.254
Conclusion: This study found no significant differences in perioperative care and outcomes between gynaecology departments of hospitals that previously followed a quality improvement project for colorectal surgery and the hospitals that did not. The benefits of implementation of ERAS seem to be restricted to the department level. Disclosure of interest: None declared. P032. IS RESTRICTIVE FLUID THERAPY IN COLORECTAL SURGERY RELATED TO TISSUE HYPOPERFUSION? Jesús Carazo*, Adela Benítez-Cano, Juan Fern andez, Esther Vila, Lluís Aguilera, Marc Sadurní. Anaesthesiology, Parc De Salut Mar, Barcelona, Spain Objectives: Optimal perioperative fluid management in colorectal surgery within an ERAS programme remains controversial. Intraoperative goal directed fluid strategies have not been shown to be superior to restrictive therapies. The goal of this study is to determine if our restrictive fluid therapy regime contributes to hypoperfusion. Methods: Observational, prospective study in 40 consecutive patients scheduled to colorectal resection. A intravenous balanced solution (Plasmalyte®) was used as the election fluid. Intraoperative fluid therapy regime was 1 ml$kg-1$h-1 in laparoscopic surgery and 2 ml$kg-1$h-1 in open surgery with the addition of fluids to compensate urinary output and blood loss. In case of preoperative mechanical bowel preparation 500 ml of Plasmalyte® was administered before induction. Intraoperative hypotension (
