Implementation of enhanced recovery pathway for lower extremity arterial bypass decreases length of stay.

Abstract

Frailty, nutrition, and comorbid conditions are all challenges that contribute to significant morbidity in patients undergoing lower extremity arterial bypass (LEAB). Evidence supports that enhanced recovery pathways (erps) can improve perioperative outcomes. However, few studies have demonstrated successful implementation of an ERP for LEAB. The goal of this study was to demonstrate the successful implementation of an ERP in a complex patient population undergoing LEAB, including elective, urgent, or emergent procedures with the goal of decreasing length of stay (LOS) and morbidity for patients undergoing these procedures at our institution. Multistakeholder meetings with representatives from all vascular surgery practice sites in the Northwestern Medicine system were conducted to review current evidence-based practices and finalize an ERP for patients undergoing LEAB. Pathway elements included standardized patient education, minimal perioperative fasting with preoperative carbohydrate loading, opioid-sparing analgesia, and early postoperative diet and mobilization. The ERP was initiated in February 2022 as a pilot at a single institution. At 20 months, patient data and process and outcome measures were abstracted from the medical record and validated by four independent reviewers for univariate analysis. Over the 20-month study period, 112 patients underwent LEAB. Process measures were tracked to determine compliance with the ERP. Patients had to receive >70% of the pathway elements to be considered part of the ERP (n = 60). If patients missed >30% of the elements, they were analyzed as traditional pathway (n = 52). There were no significant differences in patient demographics, body mass index, or hemoglobin a1c. ERP patients were more likely to be elective (76.7% vs 48.1%; P = .0004) and for chronic limb-threatening ischemia (76.7% vs 48.1%; P = .001) and less likely to be urgent or emergent. No significant difference was observed in frequency of infrageniculate bypass target or operative duration. Compliance with 10 perioperative process measures ranged from 28% to 98% in the ERP group. Compliance was most successful with preoperative education (81.6%), chlorhexidine wash (80.0%), postoperative mobilization (90.0%), early solid diet (98.3%), and postoperative opioid sparing strategies (98.3%). Challenges included preoperative acetaminophen (28.3%), carbohydrate load (33.8%), and postoperative protein supplementation (28.3%). Notably, ERP patients demonstrated significantly reduced total LOS (7.8 days vs 13.6 days; P = .014), postoperative LOS (6.0 days vs 11.0 days; P = .0058), and unplanned reoperations (10.0% vs 28.9%; P = .015) when compared with traditional pathway patients. ERP patients trended toward fewer unplanned readmissions (13.3% vs 26.9%; P = .095). Our findings suggest that an ERP for LEAB is feasible in both elective and nonelective settings, although compliance with the ERP individual elements was more challenging for patients undergoing procedures for emergent or urgent indications. Patients undergoing ERP had improved compliance with process measures, reduced LOS, and fewer unplanned reoperations. Our results highlight the benefits of ERP for LEAB and the complex vascular surgery population and some of the potential barriers worth considering in this patient population.