Objective: We sought to evaluate how implementing a thoracic Enhanced Recovery After Surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. Summary Background Data: The effect of implementing the ERAS Society/European Society of Thoracic Surgery (ESTS) thoracic ERAS protocol on postoperative outcomes throughout an entire healthcare system has not yet been reported. Methods: This was a prospective cohort study within one healthcare system (1/2019-3/2023). A thoracic ERAS protocol was implemented on 5/1/2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay (LOS), opioid use, chest tube duration, and total cost. Patients were grouped into pre- and post-ERAS cohorts. Bivariable comparisons were performed using independent t-test, chi-square, or Fisher’s exact tests, and multivariable logistic regression was performed to control for confounders. Results: There were 1,007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a BMI between 18.5-29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the post-implementation group had lower risk-adjusted rates of any morbidity, any respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative LOS (all P <0.05). Conclusions: Postoperative outcomes were improved after implementation of an evidence-based thoracic ERAS protocol throughout the healthcare system. This study validates the ERAS Society/ESTS guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.

Introduction: Compliance with thoracic Enhanced Recovery After Surgery (ERAS) protocols is critical to achieving their maximum benefits. We sought to examine utilization of quality review meetings as a method to improve protocol compliance through identification and resolution of barriers with compliance.Methods: A multidisciplinary committee implemented a thoracic ERAS protocol for anatomic lung resections across five hospitals within our health system. Compliance data at one institution were tracked for 4 mo after initiation of the ERAS protocol; a quality review meeting was held at one hospital, and two additional months of compliance data were recorded. Outcomes of interest were compliance changes to five protocol elements. Pathway elements deferred due to "mindful deviation" were excluded. Chi-square and Fisher's exact tests were used to compare compliance differences.Results: We included 81 patients: 53 patients before the quality review meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall compliance improved from 53% before to 84% after the quality review meeting. Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in postanesthesia care unit, liberal chest tube removal, and postoperative multimodal pain regimen use improved after the quality review meeting (P values <0.05). Use of preoperative pain bundles was not significantly different (87% versus 96%, P = 0.25).Conclusions: Conducting a quality review meeting significantly improved ERAS protocol element use at our intervention healthcare region. This methodology should be considered at other institutions implementing surgical protocols.(c) 2023 Elsevier Inc. All rights reserved.

Background:The impact of post-surgical same day ambulation in lung resection patients is relatively unstudied. We sought to determine the relationship between day of surgery ambulation and postoperative outcomes after lung resection. Methods:This was a prospective cohort study at one healthcare system with six hospitals (1/2019-3/2023). Patients undergoing segmentectomy and lobectomy were targeted for inclusion. Patients who had missing ambulation data were excluded. Patients were divided into two cohorts based on whether or not they ambulated postoperatively on the day of surgery. Postoperative outcomes were compared using chi-square, Fisher's exact, or Mann-Whitney-U tests. Multivariable logistic regression controlling for pertinent perioperative confounders was performed to identify the independent effect of ambulation on complication rates. Results:Of 1,056 patients included in the analytic cohort, 443 patients (42.0%) ambulated postoperatively on the day of surgery. Patients who ambulated day of surgery had significantly lower rates of morbidity, including respiratory complications, surgical site infection, bleeding, cardiac complications, cardiac arrhythmias, infectious complications, and opioid use, and had shorter length of stay, shorter chest tube duration, and lower total hospital cost. After risk-adjustment, patients who ambulated day of surgery had lower odds of overall morbidity, less opioid consumption, shorter length of stay, and shorter chest tube duration. Conclusions:Patients who ambulated postoperatively on the day of surgery had better surgical recovery and outcomes after lung resection than those who did not. Day of surgery ambulation is an excellent quality metric and associated with avoidance of postoperative complications.

Background: Benefits of thoracic enhanced recovery after surgery programs have been described. However, there is ongoing discussion on the importance of full protocol compliance. The objective of this study was to determine whether strict adherence to an enhanced recovery after surgery protocol leads to further improvement in outcomes compared with less strict compliance. Methods: This was a multihospital prospective cohort study of all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023, with comparison with a historical control from January 2019 to April 2021. Compliance to 5 key protocol elements was tracked. Patients were grouped into high- and low-compliance cohorts, defined as adherence to 4-5/5 or 0-3/5 elements, respectively. The primary outcome was overall morbidity; secondary outcomes included cardiac, respiratory, and infectious morbidity and length of stay. Results: Of the 960 patients, 429 (4 4.7%) were enhanced recovery after surgery patients and 531 (55.3%) were in the historical control group. Across all patients, 250 (26.0%) were considered high compliance and 710 (74.0%) were considered low compliance. After adjustment for enhanced recovery after surgery status and confounders, the association between high compliance and improved outcomes persisted for all but infectious morbidity. Compared with low compliance, high compliance was associated with decreased odds of any morbidity (0.41 [95% CI, 0.22-0.77]), cardiac morbidity (0.31 [0.11-0.91]), respiratory morbidity (0.46 [0.23-0.90]) and decreased length of stay (0.38 [0.18-0.87]). Conclusion: Enhanced recovery after surgery protocols improve outcomes after anatomic lung resection. Increasing compliance to individual elements (>80%) further improves patient outcomes. Continued efforts should be directed at increasing compliance to individual protocol elements. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

INTRODUCTION: Benefits of thoracic Enhanced Recovery After Surgery (ERAS) programs have been well described in the literature. After implementing a thoracic ERAS program, we sought to determine if compliance review during quality improvement meetings improved protocol adherence. METHODS: A multidisciplinary committee developed and implemented a thoracic ERAS protocol for anatomic lung resections across 6 hospitals within our health system. Adherence data was tracked for 3 months after initiation of the ERAS protocol, a quality review committee meeting was held to review compliance barriers, and 2 additional months of compliance data were recorded. We examined compliance changes to 5 key protocol elements. Pathway elements deferred due to mindful deviation were excluded. Chi-square and Fisher’s exact tests were used to compare categorical data where appropriate. RESULTS: We included 81 patients, 53 patients before the quality review committee meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall adherence improved after the quality review committee meeting (Table; 53% vs 84%, p < 0.001). Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in post-anesthesia recovery unit, early chest tube removal, and postoperative multimodal pain regimen use improved after the quality review committee meeting (all p < 0.05). Use of preoperative pain bundles improved, but this did not reach statistical significance (87% vs 96%, p = 0.25). CONCLUSION: Conducting a thoracic ERAS quality review meeting to identify compliance barriers significantly improved protocol adherence. This experience can be extrapolated to other institutions implementing ERAS protocols. Table. - Adherence to Targeted Enhanced Recovery After Surgery (ERAS) Elements Before and after the First Quality Review Committee Meeting Adherence item Pre-meeting cohort adherence Post-meeting cohort adherence p Value Preoperative pain bundle given 45/52 (87%) 26/27 (96%) 0.25 Intraoperative indwelling urinary catheter avoided 5/33 (15%) 22/27 (81%) <0.001 Chest tube placed to water seal in PACU 4/29 (14%) 9/16 (56%) 0.005 Early chest tube removal 21/52 (40%) 15/21 (71%) 0.02 Use of opioid sparing multimodal pain regimen 39/52 (75%) 28/28 (100%) 0.002 Overall 114/218 (53%) 100/119 (84%) <0.001