The implementation of an enhanced recovery pathway (an “Optimized Surgical Journey”) for patients undergoing cystectomy at MD Anderson Cancer Center resulted in improved outcomes and significant cost reductions. We believe that the application of OSJ principles to other surgical procedures could yield similar benefits.
Postoperative complications in a high-risk, elderly population can be reduced by integrating evidence-based interventions into a perioperative pathway.
A multidisciplinary, team-based approach with free communication between providers is required for successful OSJ implementation.
Consistency of personnel improves adherence to the OSJ.
Knowledge of clinical outcomes was essential in order to effectively administer the OSJ program.
In 2014, at MD Anderson Cancer Center, we implemented an Enhanced Recovery After Surgery (ERAS) program for the specific purpose of hastening patients’ return to baseline functional status following cystectomy. This program, subsequently renamed the Optimized Surgical Journey (OSJ), has reduced the rate of common postoperative complications, shortened the average length of stay, and lowered costs related to the cycle of care.
Patients who have been diagnosed with muscle-invasive bladder cancer typically are managed with cystectomy, surgical removal of the bladder, pelvic lymph node dissection, and the creation of a urinary diversion to allow urine to leave the body, usually via a segment of bowel. Complication and mortality rates following cystectomy have remained high over the past 30 years, with the rate of postoperative complications estimated to be between 60% and 70% and the incidence of 90-day mortality commonly accepted to be around 10%.
Patients have a very difficult time recovering from cystectomy, often requiring prolonged hospitalization after surgery. The most common reasons for a prolonged length of stay include delayed return of bowel function, difficulty with pain management, and procedure-related complications such as infections or blood clots. To complicate matters, care delivery mechanisms across providers frequently are inconsistent, with each surgeon having his or her own preferences with regard to perioperative medication and procedure regimens. In addition, although patients who have undergone cystectomy typically recover on specific hospital floors, the nurses who treat them may float through different units, and surgical teams (including anesthesiologists and nurse anesthetists) may vary significantly.
Our goals were (1) to create a multidisciplinary team for the purposes of reducing postoperative complications and minimizing the functional impact for patients with invasive bladder cancer through the development, implementation, and evaluation of the OSJ program and (2) to measure the impact of the OSJ pathway on costs of care.
The OSJ was created to standardize the clinical care pathway for patients undergoing cystectomy, from the first preoperative clinic visit through the 90-day follow-up visit. The initial pilot test of the OSJ involved patients who were under the care of a single attending physician. On the basis of the initial positive results, it was subsequently adopted for all patients undergoing cystectomy.
- Preoperative Visit: During the preoperative clinic visit, patients are given an expected timeline and are asked to complete a survey to elicit their baseline functional status. Next, they meet with a nurse specializing in urinary diversions for counseling. Elderly patients receive a comprehensive geriatric assessment to optimize medications and to assess frailty.
- Day Before Surgery: Patients are no longer told to fast on the day before surgery, and bowel preps have been eliminated. All patients are encouraged to eat carbohydrate-rich meals on the day before surgery. Patients are encouraged to drink high-carbohydrate clear fluids until 2 hours before surgery.
- Day of Surgery: On the day of surgery, all patients receive a preoperative cocktail of tramadol and 3 oral non-narcotic pain medications, each with a distinct mechanism of action to initiate the multimodal pain management protocol. Both medications and physical mechanisms are implemented to reduce the risk of blood clots.
- During Surgery: Intraoperative anesthetic medications are standardized, with an emphasis on opioid restriction. The criteria for fluid administration and blood transfusions were developed collaboratively between the anesthesia and surgery teams.
- Immediately After Surgery: Postoperative pain medications and fluid rates are standardized, as is diet progression. In the hours immediately following surgery, patients are expected to transfer from the bed to a separate chair and are given clear liquids to drink. Non-opioid pain medications are emphasized. Patients with excessive comorbidities or intraoperative complications are managed individually, but the treatment adheres to the standardized pathway to the extent possible.
- Day After Surgery: On the day after surgery, clear fluids are provided for breakfast, and solids are given for lunch. Patients remain on an opioid-restrictive pain regimen. Pain is assessed regularly to ensure comfort, and patients are expected to spend 6 to 8 hours of the day in a chair and to walk the halls of the hospital at least 4 times. Social workers and ostomy nurses begin counseling and early discharge planning.
- Early Discharge Planning: Discharge criteria are preset, and all patients receive a discharge information sheet that includes phone numbers for team members who will be available 24/7, as well as emergency contact information. Communication with post-discharge facilities and primary care physicians is accomplished by means of a standard discharge communication template.
- Follow-up After Discharge: Postoperative visits at 1 and 3 months after discharge follow standardized processes and procedures. The functional status at each visit is compared with the baseline status.
The team originally included surgeons, anesthesiologists, clinic nurses, physician assistants, nurse practitioners, inpatient nurses, physical therapists, social workers, and ostomy nurses. This team was instrumental in overcoming the obstacles of implementing a broad recovery program.
Over the past 3 years, the team has expanded to include more supporting roles, such as a cystectomy-specific nurse practitioner. The team leader — and program champion — was a cystectomy surgeon who first implemented the OSJ for his own patients and then presented the data to other cystectomy surgeons at the institution. On the basis of these data, the team leader was able to persuade other surgeons to implement the OSJ pathway for their own patients. In addition, the OSJ team was supported by the departmental leadership, which was a key factor in achieving department-wide implementation.
During the first 3 years, approximately 100 patients were enrolled in the OSJ program. The incidence of gastrointestinal complications decreased by 59%, the time to tolerating a regular diet decreased from 6.6 to 3.2 days, the average length of stay decreased from 8 to 5 days, and the average cost per patient over the 90-day cycle of care decreased by $14,656. The total cost savings for this program are estimated to be just under $1.5 million thus far. There was no change in the rate of readmissions, so readmission costs were not incorporated into the final costs. Given the success of this pathway, we plan to expand this program to other procedures, as well as to other centers within in our own institution.
The implementation of a comprehensive, multimodal enhanced recovery pathway can substantially improve outcomes and lower the costs of care in a high-risk, elderly population. However, the implementation of such a program represents a difficult change in the care pathway. For example, nurses may question why procedures and conventions are changing, and other surgeons may not believe that the pathway will be successful. Therefore, the importance of multidisciplinary buy-in and teamwork cannot be overemphasized, and a team leader to champion the program is critically important.
While obstacles remain, future work will continue to improve the impact of the OSJ. The next steps will be to focus on ensuring that our methods and results are reproducible in other environments and on piloting new preoperative programs to reduce postoperative complications.
First, we plan to partner with external institutions to implement the OSJ in their clinical practices, measure outcomes, and share lessons learned. To that end, we plan to move forward with a multicenter study to determine the external validity of the OSJ pathway.
Second, we plan to expand the reach of the perioperative pathway in advance of surgery in order to minimize medical comorbidities and optimize physical fitness prior to surgery.
On the basis of our experience, we believe that the application of OSJ principles to other surgical procedures could yield similar benefits in terms of improved patient outcomes and significant cost reductions.