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Enhanced recovery after minimally invasive gynecologic oncology surgery to improve same day discharge: a quality improvement project
  1. Soyoun Rachel Kim1,2,
  2. Stephane Laframboise1,2,
  3. Gregg Nelson3,
  4. Stuart A McCluskey4,
  5. Lisa Avery5,
  6. Nastasia Kujbid1,
  7. Aysha Zia1,
  8. Elisabeth Spenard1,2,
  9. Marcus Q Bernardini1,2,
  10. Sarah Elizabeth Ferguson1,2,
  11. Taymaa May1,2,
  12. Liat Hogen1,2,
  13. Paulina Cybulska1,2,
  14. Edyta Marcon6 and
  15. Geneviève Bouchard-Fortier1,2
  1. 1Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Sinai Health Systems, Toronto, Ontario, Canada
  2. 2Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
  3. 3Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
  4. 4Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
  5. 5Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Ontario, Canada
  6. 6Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Geneviève Bouchard-Fortier, Princess Margaret Cancer Centre 610 University Avenue, Toronto, Ontario, Canada; genevieve.bouchard-fortier{at}uhn.ca

Abstract

Objectives Same day discharge after minimally invasive hysterectomy has been shown to be safe and feasible. We designed and implemented a quality improvement perioperative program based on early recovery after surgery principles to improve the rate of same day discharge from 30% to 75% after minimally invasive gynecologic oncology surgery over a 12 month period.

Methods We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12 month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison of clinicodemographic variables and perioperative outcomes. A multidisciplinary team developed a comprehensive perioperative care program and followed quality improvement methodology. Patients were followed up for 30 days after discharge. A statistical process chart was used to monitor the effects of our interventions, and a multivariate analysis was conducted to determine factors associated with same day discharge.

Results Same day discharge rate increased from 29% to 75% after implementation (p<0.001). The post-intervention cohort was significantly younger (59 vs 62 years; p=0.038) and had shorter operative times (180 vs 211 min; p<0.001) but the two groups were similar in body mass index, comorbidity, stage, and intraoperative complications. There was no difference in 30 day perioperative complications, readmissions, reoperations, emergency department visits, or mortality. Overnight admissions were secondary to nausea and vomiting (16%), complications of pre-existing comorbidities (12%), and urinary retention (8%). On multivariate analysis, longer surgery, timing of surgery, and narcotic use on the ward were significantly associated with overnight admission. Overall, 89% of patients rated their experience as ‘very good’ or ‘excellent’, and 87% felt that their length of stay was adequate.

Conclusions Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, our intervention significantly improved same day discharge rates while maintaining a low 30 day perioperative complication rate and excellent patient experience.

  • gynecologic surgical procedures
  • postoperative care
  • postoperative period
  • surgery

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Footnotes

  • Twitter @GreggNelsonERAS

  • Contributors SRK: guarantor, data curation, formal analysis, project administration, visualization, writing—original draft, writing—review, and editing. SL: conceptualization, funding acquisition, project administration, data curation, investigation, methodology, writing—review, and editing. GN: investigation, writing—review, and editing. SAM: investigation, writing—review, and editing. LA: formal analysis, and visualization. NK: investigation, data curation, writing—review, and editing. AZ: investigation, data curation, resources, writing—review, and editing. ES: visualization. MQB: resources, writing—review, and editing. SEF: resources, writing—review, and editing. TM: resources, writing—review, and editing. LH: resources, writing—review, and editing. PC: resources, writing—review, and editing. EM: supervision. GBF: guarantor, conceptualization, formal analysis, funding acquisition, project administration, investigation, methodology, supervision, writing—review, and editing.

  • Funding The project was supported by the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centers of Ontario (MSU 19-019); the funding source had no involvement in the conduct of the research, study design, or preparation of this article.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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