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Quality Improvement/Clinical Outcomes

E396: Designing a System-wide Enhanced Recovery Protocol for Liver Resections across a Large Health System

ePoster Abstract Author(s)

Manav Shah, BS (he/him/his)

Medical Student
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, United States

Submitter(s)

Manav Shah, BS (he/him/his)

Medical Student
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, United States

Author(s)

Manav Shah, BS (he/him/his)

Medical Student
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, United States
NA

Neda Amini, MD

Fellow
Zucker School of Medicine at Hofstra/Northwell Depratment of Surgical Oncology, United States
SA

Sandeep Anantha, MD

Director, Surgical Oncology
Division of Surgical Oncology, Department of Surgery, Northwell Health, United States
BA

Basem Azab, MD

Director, Surgical Oncology
Division of Surgical Oncology, Department of Surgery, Northwell Health, United States
GC

Gene Coppa, MD

Med School Chair Surgery
Department of Surgery, Northwell Health, United States
ND

Nabil Dagher, MD

Vice President, Transplant Center
Transplant Institute, Northwell Health, United States
Danielle DePeralta, MD

Attending physician
Northwell Health, New York, United States
GD

Gary Deutsch, MD

Attending Physician
Northwell Health, United States
SG

Sepideh Gholami, MD

Attending physician
Northwell Health, United States
EG

Elliot Grodstein, MD

Fellowship Training Director, Surgery
Transplant Surgery, Northwell Health, United States
MK

Michael Kuncewitch, MD

Director, Surgical Oncology
Division of Surgical Oncology, Department of Surgery, Northwell Health, United States
LL

Lawrence Lau, MD

Attending Physician
Transplant Surgery, Northwell Health, United States
MM

Marcovalerio Melis, MD

Professor
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, United States
EN

Elliot Newman, MD

Chief of Surgical Oncology
Northwell Health, Lenox Hill, United States
RN

Richard Newman, MD

Attending Physician
Department of Surgery, Northwell Health, United States
GV

Gerardo Vitiello, MD

Attending Physician
Department of Surgery, Northwell Health, United States
JW

John Wang, MD

Attending Physician
Division of Surgical Oncology, Department of Surgery, Northwell Health, United States
AW

Aaron Winnick, MD

Attending Physician
Transplant Surgery, Northwell Health, United States
RZ

Raza Zaidi, MD

Attending Physician
Division of Surgical Oncology, Department of Surgery, Northwell Health, United States
Matthew Weiss, MD (he/him/his)

Attending physician
Northwell Health, United States

Introduction: Standardizing perioperative surgical care with an enhanced recovery protocol (ERP) eliminates the variability in patient care that currently exists in large health systems, improving both quality and patient outcomes. Here, we present an ERP for liver surgery based upon the latest guidelines for the largest health system in New York, the first of its kind to exist across an expansive health system.

Methods: We conducted a targeted search of PubMed/MEDLINE, Web of Science, and Google Scholar for literature on the perioperative care of patients undergoing liver surgery. Recommendations from the 2022 Enhanced Recovery After Surgery (ERAS) Society guidelines for liver surgery were incorporated into our pathway when in concordance with the literature and when compatible with our health system’s resources/policies. The protocol was discussed in a meeting with all liver surgeons, both from the surgical oncology and transplant groups. Each item was discussed separately. If there was no agreement on any item amongst the surgeons, it was removed from the pathway.

Results: Liver resections were separated into three categories: major open, minor open, and minimally invasive (laparoscopic or robotic). The target discharge time was 4-7 days for a major open liver resection, 2-5 days for a minor open procedure, and 1-4 days for a minimally invasive surgery. The ERP was defined from the day before surgery to postoperative day 5. Elements of the ERP were organized into the following categories: diet, fluids, pain, supplemental medications, activity, labs, phosphate repletion, and device and procedures. Key modifications derived from the latest recommendations included the addition of a carbohydrate loading dose the evening before and 2-4 hours before surgery, the removal of preoperative nonsteroidal anti-inflammatory drugs, an earlier transition to oral pain medications for minor open and minimally invasive procedures, administration of a single preoperative dose of steroids, and maintenance of postoperative glycemic control. The finalized liver ERP is shown here (Figure 1). Consensus was reached amongst 19 liver surgeons spanning across six tertiary sites in our health system, establishing a protocol for system-wide implementation.

Conclusions: Given the size of our health system, there is currently variability in patient care during the perioperative period for liver surgery across sites. Through this quality improvement initiative, we designed a novel liver ERP specifically to be used across a large health system that aims to optimize patient outcomes, redefining the scope of standardized care.

Learning Objectives:

Upon completion, participants will be able to describe the utility of performing a literature search to create up-to-date protocols for surgical care.
Upon completion, participants will be able to define the various factors that must be accounted for when designing a pathway to standardize surgical care.
Upon completion, participants will be able to recognize the importance of standardizing surgical care to eliminate variability that may exist within a health system.