Implementation of Enhanced Recovery Protocol in Spain

Study Overview
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Brief Summary
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The main objective is the multicenter and uniform implementation of a agreed upon perioperative evidence based program emanated from the Enhanced Recovery for abdominal surgery pathway (RICA) published by the Spanish National Health Service and the Aragon Institute of Health, in hospitals of the National Health Network. The evaluation and outcomes of such implementation is proposed as a secondary objective. Different established indicator will compared traditional care results with those from the new program in the short and medium term. 10 interested hospital centers are selected. In each of them a retrospective study will be conducted to analyze the clinical results obtained in abdominal surgery in the past six months. After making the necessary training to clinical teams and assure the project development and implementation in each center, a prospective study in which all patients in the program are being recruited will be held. Hospital stay as well as perioperative mortality and morbidity will be collected. We will analyze data from: days of hospital stay (potential and actual), efficiency (cost/procedure), quality of care, time to complete reintegration into family, social and labor environment and quality of life.

Detailed Description
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A uniform, consensual and multicentric implementation of the multidisciplinary Perioperative Medicine Program is proposed, the program comes form the Clinical Pathway of Intensified Recovery in Abdominal Surgery -RICA-, published by the Spanish National Health System as clinical guideline. It covers the perioperative area in complex abdominal surgery and extends from the moment of diagnosis in the Surgery office until the last revision performed one year after surgery. It is proposed as a double study; a first retrospective analysis of the results and perioperative complications referred and available in the Centers involved in the study; and a second analysis of results after the implementation of the Program, in the same Centers. Once both are finished, the comparison between them and their communication will be carried out using the appropriate reports. Actors: Multidisciplinary teams made up of nurses, surgeons, anesthesiologists, nutritionists / endocrinologists, physiotherapists and rehabilitators. Patients: All patients recruited in the different hospitals for the RICA Perioperative Medicine Program susceptible to performing complex abdominal surgery. Variables under study: Perioperative complications according to the Clavien-Dindo classification and the European Perioperative Clinical Outcome definitions (EPCO); Times of global hospital stay and in critical care units; the rate of readmissions and the complications derived from them, the rate of surgical reoperations, the analysis of cost per process (including the total cost in the study period-two years-), the time until complete reincorporation into the family environment and socio-labor, the indices of quality perceived by the patient and / or their caregivers, the final quality of life index obtained by each patient (resulting quality of life). Data collection and analysis: Record of described variables were be included in an on linedatabase available to all centers. Limitations of the Study: impossibility to include all the patients that can be recruited in surgery consultations due to rejection of the staff (negative to the benchmarking and / or to the program) or negative of the patient. Loss of data in follow-up due to the failure of patients. Difficulty in analyzing costs due to lack of economic data in the Centers. Lack of motivation in the multidisciplinary teams. Rupture of the program in case of emergency / emergency. Material and Methodology: Participating Centers: Previously selected for their well-known Organizational capacity and their experience and interest. First Phase: Realization of retrospective study of existing results in each Center in the six months prior to the implementation of the Program and Conformation of the multidisciplinary teams that will implement the Intensified Recovery Program. Second phase: Training of the Teams in IACS (Instituto Aragones Ciencias de la Salud) on the implementation of enhanced recovery programs provided with online training through platform built ad hoc and in person for training with experts. Development of the Normalized Work Protocol (NTP) in each assigned Center and implementation of the forms and database in the Clinical History of the Centers (considering electronic Clinical History). Third phase: Progressive recruitment of patients and inclusion in the Program (on-line database) and start of the one-year prospective study from the patient's inclusion. Inclusion Criteria: -Patients over 18 years old, scheduled for major abdominal surgical surgery, due to malignant or benign causes. (It is defined as complex major surgery that lasts more than two hours, it is estimated that it may require the transfusion of at least 2 red cell concentrates or it is estimated a loss greater than or equal to 15% of the patient's blood volumen).

Official Title
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Implementation of the Enhanced Recovery in Abdominal Surgery Pathway in the National Health Network (IMPRICA Project)

Conditions
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Major Surgery

Intervention / Treatment
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* Procedure: ERAS program


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: • Patients over 18 years old, scheduled for major abdominal surgical surgery, due to malignant or benign causes. Exclusion Criteria: Urgent Surgery. Patients ASA (American Society of Anesthesiology) IV or higher.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Traditional care<br>Patients with major abdominal surgery without before a enhanced recovery program was stablished | |
| ERAS care<br>Patients with major abdominal surgery within a enhanced recovery program was stablished | Procedure: ERAS program<br>* ERAS pathway according to the Spanish Via RICA<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with postoperative complications | complications after surgery | 30 days after surgery | 
| Mortality | Number of patients dead after surgery | 3 years | 
| Long term mortality | Number of patients dead after surgery | 5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital stay | Days of stay in hospital after surgery | perioperative stay | 
| compliance of the protocol | Rate of compliance of each ERAS (Enhanced Recovery After Surgery) item | 1 month after surgery | 
| re-admission | patient needing hospital stay after being at home after primary surgery | 1 month after surgery | 
| Cost | Price of the intervention | 1 month after surgery |