Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY): a national quality improvement project using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

Abstract

Background: To date, there have been no large-scale enhanced recovery projects in bariatric surgery in the United States.

Objective: The aim of this project was to implement an enhanced recovery protocol for selected Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program centers and determine its impact on length of stay, bleeding, readmissions, and reoperation rates.

Setting: University and private practice programs, United States.

Methods: Participating sites were identified based on historical extended length of stay (ELOS, ≥4 d). A 6-month run-up period was used to allow implementation of the protocol. Primary bariatric procedures were included in the analysis, which compared ELOS from historic data (2016) with outcomes during the Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY) project. Relationships between adherence to the 26 process measures and ELOS were analyzed. Specific adverse 30-day outcomes were monitored.

Results: Thirty-six centers participated in the project. The final analytic sample consisted of 18,048 cases total over a 24-month period, including 8946 from the 2016 calendar year and 9102 from the ENERGY period. The overall rates of ELOS for pre- and postintervention were 8.1% and 4.5%, respectively, without increasing readmission rates, reoperation rates, or overall morbidity. Bleeding rates increased from .8% preintervention to 1.1% during ENERGY (adjusted P = .06). There was a significant association between increased adherence score and decreased odds of ELOS (P < .01).

Conclusion: Implementation of a large-scale enhanced recovery project is feasible and results in decreased ELOS without increasing overall adverse events or readmissions. Increased adherence to the protocol was closely associated with decreased ELOS. The ENERGY protocol or similar enhanced recovery pathways should be implemented on a larger scale to further improve the care and outcomes of bariatric surgery patients.

Keywords: Bariatric; Complications; ERAS; Enhanced recovery after surgery; Fast track; Length of stay; Outcomes; Quality; Surgery.