Clinical Impact of an Enhanced Recovery Program for Lower Extremity Bypass

Abstract

Objective: To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower extremity bypass (LEB). Background: ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown. Methods: Patients undergoing LEB who received or did not receive care under the ERP were included: pre-ERP (1/1/2016–05/13/2018) and ERP (05/14/2018–7/31/2022). Clinicopathologic characteristics and perioperative outcomes were analyzed. Results: Of 393 patients who underwent LEB (pre-ERP, n=161 (41%); ERP, n=232 (59%)), most were male (n=254, 64.6%), white (n=236, 60%), and government-insured (n=265, 67.4%). Pre-ERP patients had higher BMI (28.8±6.0 vs. 27.4±5.7, P=0.03) and rates of diabetes (52% vs. 36%, P=0.002). ERP patients had shorter total (6 (3-13) vs. 7 (5-14) days, P=0.01) and postoperative LOS (5 (3-8) vs. 6 (4-8) days, P<0.001). Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs. 5 d, P=0.01), rest pain (5 vs. 6 d, P=0.02) and tissue loss (6 vs. 7 d, P=0.03). ERP patients with rest pain also had a shorter total LOS (6 vs. 7 d, P=0.04) and lower 30-day readmission rates (32% to 17%, P=0.02). After ERP implementation, the average daily oral morphine equivalents (OMEs) decreased (median (IQR) 52.5 (26.6-105.0) vs. 44.12 (22.2-74.4), P=0.019), while the rates of direct discharge to home increased (83% vs. 69%, P=0.002). Conclusions: This is the largest single center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes.