Efficacy of Electronic Reminders In Increasing ERAS Protocol Utilization During Major Breast Surgery (Preprint)

Abstract

Enhanced recovery after surgery (ERAS) protocols are patient centered, evidence-based guidelines for peri, intra, and post operative management of surgical candidates that aim to decrease operative complications and facilitate recovery after surgery. Anesthesia providers can utilize these protocols to guide decision making and standardize aspects of their anesthetic plan in the operating room.

Research across multiple disciplines has demonstrated that clinical decision support systems (CDSS) have the potential to improve protocol adherence by reminding providers about departmental policies and protocols via notifications. There remains a gap in literature about whether CDSS can improve patient outcomes by improving anesthesia providers adherence to protocols. Our hypothesis is that implementation of an electronic notification system to anesthesia providers the day prior to scheduled breast surgeries will increase the use of the already existing but under-utilized ERAS protocols.

This was a single-center prospective cohort study conducted between October 2017 – August 2018 at an urban academic medical center. After obtaining Institutional Review Board approval, anesthesia providers assigned to major breast surgery cases were identified. Patient data were collected pre- and post-implementation of an electronic notification system that sent the anesthesia providers an email reminder of the ERAS breast protocol the night before scheduled surgeries. Each patient’s record was then reviewed to assess the frequency of adherence to the various ERAS protocol elements.

Implementation of an electronic notification significantly improved overall protocol adherence and several pre-operative markers of ERAS protocol adherence. Protocol adherence increased from 16.5% to 44.4% (p < 0.001), pre-operative administration of gabapentin (600 mg PO) increased from 12.9% to 43.4% (p < 0.001), Celebrex (400 mg PO) utilization increased from 16.5% to 35.4% (p = 0.006). There were no statistically significant differences in utilization of scopolamine transdermal patch (p=0.052), ketamine (p = 0.345), and oral acetaminophen (p = 0.306) between the groups. Secondary outcomes such as intraoperative and postoperative morphine equivalent administered, PACU length of stay, postoperative pain scores, and incidence of postoperative nausea and vomiting did not show statistical significance.

This study examines whether sending automated notifications to anesthesia providers increases the utilization of ERAS protocols in a single academic medical center. Despite the lack of a statistically significant difference in secondary post-operative outcomes, our analysis contributes to the limited literature on the relationship of using push notifications and clinical decision support on perioperative decision making. A variety of techniques can be implemented, including technological solutions such as automated notifications to providers, to improve awareness and adherence of ERAS protocols.