Enhanced recovery after brain tumor surgery: pilot protocol implementation in a large healthcare system

Walavan Sivakumar Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
Department of Neurosurgery and Neuroscience, Saint John’s Cancer Institute, Santa Monica, California

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Jian Guan Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
Department of Neurosurgery and Neuroscience, Saint John’s Cancer Institute, Santa Monica, California

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Jean-Philippe Langevin Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and

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Garni Barkhoudarian Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
Department of Neurosurgery and Neuroscience, Saint John’s Cancer Institute, Santa Monica, California

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Daniel F. Kelly Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
Department of Neurosurgery and Neuroscience, Saint John’s Cancer Institute, Santa Monica, California

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Neil Martin Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
Department of Neurosurgery and Neuroscience, Saint John’s Cancer Institute, Santa Monica, California

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OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been used in numerous specialties to improve the safety, efficiency, and cost of surgical interventions. Despite these successes, implementation of ERAS in cranial neurosurgery remains limited. In this study, a comprehensive ERAS protocol was implemented at two pilot sites within the Providence Health & Services system, and groundwork was laid for systemwide adoption.

METHODS

An enhanced recovery protocol was developed and implemented through an interdisciplinary team of clinicians, executive leadership, and clinical informatics professionals across preoperative, intraoperative, and postoperative domains. Outcomes including length of stay, discharge destination, and cost were collected through systemwide databases and compared with nonprotocolized sites.

RESULTS

During the study period, both pilot sites became top performers across the regional system in all evaluated metrics. The median length of stay for elective craniotomy at site 1 was reduced to 1.25 days, with a home discharge rate of > 90%. The cost per case at the pilot sites was nearly $7000 less on average than that of the nonprotocolized sites.

CONCLUSIONS

Implementation of enhanced recovery protocols for brain tumor surgery is feasible and effective, resulting in marked improvements in healthcare efficiency. Future studies, including implementation of the current protocol across the entire Providence system, are needed to maximize the potential benefits of enhanced recovery programs.

ABBREVIATIONS

ERAS = enhanced recovery after surgery; ERP = enhanced recovery protocol; ICU = intensive care unit; LCM = Little Company of Mary; LOS = length of stay; SJHC = Saint John’s Health Center; VOA = Value Oriented Architecture.

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been used in numerous specialties to improve the safety, efficiency, and cost of surgical interventions. Despite these successes, implementation of ERAS in cranial neurosurgery remains limited. In this study, a comprehensive ERAS protocol was implemented at two pilot sites within the Providence Health & Services system, and groundwork was laid for systemwide adoption.

METHODS

An enhanced recovery protocol was developed and implemented through an interdisciplinary team of clinicians, executive leadership, and clinical informatics professionals across preoperative, intraoperative, and postoperative domains. Outcomes including length of stay, discharge destination, and cost were collected through systemwide databases and compared with nonprotocolized sites.

RESULTS

During the study period, both pilot sites became top performers across the regional system in all evaluated metrics. The median length of stay for elective craniotomy at site 1 was reduced to 1.25 days, with a home discharge rate of > 90%. The cost per case at the pilot sites was nearly $7000 less on average than that of the nonprotocolized sites.

CONCLUSIONS

Implementation of enhanced recovery protocols for brain tumor surgery is feasible and effective, resulting in marked improvements in healthcare efficiency. Future studies, including implementation of the current protocol across the entire Providence system, are needed to maximize the potential benefits of enhanced recovery programs.

Enhanced recovery after surgery (ERAS) protocols, first initiated as "fast-track surgery" by Professor Henrik Kehlet in the early 1990s,1 are multimodality care pathways designed to decrease the physiological stress of surgery, reduce complications, minimize postoperative debility, and accelerate recovery. These protocols, originally applied to colorectal surgery, include preoperative patient education, medical optimization, nutritional supplementation, presurgical hydration and carbohydrate loading, opioid-avoiding analgesic cocktails, minimally invasive surgical techniques, and early postoperative mobilization.2 The use of ERAS protocols has led to reductions in complication rates and hospital length of stay (LOS) by 30%–50%,35 resulting in their aggressive adoption across various subspecialties. Beginning in spine and peripheral nerve surgery 5 years ago,6,7 they have become increasingly prevalent in the neurosurgical realm. Studies in cranial surgery are currently building the body of evidence needed to formalize ERAS protocols, and although ERAS is still in its infancy for cranial surgery, several larger institutions and health systems have already realized its impact and begun protocolizing efforts.

The following strategies represent a collaborative effort of the Pacific Neuroscience Institute faculty and Providence Health & Services 51-hospital system to implement enhanced recovery protocols (ERPs) after cranial surgery initiatives. This paper describes the processes we used over the past 3 years to scale cranial surgery redesign from a pilot study to systemwide multidisciplinary deployment.

The Argument for Enhanced Recovery After Cranial Surgery Efforts Across a System

Globally, more than 300–310 million patients have major surgery every year.8 Of these, approximately 50 million (14%–17%) have complications, with 0.5%–2.8% dying before they leave the hospital.9 Cranial neurosurgery accounts for 13.8 million cases annually, many being performed on an urgent basis with higher morbidity and mortality rates. In addition to the human cost of morbidity and mortality, surgery represents the single largest US healthcare cost, accounting for $575 billion in expenditures per year. Given its complexity, as well as the overall cost of care and profit margins for hospital systems, cranial surgery remains a prime target for value-based care redesign.

Using previous work done from our group as a template,10 we developed protocols to reduce variation to ensure dependable, every-time application of evidence-based best practices. Noncranial surgery–specific ERAS elements that were absent from the cranial literature were adapted from existing ERAS pathways in other specialties.

Methods

The Team

Physician Leaders

This project was developed by two physicians in the clinical (W.S.) and administrative (N.M.) space of the Providence system neuroscience institute. Significant involvement from these two physicians at all coalition, steering committee, and regional and system meetings was paramount to ensuring the consistency of messaging and maintenance of project goals.

Leadership Coalition

This team consisted of highly engaged senior clinical and administrative leaders from neurosurgery, anesthesiology, and regional and system administration who initiated the project, approved urgent implementation, and defined the vision, goals, and strategy. This group was essential to persuading and enlisting support from both executive leadership and frontline clinicians, and it formed the core of the steering committee. Clinical institute staff and a dedicated project manager assisted in educational tool development, performance metrics acquisition, and project monitoring.

Steering Committee

Representatives from neurosurgery, along with anesthesiologists, pharmacists, and ancillary staff, evaluated evidence-based best practices and defined cranial surgery perioperative protocols. Additionally, after the development and implementation of an ERP was labeled as a high-priority system initiative, key administration leadership at each individual hospital (chief executive officer, chief medical officer, chief nursing officer, and neuroscience administrative leadership) were included in such meetings.

Clinical Informatics Team

The Providence system clinical informatics team provided the framework for the universal protocol and guided procedure-specific customization of the order sets and template notes. They coordinated hardwiring (implementation into Epic) of the customized order sets and notes into the Epic electronic medical record with the programming team.

Implementation of Enhanced Recovery in Cranial Surgery

The enhanced recovery after cranial surgery implementation program began in response to the COVID-19 pandemic. Given the decrease in bed availability, several Providence hospitals stopped nonurgent neurosurgical procedures for anywhere from several weeks to months. During both regional and system neuroscience institute meetings, early results from the two pilot hospitals (Little Company of Mary [LCM] and Saint John’s Health Center [SJHC]) highlighted not only a decreased LOS and intensive care unit (ICU) use in cranial surgery patients, but also an overall increase in cranial surgery volume compared with pre-COVID time epochs.8 The enhanced recovery after cranial surgery protocol was highlighted as a key driver for these results and as a model for resource utilization in system surgical recovery efforts. Labeled as a high-priority initiative by system leadership, the physician leaders (W.S. and N.M.) and leadership coalition were tasked with developing a ministry implementation process (Fig. 1).

FIG. 1.
FIG. 1.

ERP ministry implementation process. Timeline of enhanced recovery for cranial surgery ministry implementation at pilot site.

Results

ERP Program Development

The physician champions, leadership coalition, and system service line clinical champions were tasked with obtaining consensus on elements of the ERP. To maintain generalizability and achieve maximal physician buy-in, focus was placed on keeping key elements of standardization as decided by evidence-based best practices and physician champion recommendations while maintaining flexibility for physician practice preferences (Fig. 2). Given the evolution of these current best practices in cranial surgery, this group was labeled as an iterative task force. They enlist their specialty colleagues and explain and advocate for protocol adoption and adherence.

FIG. 2.
FIG. 2.

Enhanced recovery program. Overview of enhanced recovery after cranial surgery protocol, divided into preoperative, intraoperative, and postoperative time epochs. DVT = deep venous thrombosis; PONV = postoperative nausea and vomiting.

Key Performance Indicators

Following the development of the protocol, key performance metrics were decided on: 1) patient outcomes, 2) complications, 3) utilization, and 4) cost. Specific outcome data included mortality rates, postprocedure LOS, rates of discharge to home, and cost per case. Secondary measures included readmission rates, ICU utilization, complication rates, and return to operating room rates.

Outcome data were garnered from the system’s Brain Tumor Metric Explorer database. This database accesses outcome data (e.g., LOS, discharge to home, and readmissions) from the Epic electronic medical record, from all Providence hospital encounters that include a primary discharge diagnosis of brain tumor and a brain tumor–related procedure. These clinical data were cross-correlated with cost data from Providence’s proprietary Value Oriented Architecture (VOA) database. The VOA database accesses granular diagnosis-specific cost data (operating room/anesthesia, room and board, supplies, implants, pharmacy, laboratory results, etc.) and can plot the costs against specific clinical outcome measures such as LOS or clinical volume by individual ministries or surgeons. Both were developed by Providence system analytics services to simultaneously measure cost and outcomes and assess specific practices that drive the variation.11

Additional metrics currently under development include adherence metrics, which evaluate reliable, consistent application of the individual process components of the protocol. The aim is to develop this at the hospital and individual provider level.

Pilot Study

The physician leaders, leadership coalition, and hospital administration leaders met for an executive introduction meeting to confirm the goals and develop a timeline for ERP implementation. The decision was made to proceed with a pilot initiative at the ministries of the physician leaders (LCM and SJHC). Concurrently, workgroups were assembled from the steering committees across the system to codify and finalize the three segments of the program: preoperative, intraoperative, and postoperative. Once consensus was reached, the finalized version of the ERP process was shared across the neuroscience system. The surgical and anesthesiology champions coached colleagues, worked through logistical challenges in frequent steering committee meetings, and monitored protocol adherence.

Clinical Informatics

Incorporating feedback of the workgroups, the physician champion (W.S.) and advanced practice provider representatives translated the additional order set changes into a format that the clinical informatics team rapidly hardwired into the established cranial postoperative order sets available to all providers within the Providence hospital system. The protocol was reinforced by standardized patient educational material and clinician notes from which templates were created. During the divisional steering committee meetings, the neurosurgeons and anesthesiologists were educated about the evidence-based and programmatic rationale and trained in the implementation of the protocol. Clinic staff and operating room team members were oriented.

The pilot study was formally launched in January 2022. Results were iteratively extracted from the Providence Brain Tumor Metric Explorer and VOA databases. Upon the study’s conclusion in March 2023, the ERP had shown impressive improvements in quality of care (Figs. 37). During the study period, 164 craniotomies for brain tumor were performed at the pilot sites. The pilot sites led the system in LOS and discharge home rates after brain tumor surgery. The sites were also found to have the lowest cost per case for high-volume brain tumor surgery sites in the system. The VOA analysis for overall LOS, cost of care, and trends for brain tumor surgery highlighted the pilot sites as high-value sites for cranial surgery.

FIG. 3.
FIG. 3.

Postprocedure LOS for elective craniotomy for brain tumor surgery during the pilot study period. The x-axis represents the number of days and the y-axis the site number. Site 1 is LCM and site 2 is SJHC.

FIG. 4.
FIG. 4.

Rates of discharge home for elective craniotomy for brain tumor surgery during the pilot study period. The x-axis represents the percentage and the y-axis the site number.

FIG. 5.
FIG. 5.

Postprocedure LOS for all craniotomies for brain tumor surgery during the pilot study period. The x-axis represents the number of days and the y-axis the site number.

FIG. 6.
FIG. 6.

Relative cost per brain tumor case at high-volume surgical sites. The x-axis represents the site number.

FIG. 7.
FIG. 7.

VOA plots. Upper: Each circle represents the performance of one high-volume neurosurgical hospital for brain tumor surgery within the system. The larger the size of the circle, the higher the volume of surgery for meningiomas, metastatic tumors, and gliomas. The y-axis represents the average normalized cost per case (plotted in reverse order so that lower costs are higher on the graph). The x-axis represents the total LOS in days (better scores are farther to the right). Circles in the right upper quadrant suggest high-value hospitals. Lower: Trend data for both cost per case and LOS for the primary pilot site (LCM).

Discussion

Implementation Challenges

Given the rapidly evolving growth of best-practice data for enhanced recovery efforts in cranial surgery, the implementation process was designed to progress in an iterative fashion. Weekly steering committee meetings were held to address implementation challenges. As expected, challenges on the single-hospital, division, and system levels echoed those of other surgical subspecialties and early reports in neurosurgery.12 For example, rates of disposition to home were different between the two pilot studies. At the primary pilot site (LCM), early interdisciplinary huddle rounds are performed daily involving the surgeons, advanced practice providers, allied health representatives, case management, dietary staff, pharmacy personnel, nursing leaders, and hospital administration. Here, essential neurosurgical issues and disposition expectations and barriers are discussed together to avoid late obstacles. This may explain the increased rates of patients who are able to be discharged home from LCM.

Difficulty Obtaining Consensus

The development of the original enhanced recovery for cranial surgery protocol and the changes made from the segmented workgroups were key to attaining consensus. Focused attention by the physician champions with the individual ministry leaders and leadership coalition was paramount to attaining physician buy-in. The physician champions and clinical institute staff took considerable time and attention to address the concerns of all system physicians and team members.

Achieving Widespread Adoption Across Neurosurgeons

The enhanced recovery after cranial surgery protocol was presented to system neurosurgeons as a high-priority initiative by the executive system and regional leadership. A major concern of the neurosurgeons involved in the task force was the difficulties associated with implementing the enhanced recovery elements into the cranial postoperative order sets. Direct involvement of the clinical informatics team and executive approval for rapid adoption of the order set changes into the Epic order set were key drivers to widespread neurosurgeon acceptance. Additionally, regular presentation of the results during the process of the pilot study played a role in further incorporation of the protocol at other ministries. During the time of the ERP implementation and pilot study process, an improvement in system LOS was also noted.

Adoption of New Protocols by Nonneurosurgical Providers

A key element to the success of this initiative was heavy involvement and buy-in from nonneurosurgeon providers. The chief executive and nursing officers were essential in engendering buy-in from hospital staff, including allied health therapy, dietary, pharmacy, and nursing personnel. Our focus was to identify nursing champions on the individual neurosurgical units (ICU, stepdown units, and telemetry floors) and lead the oversight of nursing adherence to the perioperative protocols. Daily neurosurgical huddle rounds were also held with representatives from nursing, allied health, pharmacy, dietary, palliative care, and case management to coordinate disposition planning.13 Monthly meetings and quarterly education sessions by the physician champion (W.S.) to review the progressive metrics ensured the ability of staff members to see the effects of their involvement in the protocol. Educational material, hardwired order sets in Epic, and rigorous adherence to the protocol by all pilot hospital neurosurgeons and advanced practice providers sped up adoption of the protocols by hospital staff members. Particular attention was given to the adoption of multimodal nonopioid pain control regimens14 (centered around strict head-of-bed elevation requirements, liberal use of ice, and scheduled administration of acetaminophen, ibuprofen, and cyclobenzaprine), early initiation of oral intake in the postanesthesia care unit (PACU), and explicit early mobilization requirements.15 Through the course of the pilot study, anesthesia teams transitioned to complete use of total intravenous anesthesia, removal of the Foley catheter in the operating room, and removal of arterial lines in the PACU. As a result of these measures, we noted a significant reduction in the time of emergence in the PACU and an increase in the rates of ambulation without assistance on the day of surgery. The initiative of early "de-lining and detethering" of patients was noted by patients and their families as a key step in giving them the confidence to continue their postoperative convalescence at home, in some cases as early as the same day of surgery.

Patient Communication

A major challenge noted during the pilot study was the maintenance of consistent communication with the patient and their families throughout the different epochs of their care. Inconsistent communication was a key barrier to protocol adherence early in the study. The neurosurgery team placed significant emphasis on consistent phrasing of all preoperative, perioperative, and postoperative care recommendations in the surgery planner, perioperative order sets, and discharge instructions. Additionally, telephone calls were made to all craniotomy patients on postdischarge day 1 to reiterate postoperative care expectations. We subsequently proceeded to incorporate an ultra-early virtual or in-person clinic visit, between postoperative days 4 and 7, to ensure protocol adherence and answer patient questions. This led to a decrease in rates of return to the emergency department during the second half of the pilot study.

Scaling Strategy

Following the early success of the enhanced recovery after cranial surgery protocol at the pilot sites, regional leadership began rapid incorporation of the protocol at the other centers of the Providence Southern California hospitals that perform brain tumor surgery. Should the results be replicated, system leadership has initiated a pro forma plan to support expansion of the protocol and implementation guide to cardiovascular surgery, digestive health, spine surgery, and orthopedic surgery. If similar quality metrics and cost savings are replicated, the same process will be expanded into all surgical instances (Fig. 8).

FIG. 8.
FIG. 8.

ERP scaling strategy. Planned rollout of ERP across the surgical subspecialties through neurosurgery, Providence Southern California division hospitals, and priority surgical subspecialties, followed by all other surgical instances. H = hospital; LCM-T = LCM Torrance; MHR/MLB = Mission Hospital Regional/Mission Laguna Beach; PHCMC = Providence Holy Cross Medical Center; PSJHC = Providence SJHC; PSJMC-B = Providence Saint Joseph Medical Center–Burbank; SJMC = St. Jude Medical Center; SJO = St. Joseph Hospital Orange.

Limitations

Limitations of this study include the extractable data points from the Brain Tumor Metric Explorer and VOA databases. Important data points such as patient well-being and specific complications are currently unable to be extracted for each of the 51 ministries from the database. These data points will be included in future studies.

Additionally, cost data for the development of the Brain Tumor Metric Explorer and VOA databases were unavailable for this publication as these systems were developed by the system leadership and clinical analytics team prior to this study. The cost of the additional personnel’s effort and time will need to be investigated in future studies and compared with the cost savings realized per case. By using established implementation guides and experienced personnel across the different system hospitals, as well as generating a culture change within hospital staff toward an enhanced recovery focus in surgical patients, we hope that future scaling can occur at a lower cost.

Conclusions

This study illustrates the effective implementation of an enhanced recovery after brain tumor surgery pilot program within a large healthcare system. The early results in hospital LOS, patient disposition outcomes, and overall cost of care are promising for follow-up studies. Additionally, institutional experience from this study on strategies to overcome implementation barriers will hopefully expedite the adoption of similar protocols across other hospital ministries and surgical disciplines.

Acknowledgments

We thank Patrice Hallak, Tom Burton, Treasure Joyce, Steven Dillavou, Hosu Lee, Lidia Lee, Valerie Santiago, Victoria Tedrow, and the administrative and hospital staff teams at Providence Little Company of Mary Torrance and Providence Saint John’s Health Center. Walavan Sivakumar acknowledges funding from the Providence Age Friendly Innovation Challenge.

Disclosures

Dr. Sivakumar reported consulting fees from Stryker and educational fees from Zeiss outside the submitted work. Dr. Kelly reported royalties from Mizuho outside the submitted work.

Author Contributions

Conception and design: Sivakumar, Martin. Acquisition of data: Sivakumar, Barkhoudarian, Martin. Analysis and interpretation of data: Sivakumar, Martin. Drafting the article: Sivakumar, Guan, Martin. Critically revising the article: all authors. Reviewed submitted version of manuscript: Sivakumar, Guan, Barkhoudarian, Kelly, Martin. Approved the final version of the manuscript on behalf of all authors: Sivakumar. Statistical analysis: Sivakumar. Administrative/technical/material support: Sivakumar. Study supervision: Sivakumar, Martin.

References

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    Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292298.

  • 2

    Basse L, Jakobsen DH, Billesbølle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000;232(1):5157.

  • 3

    Rasmussen ML, Leeds SG, Whitfield EP, Aladegbami B, Ogola GO, Ward MA. Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients. Surg Endosc. 2023;37(4):28422850.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bisch SP, Jago CA, Kalogera E, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology—a systematic review and meta-analysis. Gynecol Oncol. 2021;161(1):4655.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Van Haren RM, Mehran RJ, Mena GE, et al. Enhanced recovery decreases pulmonary and cardiac complications after thoracotomy for lung cancer. Ann Thorac Surg. 2018;106(1):272279.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Grasu RM, Cata JP, Dang AQ, et al. Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis. J Neurosurg Spine. 2018;29(5):588598.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Ali ZS, Flanders TM, Ozturk AK, et al. Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine. 2019;30(4):532540.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385(suppl 2):S11.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Dobson GP. Trauma of major surgery: a global problem that is not going away. Int J Surg. 2020;81:4754.

  • 10

    Mallari RJ, Avery MB, Corlin A, et al. Streamlining brain tumor surgery care during the COVID-19 pandemic: a case-control study. PLoS One. 2021;16(7):e0254958.

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    Stowell C, Robicsek A. Endless forms most beautiful: evolving toward higher-value care. NEJM Catal. Published online July 26, 2018. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0126

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Agarwal P, Frid I, Singer J, et al. Neurosurgery perception of enhanced recovery after surgery (ERAS) protocols. J Clin Neurosci. 2021;92:110114.

  • 13

    Chan AY, Vadera S. Implementation of interdisciplinary neurosurgery morning huddle: cost-effectiveness and increased patient satisfaction. J Neurosurg. 2018;128(1):258261.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Sivakumar W, Jensen M, Martinez J, et al. Intravenous acetaminophen for postoperative supratentorial craniotomy pain: a prospective, randomized, double-blinded, placebo-controlled trial. J Neurosurg. 2018;130(3):766772.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Karic T, Røe C, Nordenmark TH, Becker F, Sorteberg W, Sorteberg A. Effect of early mobilization and rehabilitation on complications in aneurysmal subarachnoid hemorrhage. J Neurosurg. 2017;126(2):518526.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1.

    ERP ministry implementation process. Timeline of enhanced recovery for cranial surgery ministry implementation at pilot site.

  • FIG. 2.

    Enhanced recovery program. Overview of enhanced recovery after cranial surgery protocol, divided into preoperative, intraoperative, and postoperative time epochs. DVT = deep venous thrombosis; PONV = postoperative nausea and vomiting.

  • FIG. 3.

    Postprocedure LOS for elective craniotomy for brain tumor surgery during the pilot study period. The x-axis represents the number of days and the y-axis the site number. Site 1 is LCM and site 2 is SJHC.

  • FIG. 4.

    Rates of discharge home for elective craniotomy for brain tumor surgery during the pilot study period. The x-axis represents the percentage and the y-axis the site number.

  • FIG. 5.

    Postprocedure LOS for all craniotomies for brain tumor surgery during the pilot study period. The x-axis represents the number of days and the y-axis the site number.

  • FIG. 6.

    Relative cost per brain tumor case at high-volume surgical sites. The x-axis represents the site number.

  • FIG. 7.

    VOA plots. Upper: Each circle represents the performance of one high-volume neurosurgical hospital for brain tumor surgery within the system. The larger the size of the circle, the higher the volume of surgery for meningiomas, metastatic tumors, and gliomas. The y-axis represents the average normalized cost per case (plotted in reverse order so that lower costs are higher on the graph). The x-axis represents the total LOS in days (better scores are farther to the right). Circles in the right upper quadrant suggest high-value hospitals. Lower: Trend data for both cost per case and LOS for the primary pilot site (LCM).

  • FIG. 8.

    ERP scaling strategy. Planned rollout of ERP across the surgical subspecialties through neurosurgery, Providence Southern California division hospitals, and priority surgical subspecialties, followed by all other surgical instances. H = hospital; LCM-T = LCM Torrance; MHR/MLB = Mission Hospital Regional/Mission Laguna Beach; PHCMC = Providence Holy Cross Medical Center; PSJHC = Providence SJHC; PSJMC-B = Providence Saint Joseph Medical Center–Burbank; SJMC = St. Jude Medical Center; SJO = St. Joseph Hospital Orange.

  • 1

    Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292298.

  • 2

    Basse L, Jakobsen DH, Billesbølle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000;232(1):5157.

  • 3

    Rasmussen ML, Leeds SG, Whitfield EP, Aladegbami B, Ogola GO, Ward MA. Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients. Surg Endosc. 2023;37(4):28422850.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bisch SP, Jago CA, Kalogera E, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology—a systematic review and meta-analysis. Gynecol Oncol. 2021;161(1):4655.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Van Haren RM, Mehran RJ, Mena GE, et al. Enhanced recovery decreases pulmonary and cardiac complications after thoracotomy for lung cancer. Ann Thorac Surg. 2018;106(1):272279.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Grasu RM, Cata JP, Dang AQ, et al. Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis. J Neurosurg Spine. 2018;29(5):588598.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Ali ZS, Flanders TM, Ozturk AK, et al. Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine. 2019;30(4):532540.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385(suppl 2):S11.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Dobson GP. Trauma of major surgery: a global problem that is not going away. Int J Surg. 2020;81:4754.

  • 10

    Mallari RJ, Avery MB, Corlin A, et al. Streamlining brain tumor surgery care during the COVID-19 pandemic: a case-control study. PLoS One. 2021;16(7):e0254958.

  • 11

    Stowell C, Robicsek A. Endless forms most beautiful: evolving toward higher-value care. NEJM Catal. Published online July 26, 2018. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0126

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Agarwal P, Frid I, Singer J, et al. Neurosurgery perception of enhanced recovery after surgery (ERAS) protocols. J Clin Neurosci. 2021;92:110114.

  • 13

    Chan AY, Vadera S. Implementation of interdisciplinary neurosurgery morning huddle: cost-effectiveness and increased patient satisfaction. J Neurosurg. 2018;128(1):258261.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Sivakumar W, Jensen M, Martinez J, et al. Intravenous acetaminophen for postoperative supratentorial craniotomy pain: a prospective, randomized, double-blinded, placebo-controlled trial. J Neurosurg. 2018;130(3):766772.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Karic T, Røe C, Nordenmark TH, Becker F, Sorteberg W, Sorteberg A. Effect of early mobilization and rehabilitation on complications in aneurysmal subarachnoid hemorrhage. J Neurosurg. 2017;126(2):518526.

    • PubMed
    • Search Google Scholar
    • Export Citation

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