Implementation of an enhanced recovery protocol in patients undergoing mastectomies for breast cancer: an interrupted time-series design

BACKGROUND: We reviewed internal data and the current literature to update our enhanced recovery protocol (ERP) for patients undergoing a total breast mastectomy. Following implementation, the protocol was audited by chart review and compliance reminders were sent through email. OBJECTIVE: Our primary research aim was to examine the protocol compliance following the update. Our secondary aims were to examine the association between the change in protocol and the rates of postoperative nausea and vomiting (PONV) and hematoma formation requiring reoperation. METHODS: We retrospectively obtained data extracted from the electronic medical record. To test for a difference in outcomes before versus after implementation of the protocol we used multivariable logistic regression with the primary comparisons excluding a ​± ​one-month window and secondary comparisons excluding a ​± ​three-month window from the date of implementation. RESULTS: Our cohort included 5853 unique patients. Total intravenous anesthesia (TIVA) compliance increased by 17%–52% (P ​< ​0.001) and the use of intraoperative ketorolac dropped from 44% to nearly no utilization (0.7%; P ​< ​0.001). The rate of reoperation due to bleeding decreased from 3.6% to 2.6% after implementation with the adjusted decrease being 1.0% (bootstrap 95% CI, 0.11%, 1.9%; P ​= ​0.053) excluding a ​± ​1 month window and 1.2% (bootstrap 95% CI, 0.24%, 2.0%; P ​= ​0.028) excluding a ​± ​3-month window. The rate of rescue antiemetics dropped by 6.4% (95% CI, 3.9%, 9.0%). CONCLUSIONS: We were able to improve compliance for nearly all components of the protocol which translated to a meaningful change in an important patient outcome.