Sustaining a multidisciplinary single-institution post-operative mobilization Clinical Practice Improvement Program following hepatopancreatobiliary surgery during the Coronavirus Disease 2019 (COVID-19) pandemic.

Chan, Kai Siang; Wang, Bei; Tan, Yen Pin; Chow, Jaclyn Jie Ling; Ong, Ee Ling; Junnarkar, Sameer P; Low, Jee Keem; Huey, Cheong Wei Terence; Shelat, Vishal G

BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resources available which can render sustainability of CPIP difficult. OBJECTIVE We report outcomes at one year following our CPIP to improve the post-operative mobilization in patients undergoing major HPB surgery amidst the COVID-19 pandemic. METHODS We divided our study into four phases: (1) phase 1: before CPIP (Jan to Apr 2019); (2) phase 2 (May to Sep 2019): implementation of CPIP; (3) phase 3: post-CPIP before COVID-19 (Oct 2019 to Mar 2020) and (4) phase 4: post-CPIP during COVID-19 (Apr 2020 to Sep 2020). Major HPB surgery was defined as any surgery on the hepato-pancreato-biliary system >2 hours and with anticipated blood loss ≥500ml. Study variables included length of hospitalization stay, distance ambulated on POD2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as able to sit out of bed for >6 hours on POD1 and ambulate ≥30m on POD2. Target mobilization rate was ≥75%. RESULTS 114 patients underwent major HPB surgery from phase 2 to phase 4 of our study: 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phase 2, phase 3 and phase 4 respectively. No baseline patient demographics was collected for phase 1 (pre-CPIP implementation); Majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). There were 76 (66.7%) patients who had ON-Q PainBuster insertion intra-operatively. The median mobilization rate was 22% for phase 1, 78% for phase 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7±1.0 on POD1 and 1.8±1.5 on POD2. The median length of hospitalization stay was six days (interquartile range (IQR) 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia. Twenty-one patients (18.4%) failed to ambulate ≥30m on POD2 from phase 2 to 4. The commonest reason for failure to achieve ambulation target was pain (n=6/21, 28.6%) and lethargy or giddiness (n=5/21, 23.8%). CONCLUSIONS This follow-up study shows the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery one year after implementation, even during the COVID-19 pandemic. Further large-scale multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.