Dedicated Operating Room Teams and Clinical Outcomes in an Enhanced Recovery after Surgery Pathway for Colorectal Surgery

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1 Dedicated Operating Room Teams and Clinical Outcomes in an Enhanced Recovery after Surgery Pathway for Colorectal Surgery Michael C Grant, MD, Andrew Hanna, MD, Andrew Benson, CRNA, Deborah Hobson, BSN, Christopher L Wu, MD, Christina T Yuan, PhD, Michael Rosen, PhD, Elizabeth C Wick, MD, FACS BACKGROUND: Our aim was to determine whether the establishment of a dedicated operating room team leads to improved process measure compliance and clinical outcomes in an Enhanced Recovery after Surgery (ERAS) program. Enhanced Recovery after Surgery programs involve the application of bundled best practices to improve the value of perioperative care. Successful implementation and sustainment of ERAS programs has been linked to compliance with protocol elements. STUDY DESIGN: Development of dedicated teams of anesthesia providers was a component of ERAS implementation. Intraoperative provider team networks (surgeons, anesthesiologists, and certified registered nurse anesthetists) were developed for all cases before and after implementation of colorectal ERAS. Four measures of centrality were analyzed in each network based on case assignments, and these measures were correlated with both rates of process measure compliance and clinical outcomes. RESULTS: Enhanced Recovery after Surgery provider teams led to a decrease in the closeness of anesthesiologists (p ¼ 0.04) and significant increase in the clustering coefficient of certified registered nurse anesthetists (p ¼ 0.005) compared with the pre-eras network. There was no significant change in centrality among surgeons (p ¼ NS for all measures). Enhanced Recovery after Surgery designation among anesthesiologists and nurse anesthetistsdwhereby individual providers received an in-service on protocol elements and received compliance data was strongly associated with high compliance (>0.6 of measures; p < for each group). In addition, high compliance was associated with a significant reduction in length of stay (p < 0.01), surgical site infection (p < 0.002), and morbidity (p < 0.009). CONCLUSIONS: Dedicated operating room teams led to increased centrality among anesthesia providers, which in turn not only increased compliance, but also improved several clinical outcomes. (J Am Coll Surg 2018;226:267e276. Ó 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.) CME questions for this article available at Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Drs Grant and Hanna contributed equally to this work. Presented at the American College of Surgeons 102 nd Annual Clinical Congress, Washington, DC, October Received November 6, 2017; Revised December 1, 2017; Accepted December 1, From the Departments of Anesthesiology and Critical Care Medicine (Grant, Benson, Wu, Yuan, Rosen) and Surgery (Hobson), the Johns Hopkins Medical Institutions, Baltimore, MD, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Hanna), and Department of Surgery, University of California, San Francisco, CA (Wick). Correspondence address: Elizabeth C Wick, MD, FACS, Department of Surgery, University of California San Francisco, 513 Parnassus Ave, San Francisco, CA Elizabeth.Wick@ucsf.edu Patients undergoing operations often see numerous providers across a number of perioperative patient care environments. This leads to substantial variation and even introduces the potential for disparate levels of patient care. During the past several years, surgeons have begun to address variability in perioperative management through the creation of Enhanced Recovery after Surgery (ERAS) programs. Enhanced Recovery after Surgery has sparked excitement in the surgical community both domestically and abroad due to its ability to lessen the impact of surgical insults and hasten patient recovery, as adoption of ERAS programs has been associated with a reduction in rates of surgical complications, ª 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved ISSN /17

2 268 Grant et al Operating Room Teamwork and Enhanced Recovery J Am Coll Surg Abbreviations and Acronyms CRNA ¼ certified registered nurse anesthetist ERAS ¼ Enhanced Recovery after Surgery LOS ¼ length of stay OR ¼ operating room QAP ¼ quadratic assignment procedure SSI ¼ surgical site infection decreased length of hospital stay, and improvement in overall patient satisfaction. 1-4 Much of the literature to date has focused on the quality of evidence associated with individual process measures included within these perioperative bundles. 5,6 However, an underappreciated element of ERAS programs is the ability to promote teamwork and coordination of care, which serves to break down pre-existing silos within the various perioperative care arenas. The success of ERAS programs is inextricably linked not only to the individual process measures, but also to the associated culture and adaptive management skills of the improvement team and clinician champions. 7 One way to foster the development of these adaptive skills is through the creation of operating room (OR) teams, which involves the engagement and support of surgical leadership, incorporation of select perioperative anesthesia and nursing providers, and concerted cohorting of patient care. Although there is limited evidence to suggest that dedicated OR teams can increase productivity and enhance teamwork and safety climate, 8 the impact of this approach has been difficult to study in a systematic fashion. In other industries and areas of medicine, the degree of teamwork has been characterized through the application of social network analysis, which allows for the quantification of inter-provider communication and organization through various metrics of social interaction. At least one group found that improved teamworkdas captured by a network measure of provider overlap with patientsdled to better outcomes after coronary artery bypass grafting. 9 In this light, our group sought to better understand the potential impact of ERAS programs on teamwork through the use of social network analysis on a recently implemented ERAS for colorectal surgery program. Our hypothesis was that creating OR teams through the identification of surgical, anesthesia, and nursing leadership coupled with recruitment of designated ERAS providers across the perioperative environment would lead to both improvements in metrics of teamwork, as well as surgical outcomes. METHODS Enhanced Recovery after Surgery program description The Enhanced Recovery after Surgery for colorectal surgery program After IRB approval, the ERAS program was implemented in February 2014 at Johns Hopkins Hospital, a 1,056-bed quaternary care hospital, in all patients scheduled for colorectal surgery by 1 of 5 surgeons. Patients were educated and individual consent was obtained for participation in the ERAS program. The pathway included bundled preoperative, intraoperative and postoperative process measures encompassing the core principles of ERAS (ie enhanced patient engagement, reduced opioid consumption, avoidance of prolonged fasting, early ambulation, goal-directed IV fluids, and best evidence to reduce preventable harms). As reported previously, implementation resulted in a significant reduction in length of stay, surgical site infections, and variable direct costs, as well as improvement in the patient experience Designation of operating room teams Before the implementation of the ERAS program, anesthesia providers (attending anesthesiologist and anesthesia resident or certified registered nurse anesthetist [CRNA]) were assigned ad hoc to colorectal surgical cases by a central anesthesiologist scheduler. Providers were selected from the entire pool of clinical providers assigned to a particular clinical day. To maximize staffing resources to all OR locations, anesthesia providers were not preferentially scheduled to specific procedures or surgeons. As part of the official ERAS program implementation, a dedicated team of colorectal ERAS anesthesia providers was identified and a pilot program developed to ensure only core ERAS providers were assigned to these cases. After development of a formal ERAS protocol, volunteers from the faculty and CRNA pool were identified who were interested in joining the core ERAS provider team. The training associated with certification to be part of the ERAS provider cohort involved the following: selfidentification of providers (CRNAs and anesthesiologists) who would be open to review the available consensus guidelines literature, were comfortable with practicing the anticipated anesthesia protocol elements and willing to standardize their approach to colorectal anesthesia delivery; orientation to the protocol during one of the monthly quality meeting for the cohort of CRNAs and attending anesthesiologists who would be involved in the initiative; inclusion of providers among a specific ERAS listserv to receive ongoing updates (ie new literature

3 Vol. 226, No. 3, March 2018 Grant et al Operating Room Teamwork and Enhanced Recovery 269 and protocol developments). Colorectal ERAS procedures were marked on the OR schedule ahead of time by the surgeons staff and the anesthesiologist scheduler began to assign only members of the core ERAS provider team to these cases. The goal was to provide at least an ERAS core anesthesiologist or a core ERAS CRNAdand ideally bothdto all colorectal ERAS procedures. Anesthesiology residents were not included as part of the core ERAS provider team because of frequent rotation and inability to ensure consistent coverage. Furthermore, it was believed that an additional provider type might undermine successful evaluation of the impact of a dedicated team of anesthesia providers on clinical outcomes. Data variable extraction Operating room staffing The intraoperative anesthesia record (Metavision; imdsoft) was used to identify the surgeon, anesthesiologist, and CRNA of record for each individual procedure. In the event that more than 1 person was entered in either role, the person who was present for the longest period of time was determined to be the primary provider for the procedure. This information was transcribed into a prescribed proforma. network from January 1, 2013 to January 31, 2014, and the second describing the ERAS network from February 1, 2014 to February 15, This network was created with the following parameters: individual providers are represented as nodes, any providers that were assigned to the same procedure were connected by ties dphysical lines adjoining 2 nodes, the size of each node correlates to the number of times that individual provider was assigned to a surgical procedure during the study period, and the thickness of each tie correlates with the number of times those 2 providers shared a procedure. Provider role is indicated by color, with surgeons, anesthesiologists, and CRNAs as blue, red, and yellow, respectively. Within the ERAS network only, node shape corresponds to ERAS certification, with diamond-shaped nodes indicating certification and circular nodes indicating no certification. Figure 1 displays both the pre-eras and ERAS networks using these conventions. For the sake of this study, we were interested in the concept of node centrality because it provides quantitative measures to either identify the most influential Clinical outcomes The primary end point of interest was overall index hospitalization length of stay (LOS). Secondary outcomes included surgical site infection (SSI) and overall postoperative morbidity, which were obtained from the hospital American College of Surgeons NSQIP database, as well as rate of return to the OR, which was obtained from the hospital administrative data records. Enhanced Recovery after Surgery program process measures The charting location of all preoperative, intraoperative and postoperative anesthesia process measures, as outlined in the institutional anesthesia protocol, were identified in the electronic medical record (Sunrise Clinical Manager; Eclipsys Inc) and individual queries were developed to facilitate their automated extraction to a centralized ERAS database. This permitted updated information about both individual and process measure compliance throughout the duration of the program. Network development and analysis of centrality Case-specific assignments for 3 separate provider typesdattending surgeons, attending anesthesiologists, and CRNAsdare recorded for each colorectal surgical procedure during the study period. Two social networks were first constructed: one describing the Pre-ERAS Figure 1. Graphic representation of (A) pre-enhanced Recovery after Surgery (ERAS) program and (B) ERAS networks. Blue node, surgeon; red node, anesthesiologist; yellow node, certified registered nurse anesthetist (CRNA). Size of each node is based on relative degree of centrality. Internode line thickness corresponds to number of shared operations. Node shape is based on ERAS designation: diamond, ERAS; circle, non-eras.

4 270 Grant et al Operating Room Teamwork and Enhanced Recovery J Am Coll Surg nodesdones that most dictates the overall data flowdor the nodes that promote the greatest level of network cohesiveness. Our group evaluated the pre-eras and ERAS networks using 4 measures of centrality, which include: 1. Degree centrality: Perhaps the simplest to conceptualize, this is defined as the total number of ties on a given node. It best estimates the likelihood the node will transfer or receive data or information within the network. 2. Closeness centrality: Focuses on how close a node is to all the other nodes in the network. Central nodes are characterized by having minimum steps to all other nodes; meaning that the paths (ie geodesics) linking a central node to the other nodes are as short as possible. 12 Greater closeness is associated with greater influence, as a node does not need to rely on the other nodes for its interactions because it is tied to all others. 3. Eigenvector centrality: Can be considered the most direct measure of the influence of a node on all other nodes in the network. In simple terms, it assigns weight to a node based on the strength of all the nodes with which it forms ties. If a node is connected to high-ranking node, its own ranking is strengthened. 4. Clustering coefficient: At the whole network level, this is a measure of the overall connectedness of a set of nodes. Ranging from 0 to 1, it is a ratio of the number of actual connections between a set of nodes over the maximum number of possible connections between those nodes. When referring to a single node, the clustering coefficient measures the extent to which neighboring nodes are connected. Figure 2 describes several social network terms and provides a correlate to the current study. Statistical analysis All relevant data for each surgical encounter were combined into a single database. Data were processed and analyzed with the software programs Excel, version 14.0 (Microsoft Inc) and STATA, version 14.2 (Stata Corp) statistical package. Network analysis was performed using UCINET 6 (Analytic Technologies). Centrality measures calculated from any social network are, by design and definition, non-independent observations, meaning that using ordinary least squares or logistic regression, which assume observational independence, would greatly overstate the statistical significance of any effect size. To circumvent this problem, social network analysis uses a method called quadratic assignment procedure (QAP) to generate a sampling distribution for effect size comparison. This is done by permutating the dependent variable across the independent variables 10,000 times and creating 10,000 completely new networks, each with its own effect estimate. The actual effect size seen in the original network is then compared with this empirically derived sampling distribution to generate a p value. Comparisons of means and multivariate logistic regressions where any Figure 2. Social network analysis terms, definitions, and study correlates. CRNA, certified registered nurse anesthetist; OR, operating room.

5 Vol. 226, No. 3, March 2018 Grant et al Operating Room Teamwork and Enhanced Recovery 271 network measure was involved was therefore performed use QAP. Categorical variables not involving network metrics were assessed by the chi-square or Fisher s exact test, where appropriate. Univariable regression using QAP was performed for outcomes variables of interest based on provider type, ERAS designation, and centrality measures. Multivariable logistic regression using QAP was conducted for each of the outcomes variables of interest incorporating all results of univariable analysis with p < 0.1. For the sake of this study, p < 0.05 was considered statistically significant. RESULTS Pre-Enhanced Recovery after Surgery vs Enhanced Recovery after Surgery global network comparison The ERAS network was associated with a statistically significant increase in the overall clustering coefficient (0.81 vs 0.51; p ¼ 0.009) compared with the pre-eras provider network. This finding was not associated with a significant difference in overall degree (10.0 ties vs 9.1 ties; p ¼ 0.53) between ERAS and pre-eras networks, despite an increase in both numbers of operations (763 vs 401) and number of involved provider personnel (204 vs 169). Visual representation of the network was constructed so that strongly tied nodes are closer together than weakly tied nodes. Figure 1 graphically depicts both the pre-eras and ERAS networks. On qualitative inspection, the ERAS network is more densely populateddwith more nodes and tiesdthan the pre-eras network. The ERAS network also appears to display a large clustering effect between a select group of individuals, much more so than the pre-eras network. In examining the members involved in the dense clustering of the ERAS network, there is noted to be a redistribution of cases to select personnel. In illustration of this, node sizesdwhich correlate with node degreedshow that attending anesthesiologists (red nodes) and CRNAs (yellow nodes) are relatively more central to the ERAS network than in the pre-eras network, where the central members were overwhelmingly surgeons (blue nodes), as indicated by their relatively larger node sizes. Pre-Enhanced Recovery after Surgery vs Enhanced Recovery after Surgery role comparisons As shown in Table 1, the centrality measures of surgeons differed significantly from both Anesthesiologists and CRNAs within the whole network. These differences were all statistically significant (p < 0.001). There was no statistical difference among any centrality measure when comparing anesthesiologists with CRNAs. There is an increase in surgeon clustering coefficient, albeit a nonsignificant one (p ¼ 0.085), from pre-eras to ERAS, which suggests a more strongly connected neighborhood of anesthesiologists and CRNAs. There is a statistically significant increase in CRNA clustering coefficient from pre-eras to ERAS (p ¼ 0.005), indicating that the surgeon-anesthesiologists network became more strongly connected as well. Anesthesiologists exhibited a decrease in average closeness from pre-eras to ERAS network (p ¼ 0.039). Table 1. Comparing Normalized Centrality Measures between Pre-Enhanced Recovery after Surgery and Enhanced Recovery after Surgery Characteristic Whole network Pre-ERAS ERAS % Change p Value Surgeon Degree Closeness Eigenvector Clustering coefficient Anesthesiologist Degree Closeness * Eigenvector Clustering coefficient Certified registered nurse anesthetist Degree Closeness Eigenvector Clustering coefficient * *Statistically significant. ERAS, Enhanced Recovery after Surgery program.

6 272 Grant et al Operating Room Teamwork and Enhanced Recovery J Am Coll Surg Table 2. Multivariate Regression of Role and Enhanced Recovery after Surgery Certification on Centrality Measures Centrality measure Effect of CRNA vs anesthesiologist p Value Effect of ERAS (vs non-eras) p Value Degree * <0.0001* Closeness <0.0001* Eigenvector * <0.0001* Clustering coefficient * Predictor variables included role (CRNA vs anesthesiologist) and ERAS certification (ERAS vs non-eras). *Statistically significant. CRNA, certified registered nurse anesthetist; ERAS, Enhanced Recovery after Surgery program. Role and Enhanced Recovery after Surgery designation comparisons within the Enhanced Recovery after Surgery network Within the ERAS network, there are minimal differences in centrality measures noted between the overall role of anesthesiologist and CRNA. However, when analyzing these end points based on ERAS designation, all 4 centrality measures were shown to have a statistically significant increase in ERAS compared with non-eras personnel. The results of bivariable regression analyses using role and ERAS designation to predict centrality measures are shown in Table 2. The provider role of CRNA (irrespective of ERAS designation) was associated with a significant increase in both degree and eigenvector within the ERAS network compared with the role of anesthesiologist. In addition, ERAS designation (irrespective of provider role) was associated with a significant increase in all centrality measures compared with non-eras designation. Effect of provider role and Enhanced Recovery after Surgery designation on clinical outcomes Overall rates of individual clinical outcomes within the ERAS network based on both provider role and ERAS designation are reported in Table 3. As shown, within the CRNA provider role, ERAS designation was associated with a statistically significant increase in the rate of high compliance (defined as >0.6 compliance with ERAS process measures; p < 0.001), as well as a significant decrease in the rate of postoperative morbidity (p ¼ 0.031), and a decrease in the rate of return to the operating room (p ¼ 0.035). Within the anesthesiologist provider role, ERAS designation was associated with a statistically significant increase in the rate of high compliance (p < 0.001). Table 4 reports the association between the overall anesthesia team ERAS designation and clinical outcomes. When at least one member of the team is ERAS designated, there is a significant increase in the number of high compliance cases (p < 0.001), as well as cases with LOS <6 days(p¼ 0.048) and a significant decrease in the rate of SSI (p ¼ 0.007) and return to the OR (p ¼ 0.029) compared with procedures when there are no ERAS designated anesthesia team members. When both members of the anesthesia team are ERAS designated, there is a significant increase in the number of high compliance cases compared with teams where at least one member is not ERAS designated (p < 0.001). Interestingly, there are no significant differences in the rest of the clinical outcomes between these 2 groups. Effect of provider role, Enhanced Recovery after Surgery designation, and individual centrality measures on clinical outcomes A multivariable regression model using the previously described QAP method was developed to determine independent predictors of various clinical outcomes. The Table 3. Effect of Team Member Designations on Primary Outcomes within the Enhanced Recovery after Surgery Network Certified registered nurse anesthetist Anesthesiologist ERAS (n ¼ 334) Non-ERAS (n ¼ 73) ERAS (n ¼ 342) Non-ERAS (n ¼ 65) Outcomes n % n % p Value n % n % p Value Compliance score > <0.001* <0.001* Length of stay <6 d Surgical site infection All morbidity * Return to operating room * *Statistically significant. ERAS, Enhanced Recovery after Surgery program.

7 Vol. 226, No. 3, March 2018 Grant et al Operating Room Teamwork and Enhanced Recovery 273 Table 4. Effect of Anesthesia Team Designation on Primary Outcomes within the Enhanced Recovery after Surgery Network Both ERAS (n ¼ 297) At least 1 non-eras (n ¼ 110) At least 1 ERAS (n ¼ 379) Both non- ERAS (n ¼ 28) Outcomes n % n % p Value n % n % p Value Compliance score > <0.001* <0.001* Length of stay <6 d * Surgical site infection * All morbidity Return to operating room * *Statistically significant. ERAS, Enhanced Recovery after Surgery program. resultsofthisanalysisareshownintable 5. Basedon multivariable logistic regression using QAP, CRNA closeness, and use of an anesthesiologist or CRNA with ERAS designation were independently associated with high compliance with ERAS process measures. When high compliance was added into the multivariable regression model, it was independently associated with cases that met the goal LOS (<6 days), as well as reduced SSI and overall morbidity. In addition, centrality measure of CRNA closeness was independently associated with meeting goal LOS (p ¼ 0.021) and reduction in returns to the OR (p ¼ 0.031). The centrality measure of CRNA clustering coefficient was independently associated with reduction in overall morbidity (p ¼ 0.038) and reduction in returns to the OR (p ¼ 0.019). DISCUSSION Analysis of the social networks associated with the recruitment of designated anesthesia providers as part of the implementation strategy of an ERAS program for colorectal surgery resulted in a significant increase in the overall centrality of the cohort. Not only was the ERAS network shown to have a significant increase in the overall clustering coefficient, but there were a number of provider type-specific changes in several other measures of centrality as well, with a significant increase in clustering among CRNAs and significant decrease in closeness among anesthesiologists. Enhanced Recovery after Surgeryedesignated anesthesia providersdboth anesthesiologists and CRNAsdwere noted to have significant increases in all 4 measures of centrality as well. Enhanced Recovery after Surgery designation was shown to correlate positively with Table 5. Significant Results of Multivariable Logistic Regression for Clinical Outcomes Outcomes and predictor variable Odds ratio Lower 95% Upper 95% p Value Compliance score > 0.6* Anesthesiologist, ERAS designation <0.001 y CRNA, ERAS designation <0.001 y CRNA closeness y Length of stay <6 d z CRNA closeness y Compliance score > y Surgical site infection, compliance score >0.6 z y All morbidity z CRNA clustering coefficient y Compliance score > y Return to the operating room z CRNA closeness y CRNA clustering coefficient y *Covariables included ERAS designation, centrality measures for anesthesiologist, CRNA, and surgeon from univariable analysis (any measure that resulted in p < 0.1). y Statistically significant. z Compliance score >0.6 was also included among covariables for the length of stay <6 d, surgical site infections, all morbidity, and return to the operating room multivariable regression analyses. CRNA, certified registered nurse anesthetist; ERAS, Enhanced Recovery after Surgery.

8 274 Grant et al Operating Room Teamwork and Enhanced Recovery J Am Coll Surg process measure compliance, an effect that ultimately led to downstream effects on several major clinical outcomes. High compliance was independently associated with reduced LOS, SSIs, and morbidity. In short, each of the clinical outcomes evaluated were positively influenced through the recruitment of dedicated ERAS-certified providers. Several more granular conclusions can be made from these network data. Importantly, despite a relative increase in the potential size of the network on implementation of ERASdas reflected by an increase in the number of cases involved in our analysisdthere was not a significant increase in the overall degree of the network. At first glance, this might suggest that centrality is shifted from one provider type (surgeons) to another (anesthesia providers). This plausible explanation might stem from the fact that our intervention specifically designated anesthesia providers to ERAS cases, and surgeons roles largely continued unchanged. However, this explanation is unlikely, as there was no significant difference in degree among all provider groups with ERAS implementation. Far more plausible an explanation lies in the interpretation of the other measures of centrality. Although degree is a measure of volume (ie the number of ties per node), clustering coefficient is a measure of interaction (ie how strongly connected the network is). Our study notes a significant increase in clustering coefficient among CRNAs with a concomitant increase (albeit nonsignificant one) among surgeons. Put simply, the ERAS network is more strongly connected than the pre-eras network independent of its larger size. In addition, our data show a decrease in closeness among anesthesiologists, which is most likely due to an inherent consolidation of their role associated with the introduction of the ERAS program. The goal of this study is to determine whether incorporating an intraoperative ERAS team into a hospital s program improves care processes and patient outcomes. The notion that teamwork impacts clinical processes and outcomes is not new. 13 In general, team performance is described in terms of inputs (ie relatively stable characteristics of the team, its members, task, and setting), mediators or processes (ie their interactions with one another preparing for, completing, and reflecting on their work), and outcomes (ie performance outcomes, learning). 14 Most interventions (eg team training, surgical team checklists) 15,16 for improving teamwork in surgical services have focused on the team s interactions or processes. This work is unique in that it focuses on the composition of the team (ie attributes of the team members). Although our study did not assess changes in team interaction, there are 2 logical mechanisms from earlier team research that could explain the observed effect: team familiarity and shared mental models. First, teams whose members have a history of working together perform better than those that do not. 17,18 The scheduling component of this intervention increased the regularity with which people on the ERAS team shared patient cases and had the opportunity to become familiar with one another. Second, teams that hold shared mental models (eg similar or complementary ideas about which protocols are appropriate for a given patient and what those protocols entail) do better than teams that do not. 19 By volunteering to become a part of the ERAS team, providers were given detailed information about ERAS protocols and ERAS patients were clearly designated to ensure all knew when those protocols were appropriate. Although all 4 measures of centrality provide unique insight as to the predominance of any specific node (or provider type), the sum effect of the available data suggest that the introduction of the ERAS program did, in fact, lead to more teamwork between providers. In fact, the centrality measures describing improved teamwork were positively associated with several noted clinical outcomes. Enhanced Recovery after Surgery designation and CRNA closeness were associated with increased process measure compliance, which was, in turn, associated with reductions in LOS, SSI, and postoperative morbidity. Several measures of centrality among CRNAs were also associated with these end points, including reduction in rates of reoperation. This large and widespread effect of the CRNA providers, both in terms of their ERAS designation and their centrality measures, is quite interesting. It is logical to conclude that regular assignment to familiar cases (and protocols) would lead to improved rates of compliance, but it is more compelling to show that it further correlates with improved clinical outcomes. Others have previously shown that increased compliance with ERAS protocols is associated with improved outcomes, 4 but obtaining strong compliance remains a difficult aspect of clinical care. Within the analyzed OR network, CRNAs are the decision makers of many of the variables that the ERAS protocol describes inthepreoperativeandintraoperative setting, such as fluid management, sedation, and narcotic use. It is clear that successful compliance of ERAS and its effect on improved outcomes in this cohort were largely affected by the ERAS certification of CRNAs. This suggests that at least one approach to improving compliance, and therefore outcomes, is to build designated teams of providers, particularly those at the forefront of administering care. To initiate this program, our strategy included identification of a core group of attending anesthesiologists and

9 Vol. 226, No. 3, March 2018 Grant et al Operating Room Teamwork and Enhanced Recovery 275 CRNAs. This was done at the exclusion of another frontline provider group, the anesthesiology residents. This was done in an effort to further reduce the potential for variation in practice, as residents rotated frequently and the volume of the residency (more than 120 residents during the study period) posed a particular challenge in providing adequate initial education and consistent program updates. This was done because the idea of following a protocol for anesthesia in the general ORs was a new concept and we wanted to control the number of people who were involved in the pilot. Although there were certainly isolated examples where inexperienced/ uncohorted providers overlapped with uncertified ERAS providers, this was very uncommon. More recently, as the ERAS program expanded to other services (liver resection, urology, gynecologic oncology), we began to incorporate the residents as rotating providers as well, provided they undergo training through a similar didactic as the CRNA cohort. There are several important limitations to this study. The results of our study are based on the selection of a primary provider for each individual procedure. Although our selection accounts for identification of providers with the greatest contact time in any given case, our analysis does not capture the potential for alterations in anesthetic plans or process measure compliance associated with intraoperative provider relief. In addition, it should be recognized that before-and-after analysis, as performed in this study, is potentially confounded by uncontrolled variables, parallel patient care initiatives, and even simple regression to the mean that cannot be entirely accounted for in multivariable analysis. That said, our model does incorporate patient-related variables, including demographics, American Society of Anesthesiology score, and procedure-specific variables, most notably open vs laparoscopic approach. Finally, our study was conducted in the setting of a large, quaternary academic institution. As such, staffing models, resource allocation and scheduling should all be accounted for when attempting to reproduce similar results in an alternative setting. CONCLUSIONS In an era where hospitals are increasingly seeking to increase the value of health care, ERAS programs have been successful not only in reducing inter-provider variability, but in improving postoperative outcomes. To ensure evidence-based process measures are used, providers are tasked with developing mechanisms to improve overall compliance with program elements. Through the designation of dedicated ERAS provider teams, our study can shed light on at least one key aspect to not only improve compliance, but extract increased value from the perioperative care environment. Author Contributions Study conception and design: Hanna, Rosen, Wick Acquisition of data: Grant, Hanna, Benson, Hobson, Wu, Wick Analysis and interpretation of data: Grant, Hanna, Benson, Hobson, Wu, Yuan, Rosen, Wick Drafting of manuscript: Grant, Hanna, Yuan, Rosen, Wick Critical revision: Grant, Hanna, Benson, Hobson, Wu, Yuan, Rosen, Wick REFERENCES 1. Wind J, Polle SW, Fung Kon Jin PH, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006;93:800e Grant MC, Yang D, Wu CL, et al. Impact of Enhanced Recovery after Surgery and fast track surgery pathways on healthcare-associated infections: results from a systematic review of meta-analysis. Ann Surg 2017;265:68e Cakir H, van Stijn MF, Lopes Cardozo AM, et al. 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