Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial

Randomized Controlled Trial of Extended Perioperative Counseling in Enhanced Recovery After Colorectal Surgery

BACKGROUND

Enhanced recovery after surgery programs reduce the length of hospital stay in patients who undergo elective colorectal resection, but the reasons for this reduction are not well understood.

OBJECTIVE

The aim of this randomized controlled trial was to assess the impact of extended perioperative counseling in treatment groups that were otherwise the same with respect to enhanced recovery after surgery criteria.

DESIGN

Patients eligible for open or laparoscopic colorectal resection were randomly assigned to extended counseling (repeated information and guidance by a dedicated nurse) or standard counseling.

SETTINGS

This study was conducted at a single institution.

PATIENTS

Patients (n = 164) were randomly assigned to enhanced recovery after surgery plus extended counseling (n = 80) or enhanced recovery after surgery with standard counseling (n = 84).

MAIN OUTCOME MEASURES

The primary end point was the total length of hospital stay. Discharge criteria were defined. Secondary end points were postoperative complications, postoperative length of hospital stay, readmission rate, and mortality.

RESULTS

Total hospital stay was significantly shorter among patients randomly assigned to enhanced recovery after surgery plus extended counseling (median 5 (range 2-29) days vs 7 (range 2-39) days, p < 0.001). The 2 treatment groups differed in adherence to the elements of postoperative enhanced recovery after surgery such as mobilization and total oral intake. The 2 treatment groups did not differ in overall, major, and minor morbidity; reoperation rate; readmission rate; and 30-day mortality.

LIMITATIONS

The main limitation of this study was the absence of blinding.

CONCLUSIONS

Perioperative information and guidance were important factors in enhanced recovery after surgery care and were associated with a significantly shorter length of hospital stay. Our findings suggest that perioperative counseling enables patients to comply with the elements of postoperative enhanced recovery after surgery and thereby reduces the length of hospital stay. This study was registered with ClinicalTrials.gov (NCT01610726). See Video Abstract at http://links.lww.com/DCR/A505.

Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy

BACKGROUND

Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs.

STUDY DESIGN

Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated.

RESULTS

The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation.

CONCLUSION

Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.

Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy

Background

Enhanced Recovery After Surgery (ERAS) pathways have been shown in multiple surgical disciplines to improve outcomes, including reduced opioid consumption, length of stay, and post-operative nausea and vomiting (PONV). However, very few studies describe the application of ERAS to breast surgery and even fewer describe ERAS for outpatient surgery. We describe the implementation and efficacy of an Enhanced Recovery After Surgery (ERAS) pathway for total skin-sparing mastectomy with immediate reconstruction in an outpatient setting.

Methods

We implemented an evidence-based, multimodal ERAS pathway for all patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction at a single 23-h stay surgery center. Highlights of the ERAS pathway included: preoperative acetaminophen, gabapentin, and scopolamine; regional anesthesia for the breast (Pectoral blocks type 1 and 2 or paravertebral block); and intraoperative dexamethasone and ondansetron. This retrospective study included all American Society of Anesthesiology (ASA) Class 1–3 patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction between July 2013 and April 2016. We compared 96 patients who were in the ERAS pathway (ERAS group) to a retrospective cohort of 276 patients (Pre group). The primary outcome was total perioperative opioid consumption. Secondary outcomes were highest postoperative pain scores, incidence of PONV, and length of stay.

Results

Patients in the ERAS group had significantly lower total perioperative opioid consumption compared to the Pre group (mean (SD): 111.4 mg (46.0) vs. 163.8 mg (73.2) oral morphine equivalents, p < 0.001). Patients in the ERAS group also had a lower incidence of PONV (28% vs. 50%, p < 0.001). Patients in the ERAS group reported less pain in the recovery room, with a two-point decrease in highest pain score (median [interquartile range (IQR)]: 4 [2,6] in ERAS group vs. 6 [4,7] in Pre group, p < 0.001). There was no clinically significant difference in length of stay (median [IQR]: 1144 min [992, 1259] in ERAS group vs. 1188 [1058, 1344] in Pre group, p = 0.006).

Conclusion

Implementation of an ERAS pathway for total skin-sparing mastectomy with reconstruction that incorporates regional anesthesia is feasible in a 23-h-stay hospital. Patients in the ERAS pathway had improved post-operative analgesia and reduced post-operative nausea and vomiting.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0505-9) contains supplementary material, which is available to authorized users.

Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.

Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients

Aim: Enhanced recovery after surgery (ERAS) is a multimodal approach that aims to optimize perioperative treatment. Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain. The aim of this study was to compare patients in different age groups participating in an ERAS program. Method: In this substudy of a randomized controlled trial, we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age. Patients were divided into three groups based on age: ≤65 years (n = 79), 66-79 years (n = 56), and ≥80 years (n = 19). The primary end point was total postoperative hospital stay (THS). Secondary end points were postoperative hospital stay, postoperative complications, postoperative C-reactive protein levels, readmission rate, mortality, and patient adherence to the different ERAS elements. All parameters and measuring the adherence to the ERAS protocol were recorded before surgery, on the day of the operation, and daily until discharge. Results: There were no significant differences in length of THS between age groups (≤65 years, median 5 [range 2-47] days; 66-79 years, median 5.5 [range 2-36] days; ≥80 years, median 7 [range 3-50] days; p = .53). All secondary outcomes were similar between age groups. Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients. Conclusion: Elderly patients adhered to and benefited from an ERAS program, similar to their younger counterparts.

Assessment of Gaps in Care and the Development of a Care Pathway for Anemia in Patients with Inflammatory Bowel Diseases

BACKGROUND

Anemia is a common complication among patients with inflammatory bowel diseases (IBD) and is associated with high rates of IBD-related complications, resource utilization, and impaired quality of life. Despite practice guidelines for anemia in patients with IBD, gaps remain in the perceptions of anemia among health care providers. The aims of this study were to identify gaps in care and to develop a care pathway for anemia in patients with IBD.

METHODS

The Crohn's & Colitis Foundation of America anemia care pathway was developed by a committee using principles of cognitive task analysis. Focus groups of providers of patients with IBD were performed to identify domains of perceptions and management decisions for anemia and IBD. Knowledge elicitation from subject experts in anemia was conducted using case-based scenarios of patients with IBD and anemia to determine decision-making branch points. The care pathway was modified in an iterative fashion to encompass clinical presentations of anemia in IBD and potential barriers to the recognition, management, and follow-up of anemia.

RESULTS

Variations were observed in how providers define iron deficiency, thresholds for treatment of anemia, and route of iron therapy. A care pathway for anemia incorporating the World Health Organization definition of anemia, universal hemoglobin and ferritin screening, evaluation of iron stores using ferritin and transferrin saturation, management of anemia based on adequacy of iron stores, and follow-up was developed.

CONCLUSIONS

The authors identified domains of how providers perceive and manage patients with IBD and anemia, and developed a care pathway to align clinical practices with guideline recommendations.