Implementation of the Enhanced Recovery After Surgery (ERAS®) program in neurosurgery

BACKGROUND

Over the past decade, Enhanced Recovery After Surgery (ERAS®) guidelines have been proven to simplify postoperative care and improve recovery in several surgical disciplines. The authors set out to create and launch an ERAS® program for cranial neurosurgery that meets official ERAS® Society standards. The authors summarize the successive steps taken to achieve this goal in two specific neurosurgical conditions and describe the challenges they faced.

METHODS

Pituitary neuroendocrine tumors (Pit-NET) resected by a transsphenoidal approach and craniosynostosis (Cs) repair were selected as appropriate targets for the implementation of ERAS® program in the Department of Neurosurgery. A multidisciplinary team with experience in managing these pathologies was created. A specialized ERAS® nurse coordinator was hired. An ERAS® certification process was performed involving 4 seminars separated by 3 active phases under the supervision of an ERAS® coach.

RESULTS

The ERAS® Pit-NET team included 8 active members. The ERAS® Cs team included 12 active members. Through the ERAS® certification process, areas for improvement were identified, local protocols were written, and the ERAS® program was implemented. Patient-centered strategies were developed to increase compliance with the ERAS® protocols. A prospective database was designed for ongoing program evaluation. Certification was achieved in 18 months. Direct costs and time requirements are reported.

CONCLUSION

Successful ERAS® certification requires a committed multidisciplinary team, an ERAS® coach, and a dedicated nurse coordinator.

Physical Activity, Quality of Life, and Nursing Workload in Colorectal Surgery

Postoperative recovery depends on a complex interplay of patient-related factors of which mobility is an essential part. The aim of this study is to evaluate correlations between perioperative physical activity, quality of life, and postoperative nursing workload in colorectal surgery. A prospective study was used to assess footsteps, quality of life, and nursing workload. Number of footsteps was recorded from preoperative day 5 to postoperative day 3. Patients with reduced and good mobilization were compared, and the cut-off defined by the median daily preoperative footsteps. Quality of life was assessed by the Cleveland Global Quality of Life (CGQL). Nursing workload was calculated using the Project Research in Nursing (PRN) score. Statistical correlation was measured by use of the Pearson coefficient. Fifty patients were included. Mean age was 59 years, mean body mass index was 25 kg/m2, and 68% of them were males. Demographics, surgical details, and clinical outcomes were comparable between the group of patients with poor mobilization compared to those with good mobilization. No correlation was found between pre- or post-operative footsteps and CGQL (r =  − 0.072, p = 0.640 and r =  − 0.127, p = 0.407), as well as between the number of pre- or post-operative footsteps and PRN (r = 0.060, p = 0.687 and r =  − 0.095, p = 0531). In conclusion, no correlation was found between the number of perioperative footsteps, quality of life, and nursing workload after colorectal surgery.

Swiss Validation of the Enhanced Recovery After Surgery (ERAS) Database

Background

Enhanced recovery after surgery (ERAS) pathways have considerably improved postoperative outcomes and are in use for various types of surgery. The prospective audit system (EIAS) could be a powerful tool for large-scale outcome research but its database has not been validated yet.

Methods

Swiss ERAS centers were invited to contribute to the validation of the Swiss chapter for colorectal surgery. A monitoring team performed on-site visits by the use of a standardized checklist. Validation criteria were (I) coverage (No. of operated patients within ERAS protocol; target threshold for validation: ≥ 80%), (II) missing data (8 predefined variables; target ≤ 10%), and (III) accuracy (2 predefined variables, target ≥ 80%). These criteria were assessed by comparing EIAS entries with the medical charts of a random sample of patients per center (range 15–20).

Results

Out of 18 Swiss ERAS centers, 15 agreed to have onsite monitoring but 13 granted access to the final dataset. ERAS coverage was available in only 7 centers and varied between 76 and 100%. Overall missing data rate was 5.7% and concerned mainly the variables “urinary catheter removal” (16.4%) and “mobilization on day 1” (16%). Accuracy for the length of hospital stay and complications was overall 84.6%. Overall, 5 over 13 centers failed in the validation process for one or several criteria.

Conclusion

EIAS was validated in most Swiss ERAS centers. Potential patient selection and missing data remain sources of bias in non-validated centers. Therefore, simplified validation of other centers appears to be mandatory before large-scale use of the EIAS dataset.

Supplementary Information

The online version contains supplementary material available at (10.1007/s00268-020-05926-z).

Impact of staffing a surgical intermediate care unit with a critical care specialist

AIM

To assess the impact of reorganising an 11-bed surgical intermediate care unit (IMCU) from an open to a semi-closed system in a Swiss University Hospital by adding a critical care specialist (CCS).

METHODS

This was a cohort study including adult IMCU patients enrolled in an Enhanced Recovery After Surgery protocol in the Department of Visceral Surgery, Lausanne University Hospital, from 1 February 2014 to 31 January 2016. Medical supervision by a CCS was implemented on 1 February 2015.

RESULTS

Introduction of a CCS in a surgical IMCU significantly reduced intensive care unit length of stay (p = 0.005) and potentially preventable operation (p = 0.04) for patients undergoing oesophageal surgery. A CCS in IMCU also proved to significantly reduce readmission in IMCU for hepatic surgery patients (p = 0.04). For other sub-specialties (colorectal, pancreatic and gastric bypass surgery) no significant difference could be found.

CONCLUSIONS

Reorganisation of a surgical IMCU from an open to a semi-closed system by implementing supervision by a CCS decreased length of stay and complications for the most fragile surgical patients (oesophageal and hepatic patients) after 12 months of implementation.

Feasibility of early postoperative mobilisation after colorectal surgery: A retrospective cohort study

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines advocate early postoperative mobilisation to counteract catabolic changes due to immobilisation and maintain muscle strength. The present study aimed to assess compliance to postoperative mobilisation according to ERAS recommendations.

MATERIALS AND METHODS

This is a retrospective cohort study on consecutive colorectal surgical procedures treated within an established ERAS protocol within a single center between May 2011 and May 2017. Demographics, surgical details, ERAS related items and surgical outcome were prospectively assessed in a dedicated database and compared between ambulant patients (at least 6 h out of bed at postoperative day (POD) 1) vs. patients not meeting the target (delayed mobilisation). Risk factors for decreased postoperative mobilisation were identified through multivariable logistic regression.

RESULTS

1170 patients were retained. 676 patients (58%) did not mobilise as recommended by ERAS protocol at POD1. Emergency operation (Odds Ratio (OR) 0.40; 95% Confidence Interval (CI) 0.18-0.91, p = 0.028), age > 70 years (OR 0.69; 95% CI 0.47-1.00, p = 0.050) and intraoperative total fluids > 2000 mL (OR 0.59; 95% CI 0.37-0.93, p = 0.025) were independent risk factors for delayed mobilisation. Patients with delayed mobilisation had significantly more overall (Clavien grade IV) (55% vs. 29%, p=<0.001), major (Clavien grade IIIb-V) (16% vs. 7%, p=<0.001) and respiratory (12% vs. 4%, p=<0.001) complications, as well as longer length of stay (12 ± 14 vs. 6±7days, p=<0.001).

CONCLUSIONS

More than half of patients did not mobilise as recommended by ERAS guidelines. Emergency surgery, advanced age and fluid overload were independent risk factors for delayed mobilisation, which was associated with increased postoperative complications.

Enhanced Recovery after Elective Colorectal Surgery - Reasons for Non-Compliance with the Protocol

BACKGROUND/AIMS

Enhanced recovery after surgery (ERAS) protocols for elective colorectal surgery reduce the intensity of postoperative complications, hospital stays and costs. Improvements in clinical outcome are directly proportional to the adherence to the recommended pathway (compliance). The aim of the present study was to analyze reasons for the non-compliance of colorectal surgeries with the ERAS protocol.

METHODS

A consecutive cohort of patients undergoing elective colorectal surgery was prospectively analyzed with regards to the surgery's compliance with the ERAS protocol. The reason for every single protocol deviation was documented and the decision was categorized based on whether it was medically justified or not.

RESULTS

During the 8-month study period, 76 patients were included. The overall compliance with 22 ERAS items was 76% (96% in the preoperative, 82% in the perioperative, and 63% in the postoperative period). The decision to deviate from the clinical pathway was mainly a medical decision, while patients and nurses were responsible in 26 and 14% of the cases, respectively. However, reasons for non-compliance were medically justified in 78% of the study participants.

CONCLUSION

'Non-compliance' with the ERAS protocol was observed mostly in the postoperative period. Most deviations from the pathway were decided by doctors and in a majority of cases it appeared that they were due to a medical necessity rather than non-compliance. However, almost a quarter of deviations that were absolutely required are still amenable to improvement.

Impact of weekday surgery on application of enhanced recovery pathway: a retrospective cohort study

OBJECTIVE

To compare the enhanced recovery after surgery (ERAS) protocol compliance and clinical outcomes depending on the weekday of surgery.

SETTINGS

Cohort of consecutive non-selected patients undergoing elective colorectal surgery from January 2012 to March 2015. This retrospective analysis of our prospective database compared patients operated early in the week (Monday and Tuesday) with patients operated in the second half (late: Thursday, Friday).

PRIMARY OUTCOME MEASURES

Compliance with the ERAS protocol, functional recovery, complications and length of stay.

RESULTS

Demographic and surgical details were similar between the early (n=352) and late groups (n=204). Overall compliance with the ERAS protocol was 78% vs 76% for the early and late groups, respectively (p=0.009). Significant differences were notably prolonged urinary drainage and intravenous fluid infusion in the late group. Complication rates and length of stay, however, were not different between surgery on Monday or Tuesday and surgery on Thursday or Friday.

CONCLUSIONS

Application of the ERAS protocol showed only minor differences for patients operated on early or late during the week, and clinical outcomes were similar. A fully implemented ERAS programme appears to work also over the weekend.

Abortion trends 1990-1999 in a Swiss region and determinants of abortion recurrence

OBJECTIVE

To assess age- and nationality-specific trends in abortion rates over the last decade, and to describe women's characteristics, identifying risk factors for repeated abortion.

METHODS

From 1990-1999, the Health Department of Canton Vaud (Switzerland) received 13'857 abortion requests from residents aged 14-49. Population data were obtained to compute rates.

RESULTS

Both the number of abortions (1400 annually) as well as their rate (8.9 per thousand women [95% confidence interval (CI) 7.3-10.5]) were stable over the decade in question. The rate of abortion for foreign women, especially from ex-Yugoslavia and Africa, was twice that for Swiss women. Half of the requests came from single women, 43% had a low education level, and half were childless. The main reason for requesting termination of pregnancy was psychosocial (93%). The mean gestational age was 7.7 weeks (SD +/- 2.3), but 96% of requests were submitted before 12 weeks. Sixty-three percent of women reported that they had used no contraception, 36% the condom and 17% the pill. Among requests, the adjusted risk of repeated abortion (22% of abortion candidates) was greater among divorced/separated/widowed women (odds ratio [OR] 1.9 [95% CI 1.5-2.4]), unemployed women (OR 1.8 [95% CI 1.5-2.1]), and those who had not attended university (OR 1.6 [95% CI 1.1-2.2]).

CONCLUSIONS

Although Swiss law only permitted abortion under strict conditions, this procedure was widely available in Vaud, which nevertheless has one of the lowest rates worldwide. Efforts must be intensified to ensure universal access to family planning services, especially for foreign women and adolescents. Professionals should also target "repeaters" to provide personalised counselling.

Abortion trends 1990-1999 in a Swiss region and determinants of abortion recurrence

OBJECTIVE

To assess age- and nationality-specific trends in abortion rates over the last decade, and to describe women's characteristics, identifying risk factors for repeated abortion.

METHODS

From 1990-1999, the Health Department of Canton Vaud (Switzerland) received 13'857 abortion requests from residents aged 14-49. Population data were obtained to compute rates.

RESULTS

Both the number of abortions (1400 annually) as well as their rate (8.9 per thousand women [95% confidence interval (CI) 7.3-10.5]) were stable over the decade in question. The rate of abortion for foreign women, especially from ex-Yugoslavia and Africa, was twice that for Swiss women. Half of the requests came from single women, 43% had a low education level, and half were childless. The main reason for requesting termination of pregnancy was psychosocial (93%). The mean gestational age was 7.7 weeks (SD +/- 2.3), but 96% of requests were submitted before 12 weeks. Sixty-three percent of women reported that they had used no contraception, 36% the condom and 17% the pill. Among requests, the adjusted risk of repeated abortion (22% of abortion candidates) was greater among divorced/separated/widowed women (odds ratio [OR] 1.9 [95% CI 1.5-2.4]), unemployed women (OR 1.8 [95% CI 1.5-2.1]), and those who had not attended university (OR 1.6 [95% CI 1.1-2.2]).

CONCLUSIONS

Although Swiss law only permitted abortion under strict conditions, this procedure was widely available in Vaud, which nevertheless has one of the lowest rates worldwide. Efforts must be intensified to ensure universal access to family planning services, especially for foreign women and adolescents. Professionals should also target "repeaters" to provide personalised counselling.

Abortion requests among adolescents in comparison with young adults in a Swiss region (1990-1998)

AIM

To examine the recent evolution of abortion request rates among adolescents and young adults in the Canton of Vaud (Switzerland) and to describe the circumstances of the abortion requests and sociodemographic characteristics by age subgroups and nationality.

METHOD

Data for women aged 14 to 24 y living in Vaud were selected from the 12,358 abortion requests from residents aged 14-49 y between 1990 and 1998.

RESULTS

Overall, abortion request rates by age were stable over the study period. However, rates for non-Swiss women were two to three times higher than those for Swiss women, at 4.5 [95% confidence interval [CI]: 3.8-5.2] vs 2.4 [95% CI: 2.1-2.7] per 1000 adolescents below the age of 18, 18.1 [95% CI: 17.2-18.9] vs 8.0 [95% CI: 7.1-8.8] per 1000 women aged 18-19 and 30.5 [95% CI: 29.1-32.0] vs 10.2 [95% CI: 9.6-10.8] per 1000 women aged 20-24. The ratio of abortions to live births was greatest for women under 20 y of age. at 1.9, in comparison with the ratio observed among adult women aged 20-24 (at 0.4). The abortion rate per 1000 conceptions >6 wk remained stable; this rate was 590 per 1000 among 14-19-y-olds in 1997.

CONCLUSION

The abortion request rate among youths in this Swiss region has not increased between 1990 and 1998. Efforts must be intensified to ensure universal access to family planning services and contraception, especially for young foreign women and adolescents.

Impact of infertility treatments on the health of newborns

OBJECTIVE

To measure the use of infertility treatments in the general population and their association with neonatal health.

DESIGN

Cross-sectional, population-based study.

SETTING

Canton of Vaud, Switzerland; Etude du Developpement des Nouveau-nés (EDEN), a prospective study of chronic childhood conditions.

PATIENT(S)

Six thousand four hundred seventy-seven live newborns (6,379 pregnancies) delivered of residents of Vaud in the 19 maternity hospitals between 1993 and 1994.

MAIN OUTCOME MEASURE(S)

Neonatal morbidity, multiplicity, low birth weight, prematurity, intrauterine growth retardation, transfer to intensive care, and length of hospital stay.

RESULT(S)

Infertility treatments were reported for 2.1% of pregnancies (129 women, 148 newborns) and were associated significantly with adverse outcomes. Population-attributable risks varied from 3%-20%. The outcomes of twins did not differ regardless of whether their mother was treated for infertility. Among singletons, only low birth weight was significantly more frequent when infertility treatments were used. Unadjusted odds ratios for neonatal morbidity were significant only for multiple births (2.56; 95% confidence interval 1.21-5.42). This association was not influenced by maternal characteristics and it disappeared after controlling for sex, gestational age, and birth weight.

CONCLUSIONS(S)

An independent effect of infertility treatments on neonatal morbidity cannot be ruled out, but most of their impact appeared to be mediated by multiplicity and prematurity. Reducing the number of medically induced multiple pregnancies is the most effective prevention of neonatal morbidity related to infertility treatments. Follow-up studies are needed.

[Induced abortion in a Swiss canton from 1990 to 1993: implications for epidemiological surveillance]

BACKGROUND

To describe abortion utilization in the Canton of Vaud (Switzerland) and to identify desirable changes in the data collection system to improve the epidemiologic monitoring

METHODS

Retrospective survey of the 5600 abortion requests to the Canton Health Authority for resident women between 1990 and 1993.

RESULTS

Nine women out of 1000 residents requested an abortion, but the abortion rate was higher among women of foreign origin compared to Swiss women (17/1000 vs. 6/1000, p < 0.0001). The proportion of terminated recognized conceptions was 127/1000, and the ratio of IVG to livebirths was 0.18. The abortion rate was lower during adolescence (6/1000) or after 40 years of age (1.8/1000), whereas the proportion of terminated conceptions was highest at these ages (527/1000 and 312/1000). Abortion utilization in Canton of Vaud is among the lowest.

CONCLUSIONS

Although these indicators do reflect a satisfactory accessibility and use of family planning services, improvements could be made. A better knowledge of the causes (motives, contraceptive method, reproductive history) and of the consequences of abortion (psycho-social implications, medical complications) would allow to design more focused prevention strategies and to fit health services to current needs. Updating the 1942 Swiss legislation is also desirable.

Enrollment of a population-based cohort of newborns at higher risk of developing a chronic condition: the EDEN study. Etude du Developpement des Nouveau-nés Study

OBJECTIVE

To describe the methods used at birth to recruit a population-based cohort of newborns of all birthweights at higher risk of having a chronic condition, and to present baseline results.

METHODS

Screening of all newborns at hospital discharge for five non-exclusive criteria: (1) low birthweight (LBW), (2) congenital anomalies or genetic disease, (3) specified conditions associated with a high probability of chronicity, (4) referral to a neonatal intensive care unit (NICU), (5) or defined social problems. Calculation of Hobel risk scores for children satisfying > or = 1 criterion.

SUBJECTS

All 6477 live births delivered in the 19 maternity hospitals of a geographically defined region (Vaud, Switzerland) to resident mothers in 1993-1994.

RESULTS

Twelve per cent (n = 760) of newborns met > or = 1 criterion: 6.3% of all newborns had an LBW (criterion 1), 2.4% had a birth defect, 0.9% met criterion (3), 4.4% stayed in an NICU and 1.6% had serious social problems. Hobel prenatal score was high (> or = 10 points) for 41% of children with > or = 1 criterion, the intrapartum score for 87% and the neonatal score for 68%.

CONCLUSIONS

Most newborns identified by the above simple criteria also had elevated perinatal risks. The validity of the criteria will later be tested against the results of the examinations of children with > or = 1 criterion at 18 months and 4 years of age, but the assessment at birth already shows that normal birthweight (NBW) children, in agreement with previous studies, contribute half the children at high risk perinatally.

Population-based incidence of injuries among preschoolers

A population survey was conducted to determine the incidence of injuries among preschoolers and their risk factors. A systematic sample (15%, n = 4540) of families with at least one child aged 0-5 years in 1991 living in the Canton of Vaud (Switzerland) received a mailed questionnaire in February 1992. There were 5827 eligible children in the sample. The response rate was 67.5% after two recall mailings. Injuries were defined as those from all causes with at least one physician contact in 1991. The overall incidence was 224 injuries per 1000 children (95% CI [= confidence intervall]: 211-237); 188 per 1000 children were injured over 1 year (95% CI: 176-200, n = 746), of whom 16.5% (n = 123) had 32 injuries. Falls represented 66% of all injuries, followed by burns (8%) and poisonings (5%). The proportion of hospitalized cases was 4.8% and the population incidence of hospitalization due to injury was 10.8/1000 children. Socioeconomic factors did not influence the occurrence of injuries.

CONCLUSION

The measured incidence of injuries among preschoolers is among the highest in developed countries. Practitioners could contribute more effectively to injury prevention through routine information and counselling of parents from all social backgrounds.