Enhanced recovery after surgery (ERAS) protocol reduces LOS without additional adverse events in spine surgery

OBJECTIVEEnhanced recovery after surgery (ERAS) has led to a paradigm shift in various surgical specialties. Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process. Still, ERAS remains relatively new to spine surgery. The authors report their 5-year experience, focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures, including anterior lumbar interbody fusion (ALIF).METHODSA multimodal ERAS protocol was applied between November 2013 and October 2018. The authors analyze hospital stay, perioperative outcomes, readmissions, and adverse events obtained from a prospective institutional registry. Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive (MI) anterior or posterior fusion cases were included. Their institutional ERAS protocol contains 22 pre-, intra-, and postoperative elements, including preoperative patient counseling, MI techniques, early mobilization and oral intake, minimal postoperative restrictions, and regular audits.RESULTSA total of 2592 consecutive patients were included, with 199 (8%) undergoing fusion. The mean hospital stay was 1.1 ± 1.2 days, with 20 (0.8%) 30-day and 36 (1.4%) 60-day readmissions. Ninety-four percent of patients were discharged after a maximum 1-night hospital stay. Over the 5-year period, a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed (p < 0.001), with a concomitant decrease in adverse events in the overall cohort (p = 0.025) and without increase in readmissions. For fusion procedures, the rate of 1-night hospital stays increased from 26% to 85% (p < 0.001). Similarly, the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days (p < 0.001), with a notable concomitant decrease in variance, resulting in an estimated reduction in nursing costs of 46.8%.CONCLUSIONSApplication of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures, including ALIF, for treatment of degenerative spine conditions was safe and effective, without increase in readmissions. The data from this large case series stress the importance of the multidisciplinary, iterative improvement process to overcome the learning curve associated with ERAS implementation, and the importance of a dedicated perioperative care team. Prospective trials are needed to evaluate spinal ERAS on a higher level of evidence.

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À propos de: ``Enhanced recovery after surgery (ERAS) protocol reduces LOS without additional adverse events in spine surgery'' d’Astorg H, Fière V, Dupasquier M, Vieira TD, Szadkowski M publié dans Orthopaedics & Traumatology: Surgery & Research. 2020:106(6):1167–1173

Revue de Chirurgie Orthopédique et Traumatologique ◽

10.1016/j.rcot.2021.03.005 ◽

2021 ◽

Vol 107 (3) ◽

pp. 390-391

Author(s):

Bhavuk Garg ◽

Nishank Mehta

Keyword(s):

Adverse Events ◽

Spine Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Surgery Research ◽

Eras Protocol

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Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20795 ◽

2020 ◽

pp. 1-23

Author(s):

Zach Pennington ◽

Ethan Cottrill ◽

Daniel Lubelski ◽

Jeff Ehresman ◽

Nicholas Theodore ◽

...

Keyword(s):

Lumbar Spine ◽

Spine Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Meta Analysis ◽

Lumbar Spine Surgery ◽

Complication Rates ◽

Protocol Implementation ◽

Eras Protocol ◽

Adult Spine

OBJECTIVESpine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.METHODSUsing the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.RESULTSOf 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference −1.22 days [95% CI −1.98 to −0.47]) and lumbar spine ERAS protocols (−1.53 days [95% CI −2.89 to −0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.CONCLUSIONSPresent data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

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P.233 Implementation of an Enhanced Recovery After Surgery (ERAS) Protocol for Scheduled Spine Surgery

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2021.524 ◽

2021 ◽

Vol 48 (s3) ◽

pp. S87-S88

Author(s):

J Smith-Forrester ◽

R Greene ◽

S Christie

Keyword(s):

Spine Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Current System ◽

Length Of Hospital Stay ◽

Care Program ◽

Cost Of Care ◽

Operative Care ◽

Eras Protocol ◽

Future Work

Background: Enhanced Recovery After Surgery (ERAS) Protocols improve post-surgical outcomes through decreased length of hospital stay, reduced readmission rates, decreased post-operative pain, and greater patient satisfaction. ERAS also has significant benefits to the healthcare system through reduced cost of post-operative care. While ERAS protocols are well established in many surgical fields, a complete guideline for spine surgery is lacking. Early ERAS studies in spine surgery suggest up to a 50% reduction in length of stay (LOS) and decreased cost of care. Methods: Primary literature review followed by multidisciplinary critical appraisal for optimization and redesign of our current system of care for scheduled spine surgery (SSS), including patient experience and team logistics from initial consultation through post-operative care and follow up. Results: An evidence-based guideline, optimizing pre-, intra-, and post-operative phases of care was developed. Specific focus catered to pre-operative education and patient barriers to discharge. Further improvements in pre-admission patient goal setting, introduction of a patient care “passport”, post-operative reduction in narcotic administration, and increased same day post-operative mobilization were means to reduce LOS. Conclusions: A spine ERAS pathway was developed, allowing our care program to better facilitate patient recovery after SSS. Future work will aim to determine economic impact of the pathway.

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The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic gynecologic oncology practice

Gynecologic Oncology ◽

10.1016/j.ygyno.2019.11.017 ◽

2020 ◽

Vol 156 (2) ◽

pp. 284-287 ◽

Cited By ~ 9

Author(s):

Zachary L. Gentry ◽

Teresa K.L. Boitano ◽

Haller J. Smith ◽

Dustin K. Eads ◽

John F. Russell ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Financial Impact ◽

Oncology Practice ◽

Eras Protocol

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The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2017.10.151 ◽

2018 ◽

Vol 155 (4) ◽

pp. 1843-1852 ◽

Cited By ~ 38

Author(s):

Luke J. Rogers ◽

David Bleetman ◽

David E. Messenger ◽

Natasha A. Joshi ◽

Lesley Wood ◽

...

Keyword(s):

Lung Cancer ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Primary Lung Cancer ◽

Protocol Compliance ◽

Eras Protocol ◽

The Impact

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Answer to the Letter to the Editor of Xu C, et al. concerning “Implementation of enhanced recovery after surgery (ERAS) protocol for anterior cervical discectomy and fusion: a propensity score-matched analysis” by Debono B et al. [Eur Spine J (2020): DOI 10.1007/s00586-020-06445-0]

European Spine Journal ◽

10.1007/s00586-021-06791-7 ◽

2021 ◽

Vol 30 (4) ◽

pp. 1083-1084

Author(s):

Bertrand Debono

Keyword(s):

Propensity Score ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Anterior Cervical Discectomy ◽

Cervical Discectomy ◽

Letter To The Editor ◽

Eras Protocol

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Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1740125 ◽

2021 ◽

Author(s):

Nicholas T. Haddock ◽

Ricardo Garza ◽

Carolyn E. Boyle ◽

Sumeet S. Teotia

Keyword(s):

Breast Reconstruction ◽

Patient Outcomes ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Compliance Rate ◽

Fluid Management ◽

Control Group ◽

Diep Flap ◽

Deep Inferior Epigastric Perforator ◽

Eras Protocol

Abstract Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

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Creation of an Enhanced Recovery After Surgery (ERAS) Guideline for neonatal intestinal surgery patients: a knowledge synthesis and consensus generation approach and protocol study

BMJ Open ◽

10.1136/bmjopen-2018-023651 ◽

2018 ◽

Vol 8 (12) ◽

pp. e023651 ◽

Cited By ~ 7

Author(s):

Ashleigh C N Gibb ◽

Megan A Crosby ◽

Caraline McDiarmid ◽

Denisa Urban ◽

Jennifer Y K Lam ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Rapid Review ◽

Second Phase ◽

Intestinal Surgery ◽

Quality Of Evidence ◽

Modified Delphi ◽

Human Ethics ◽

Eras Protocol

IntroductionEnhanced Recovery After Surgery (ERAS) guidelines integrate evidence-based practices into multimodal care pathways designed to optimise patient recovery following surgery. The objective of this project is to create an ERAS protocol for neonatal abdominal surgery. The protocol will identify and attempt to bridge the gaps between current practices and best evidence. Our study is the first paediatric ERAS protocol endorsed by the International ERAS Society.MethodsA research team consisting of international clinical and family stakeholders as well as methodological experts have iteratively defined the scope of the protocol in addition to individual topic areas. A modified Delphi method was used to reach consensus. The second phase will include a series of knowledge syntheses involving a rapid review coupled with expert opinion. Potential protocol elements supported by synthesised evidence will be identified. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system will be used to determine strength of recommendations and the quality of evidence. The third phase will involve creation of the protocol using a modified RAND/UCLA Appropriateness Method. Group consensus will be used to rate each element in relation to the quality of evidence supporting the recommendation and the appropriateness for guideline inclusion. This protocol will form the basis of a future implementation study.Ethics and disseminationThis study has been registered with the ERAS Society. Human ethics approval (REB 18–0579) is in place to engage patient families within protocol development. This research is to be published in peer-reviewed journals and will form the care standard for neonatal intestinal surgery.

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