Enhanced Recovery after Surgery for Cesarean Delivery Decreases Length of Hospital Stay and Opioid Consumption: A Quality Improvement Initiative

2020 ◽  
Author(s):  
Julia K. Shinnick ◽  
Merima Ruhotina ◽  
Phinnara Has ◽  
Bridget J. Kelly ◽  
E. Christine Brousseau ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Cesarean Delivery ◽  
Enhanced Recovery ◽  
Length Of Hospital Stay ◽  
Hospital Length ◽  
Opioid Consumption ◽  
Hospital Length Of Stay ◽  
Pain Scores ◽  
Cesarean Deliveries ◽  
Eras Protocol

Objective The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption. Study Design This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation. Results A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05). Conclusion A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective. Key Points

Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction?

2021 ◽  
Author(s):  
Min-Jeong Cho ◽  
Ricardo Garza ◽  
Sumeet S. Teotia ◽  
Nicholas T. Haddock
Keyword(s):  
Length Of Stay ◽  
Breast Reconstruction ◽  
Statistical Difference ◽  
Enhanced Recovery ◽  
Oral Morphine ◽  
Hospital Length ◽  
Opioid Consumption ◽  
Hospital Length Of Stay ◽  
Procedure Time ◽  
Eras Protocol

Abstract Background Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. Methods Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. Results A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. Conclusion Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.

scholarly journals Implementation of an ERAS Pathway in Colorectal Surgery

2019 ◽  
Vol 32 (02) ◽  
pp. 102-108 ◽  
Author(s):  
Liliana Bordeianou ◽  
Paul Cavallaro
Keyword(s):  
Colorectal Surgery ◽  
Length Of Stay ◽  
Postoperative Care ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Standardized Protocol ◽  
Improve Hospital ◽  
Eras Protocol

AbstractEnhanced Recovery after Surgery (ERAS) protocols have been demonstrated to improve hospital length of stay and outcomes in patients undergoing colorectal surgery. This article presents the specific components of an ERAS protocol implemented at the authors' institution. In particular, details of both surgical and anesthetic ERAS pathways are provided with explanation of all aspects of preoperative, perioperative, and postoperative care. Evidence supporting inclusion of various aspects within the ERAS protocol is briefly reviewed. The ERAS protocol described has significantly benefitted postoperative outcomes in colorectal patients and can be employed at other institutions wishing to develop an ERAS pathway for colorectal patients. A checklist is provided for clinicians to easily reference and facilitate implementation of a standardized protocol.

scholarly journals The independent patient factors that affect length of stay following hip fractures

2018 ◽  
Vol 100 (7) ◽  
pp. 556-562 ◽  
Author(s):  
T Richards ◽  
A Glendenning ◽  
D Benson ◽  
S Alexander ◽  
S Thati
Keyword(s):  
Hip Fracture ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Hip Fractures ◽  
Length Of Hospital Stay ◽  
Hospital Length ◽  
Acute Hospital ◽  
Hospital Length Of Stay ◽  
Patient Factors ◽  
Mobility Status

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

scholarly journals Effect of alvimopan on gastrointestinal recovery and length of hospital stay after retroperitoneal lymph node dissection for testicular cancer

2018 ◽  
Vol 12 (2) ◽  
pp. 122-128 ◽  
Author(s):  
Kushan D Radadia ◽  
Nicholas J Farber ◽  
Alexandra L Tabakin ◽  
Wei Wang ◽  
Hiren V Patel ◽  
...  
Keyword(s):  
Lymph Node ◽  
Length Of Stay ◽  
Testicular Cancer ◽  
Lymph Node Dissection ◽  
Length Of Hospital Stay ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Retroperitoneal Lymph Node Dissection ◽  
Node Dissection ◽  
Retroperitoneal Lymph Node

Objective: Alvimopan use has reduced the length of hospital stay in patients undergoing major abdominal surgeries and radical cystectomy. Retroperitoneal lymph node dissection for testicular cancer may be associated with delayed gastrointestinal recovery prolonging hospital length of stay. We evaluate whether alvimopan is associated with enhanced gastrointestinal recovery and shorter hospital length of stay in men undergoing retroperitoneal lymph node dissection for testicular cancer. Materials and methods: From 2010 to 2016, 29 patients underwent open, transperitoneal bilateral template retroperitoneal lymph node dissection. Data for patients who received alvimopan were prospectively collected and compared to a historical cohort of patients who did not receive alvimopan. Primary outcome measures were length of stay and recovery of gastrointestinal function. Descriptive statistics were reported. Time-to-event outcomes were evaluated using cumulative incidence curves and log rank test. Factors associated with length of stay were analyzed for correlation using multiple linear regression. Results: Of 29 men undergoing retroperitoneal lymph node dissection, eight received alvimopan and 21 did not. The two cohorts were well matched, with no significant differences. In the alvimopan cohort compared with those who did not receive alvimopan median time to return of flatus was 2 versus 4 days ( p=0.0002), and median time to first bowel movement was 2.5 versus 5 days ( p=0.046), respectively. Median length of stay in the alvimopan cohort was 4 days versus 6 days in those who did not receive alvimopan ( p=0.074). In adjusted analyses, receipt of alvimopan did not influence length of stay. Conclusion: Alvimopan may facilitate gastrointestinal recovery after retroperitoneal lymph node dissection for testicular cancer. Whether this translates into reduced length of stay needs to be determined by randomized controlled trials using larger cohorts. Level of evidence: 3b.

Early versus Delayed Amputation in the Setting of Severe Lower Extremity Trauma

2015 ◽  
Vol 81 (6) ◽  
pp. 564-568 ◽  
Author(s):  
Zachary F. Williams ◽  
Lindsay M. Bools ◽  
Ashley Adams ◽  
Thomas V. Clancy ◽  
William W. Hope
Keyword(s):  
Length Of Stay ◽  
Lower Extremity ◽  
Limb Salvage ◽  
Length Of Hospital Stay ◽  
Hospital Length ◽  
Lower Extremity Amputation ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Early Group ◽  
Extremity Amputation

Leg-threatening injuries present patients and clinicians with the difficult decision to pursue primary amputation or attempt limb salvage. The effects of delayed amputation after failed limb salvage on outcomes, such as prosthetic use and hospital deposition, are unclear. We evaluated the timing of amputations and its effects on outcomes. We retrospectively reviewed all trauma patients undergoing lower extremity amputation from January 1,2000 through December 31, 2010 at a Level 2 trauma center. Patients undergoing early amputation (amputation within 48 hours of admission) were compared with patients undergoing late amputation (amputations >48 hours after admission). Patient demographics, injury specifics, operative characteristics, and outcomes were documented. During the 11-year study period, 43 patients had a lower extremity amputation and 21 had early amputations. The two groups were similar except for a slightly higher Mangled Extremity Severity Score in the early amputation group. Total hospital length of stay significantly differed between groups, with the late amputation group length of stay being nearly twice as long. The late amputation group had significantly more ipsilateral leg complications than the early group (77% vs 15%). There was a trend toward more prosthetic use in the early group (93%vs 57%, P = 0.07). Traumatic lower extremity injuries requiring amputation are rare at our institution (0.3% incidence). Regardless of the amputation timing, most patients were able to obtain a prosthetic. Although the late group had a longer length of hospital stay and more local limb complications, attempted limb salvage still appears to be a viable option for appropriately selected trauma patients.

scholarly journals Benefits of Transversus Abdominis Plane Block on Postoperative Analgesia after Bariatric Surgery: A Systematic Review and Meta-Analysis

2021 ◽  
pp. 345-358
Keyword(s):  
Bariatric Surgery ◽  
Postoperative Pain ◽  
Length Of Stay ◽  
Multimodal Analgesia ◽  
Opioid Consumption ◽  
Transversus Abdominis ◽  
Hospital Length Of Stay ◽  
Tap Block ◽  
Transversus Abdominis Plane ◽  
Pain Scores

BACKGROUND: Patients undergoing bariatric surgery present unique analgesic challenges, including poorly controlled pain, increased prevalence of obstructive sleep apnea, and opioid-induced respiratory depression. The transversus abdominis plane (TAP) has been demonstrated to be a safe and effective component of multimodal analgesia for a variety of abdominal surgeries. OBJECTIVE: To determine the benefits of the TAP block on postoperative analgesia and recovery in patients undergoing bariatric surgery. STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies. METHODS: We conducted a comprehensive search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to April 2020 for studies using TAP block in bariatric surgeries and reporting postoperative pain, opioid consumption, and recovery-related outcomes. Primary outcomes included postoperative pain scores, opioid consumption, and recovery-related outcomes (e.g., length of stay, time to ambulation). Outcomes were pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). RESULTS: Twenty-one studies (15 RCTs [n = 1410] and 6 nonrandomized studies [n = 1959]) were included. Among RCTs, the TAP block group required fewer opioid rescues (RR 0.28; 95% CI 0.18 to 0.42, P < 0.001) (moderate quality); reduced total opioid use over 24 hours (MD –8.33; 95% CI –14.78 to –1.89, P = 0.01); decreased time to ambulation (MD –1.12 hours; 95% CI –1.50 to –0.73, P < 0.001) (high quality); and had significantly lower pain scores at 6 hours (MD –1.52; 95% CI –1.90 to –1.13, P < 0.01) and 12 hours (MD –0.95; 95% CI –1.34 to –0.56, P < 0.001) on a 0-10 pain scale (moderate quality). No difference was observed for nausea and vomiting, or hospital length of stay. Meta-analyzed outcomes from observational studies supported these results, suggesting decreased postoperative pain and opioid consumption. LIMITATIONS: Studies varied with respect to type of surgery and components of comparator multimodal analgesia, likely contributing to heterogeneity. Subgroup analyses by type of comparator group were conducted to address these differences. We were unable to extract data from all trials included due to variability in outcomes reporting, such as non-opioid drugs for postoperative pain management or invalid dosages. Pain-related outcomes may be affected by operative differences leading to variation in visceral pain. Observational studies have their inherent limitations, such as confounding due to lack of participant randomization and intervention blinding, potentially affecting subjective outcomes, such as pain scores, as well as provider-dependent outcomes, such as hospital length of stay. Lastly, there was significant variation of TAP block technique across all studies. CONCLUSION: TAP block is an effective, safe modality that can be performed under anesthesia. It decreases pain, opioid use, and time to ambulation after bariatric surgeries and should be considered in multimodal analgesia for enhanced recovery in this high-risk surgical population. KEY WORDS: Analgesia, bariatric surgery, enhanced recovery after surgery, multimodal analgesia, opioid-sparing analgesia, pain, postoperative, regional block, transversus abdominis plane block

Opioid Requirements in Laparoscopic Colectomies: Do Enhanced Recovery After Surgery Protocols Make a Difference?

2020 ◽  
pp. 000313482095631
Author(s):  
Samer Kawak ◽  
Joanna F. Wasvary ◽  
Matthew A. Ziegler
Keyword(s):  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Tertiary Care ◽  
Patient Characteristics ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Care Hospital ◽  
Pain Scores ◽  
Enhanced Recovery Pathways ◽  
Recovery Pathways

Background With the growing opioid epidemic and recent focus on the quantity of opioids prescribed at discharge after surgery, enhanced recovery pathways provide another tool to counteract this epidemic. The aim of this current study is to analyze the differences in opioid requirements and pain scores in the immediate postoperative period for patients who underwent laparoscopic colectomies before and after the implementation of enhanced recovery after surgery (ERAS) protocols. Materials and Methods This study is a retrospective review of patients and was conducted at an academically affiliated tertiary care hospital. In patients undergoing elective laparoscopic colectomies before December 1, 2013-July 31, 2015 and after September 1, 2015-May 31, 2018, the implementation of enhanced recovery pathways was included. The primary end point was opioid consumption from the end of surgery until 48 hours after surgery. Secondary end points included pain scores, surgery length of time, and hospital length of stay after surgery. Results A total of 242 patients (122 pre- and 120 postimplementation) were analyzed. Patient characteristics were similar between groups. Pain scores were higher in the preimplementation patients for postoperative day (POD) 0 scores ( P = .019). There was a decrease in the morphine milligram equivalents (MME) on POD 0-2 for the postimplementation patients. This decrease resulted in a 61% reduction in opioid requirements after implementation of ERAS protocols (32 vs. 12.5 MME, P < .0001). Discussion Enhanced recovery after surgery protocols can reduce opioid requirements after elective laparoscopic colectomies without negatively affecting pain scores.

Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

2021 ◽  
Author(s):  
Jared L. Tepper ◽  
Olivia M. Harris ◽  
Jourdan E. Triebwasser ◽  
Stephanie H. Ewing ◽  
Aasta D. Mehta ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Cesarean Delivery ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Opioid Consumption ◽  
Quality Improvement Initiative ◽  
Adjusted Relative Risk ◽  
Opioid Use ◽  
Opioid Prescription ◽  
The Impact

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points

The Impact of an Enhanced Recovery After Surgery Program on Patients Treated for Gynecologic Cancer in the Community Hospital Setting

2018 ◽  
Vol 28 (3) ◽  
pp. 581-585 ◽  
Author(s):  
Alberto A. Mendivil ◽  
Justin R. Busch ◽  
David C. Richards ◽  
Heather Vittori ◽  
Bram H. Goldstein
Keyword(s):  
Enhanced Recovery ◽  
Gynecologic Oncology ◽  
Hospital Costs ◽  
Hospital Setting ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Readmission Rates ◽  
Historical Cohort ◽  
Eras Protocol ◽  
The Impact

ObjectivesThe purpose of this study was to compare the outcomes of gynecologic oncology patients treated in the community hospital setting either under the auspices of an enhanced recovery after surgery (ERAS) protocol or in accordance with physician discretion.MethodsWe retrospectively evaluated a series of consecutive gynecologic oncology patients who were managed via open surgery in coincident with an ERAS pathway from January 2015 to December 2016. They were compared with a historical open surgery cohort who was treated from November 2013 to December 2014. The primary clinical end points encompassed hospital length of stay, hospital costs, and patient readmission rates.ResultsThere were 86 subjects accrued in the ERAS group and 91 patients in the historical cohort. The implementation of ERAS occasioned a greater than 3-day mean reduction in hospital stay (8.04 days for the historical group vs 4.88 days for the ERAS subjects; P = 0.001) and correspondingly diminished hospital costs ($11,877.47/patient vs $9305.26/patient; P = 0.04). Moreover, there were 2 readmissions (2.3%) in the ERAS group compared with 4 (4.4%) in the historical cohort (P = 0.282).ConclusionsThe results from our investigation suggest that adhering to an ERAS protocol confers beneficial hospital length of stay and hospital cost outcomes, without compromising patient readmission rates. Additional investigation scrutinizing the impact of ERAS enactment with more defined study variables in a larger, randomized setting is warranted.

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