“Enhanced Recovery” Protocol Compliance Influences Length of Stay: Resolving Barriers to Implementation

Initial implementation and maintenance of an enhanced recovery protocol (ERP) is complex and has not been adequately described. The aim of this study was to investigate the efficacy of an ERP at a tertiary care academic institution. A secondary aim was to identify barriers to implementation and continued protocol compliance (PC) to further decrease length of stay (LOS). Patients undergoing colon resection from February 2, 2011 to December 19, 2014 were compared with patients that followed implementation of an ERP from August 10, 2015 to July 14, 2016. The primary endpoint was LOS. Secondary endpoints were PC, analgesia requirements, time to return of bowel function, and ileus. One hundred and seventy-seven historical controls were compared with 68 ERP patients. LOS was shorter in study patients (4.9 vs 7.1 days for open surgery; 3.3 vs 6.1 for laparoscopic surgery). Intraoperative IVF balance, morphine equivalents, and length of time to return of bowel function were significantly less in the ERP group (1445.89 ± 845.25 mL vs 3006.08 ± 1197.97 mL), (64.48 ± 114.49 vs 232.90 ± 541.47), (2.41 ± 1.32 days vs 3.82 ± 2.00 days). Rate of ileus was less in study patients (4.8 vs 14.7%). The readmission rate and 30-day National Surgical Quality Improvement Program complication rates were not significantly different. PC was negatively associated with LOS (r = -0.35, P = 0.0026). Similar to prior studies, this study demonstrates the efficacy of an ERP. Increased PC is associated with decreased LOS, thus providing further evidence that ERPs should be the standard of care. Scheduled interdisciplinary meetings to discuss patient outcomes and methods to increase PC can help further improve efficacy of ERPs.

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The impact of multimodal analgesia based enhanced recovery protocol on quality of recovery after laparoscopic gynecological surgery: a randomized controlled trial

BMC Anesthesiology ◽

10.1186/s12871-021-01399-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Zhiyu Geng ◽

Hui Bi ◽

Dai Zhang ◽

Changji Xiao ◽

Han Song ◽

...

Keyword(s):

Enhanced Recovery ◽

Controlled Trial ◽

Bowel Function ◽

Multimodal Analgesia ◽

Study Group ◽

Gynecological Surgery ◽

Quality Of Recovery ◽

Enhanced Recovery Protocol ◽

The Impact

Abstract Background Our objective was to evaluate the impact of multimodal analgesia based enhanced recovery protocol on quality of recovery after laparoscopic gynecological surgery. Methods One hundred forty female patients scheduled for laparoscopic gynecological surgery were enrolled in this prospective, randomized controlled trial. Participants were randomized to receive either multimodal analgesia (Study group) or conventional opioid-based analgesia (Control group). The multimodal analgesic protocol consists of pre-operative acetaminophen and gabapentin, intra-operative flurbiprofen and ropivacaine, and post-operative acetaminophen and celecoxib. Both groups received an on-demand mode patient-controlled analgesia pump containing morphine for rescue analgesia. The primary outcome was Quality of Recovery-40 score at postoperative day (POD) 2. Secondary outcomes included numeric pain scores (NRS), opioid consumption, clinical recovery, C-reactive protein, and adverse events. Results One hundred thirty-eight patients completed the study. The global QoR-40 scores at POD 2 were not significantly different between groups, although scores in the pain dimension were higher in Study group (32.1 ± 3.0 vs. 31.0 ± 3.2, P = 0.033). In the Study group, NRS pain scores, morphine consumption, and rescue analgesics in PACU (5.8% vs. 27.5%; P = 0.0006) were lower, time to ambulation [5.0 (3.3–7.0) h vs. 6.5 (5.0–14.8) h; P = 0.003] and time to bowel function recovery [14.5 (9.5–19.5) h vs.17 (13–23.5) h; P = 0.008] were shorter, C-reactive protein values at POD 2 was lower [4(3–6) ng/ml vs. 5 (3–10.5) ng/ml; P = 0.022] and patient satisfaction was higher (9.8 ± 0.5 vs. 8.8 ± 1.2, P = 0.000). Conclusion For minimally invasive laparoscopic gynecological surgery, multimodal analgesia based enhanced recovery protocol offered better pain relief, lower opioid use, earlier ambulation, faster bowel function recovery and higher patient satisfaction, while no improvement in QoR-40 score was found. Trial registration ChiCTR1900026194; Date registered: Sep 26,2019.

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An Expanded Preoperative Component within an Enhanced Recovery Protocol Improves Outcomes in Colorectal Surgery

The American Surgeon ◽

10.1177/000313481708300849 ◽

2017 ◽

Vol 83 (8) ◽

pp. 928-934

Author(s):

Nathan M. Johnson ◽

Sandy L. Fogel

Keyword(s):

Colorectal Surgery ◽

Length Of Stay ◽

Enhanced Recovery ◽

Statistical Significance ◽

Current Evidence ◽

P Value ◽

Postoperative Length ◽

Enhanced Recovery Protocol ◽

Recovery Protocols ◽

Colorectal Procedures

Enhanced Recovery Protocols (ERPs) have been shown to lead to quicker recovery in colorectal surgery, with reduced postoperative length of stay (LOS). ERPs could potentially be improved with an expanded preoperative component reflecting current evidence. We hypothesize that an ERP with an expanded preoperative component will reduce LOS consistent with or exceeding that seen with traditional ERPs. Our ERP was implemented in June of 2014. Data was collected for two full years from July 2014 through June 2016. The protocol was employed in colorectal cases, both elective and emergent. Data from ERP cases were compared with contemporaneous controls that did not go through the ERP. Patients who underwent colorectal procedures and participated in the ERP with the expanded preoperative component had an average LOS of 5.33 days, whereas controls stayed for an average of 7.93 days (P value, <0.01). ERP cases also experienced fewer read-missions and complications, although statistical significance could not be established. The results demonstrate that an ERP with an enhanced preoperative component significantly reduces LOS and potentially decreases the rate of readmissions and total complications.

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Surgery Delay Increases Length of Stay in Thoracolumbar Trauma

Neurosurgery ◽

10.1093/neuros/nyz310_446 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Lawrence Zeldin ◽

Sean N Neifert ◽

Robert J Rothrock ◽

Ian T McNeill ◽

Jonathan S Gal ◽

...

Keyword(s):

Length Of Stay ◽

Spinal Injury ◽

Specific Effect ◽

Spinal Trauma ◽

Spine Injury ◽

Complication Rates ◽

Improvement Program ◽

Delayed Surgery ◽

Significant Difference ◽

Surgery Timing

Abstract INTRODUCTION The ideal timing from admission of a thoracolumbar spinal trauma patient to the start of surgery at US trauma centers remains a hotly contested area of debate. The effect of surgical latency on patient outcomes in thoracolumbar trauma remains unclear. METHODS All 2013 to 2015 thoracolumbar spinal trauma cases from the American College of Surgeons Trauma Quality Improvement Program (TQIP) were analyzed. Patients with unsurvivable spine injury, polytraumas (serious injuries in more than one bodily region), and those discharged within 24 h were excluded. Patients were classified into 3 groups by surgery timing: less than 8 h (early, N = 1699), between 8 and 24 h (normal, N = 946), and over 24 h (delayed, N = 1601). Mortality, length of stay (LOS), and complication rates were compared between groups. Demographic variables and complication rates were compared. Multivariate logistic regression was utilized to determine the specific effect of surgery timing on outcomes. RESULTS Patients with earlier surgery presented with more severe spinal trauma (P < .0001). Patients in the normal surgical timing cohort were most likely to have altered mental status (4.97% vs 3.24%, P = .05), and less likely to suffer from UTI (4.97% vs 3.24%, P = .03). Patients in the delayed cohort were older (46.2 vs 43.7 yr, P = .0003), more likely to have a longer LOS (11.3 vs 10.6 d, P = .02), return to the ICU (2.94% vs 1.29%, P = .001), experience unplanned intubation (2.06% vs 1%, P = .01) and suffer from cardiac arrest (0.53% vs 1.19%, P = .04). Upon multivariate analysis, delayed surgery was an independent risk factor for prolonged LOS (OR: 1.21, 95% CI: 0.56-1.87, P = .0003). CONCLUSION Patients with earlier surgery possessed more severe spinal injury. When adjusting for demographics and severity, no significant difference is seen in mortality between the different surgery times; however, LOS is prolonged in patients with delayed surgery.

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Enhanced Recovery Protocol Reduces Transfusion Requirements and Hospital Stay in Patients Undergoing an Elective Arthroplasty Procedure

Advances in Orthopedic Surgery ◽

10.1155/2016/9846910 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Kirsten Juliette de Burlet ◽

James Widnall ◽

Cefin Barton ◽

Veera Gudimetla ◽

Stephen Duckett

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Transfusion Rate ◽

Transfusion Requirements ◽

Total Knee ◽

Enhanced Recovery Protocol ◽

Knee Arthroplasty Surgery ◽

The Impact ◽

Arthroplasty Surgery ◽

Arthroplasty Procedure

Background. Enhanced recovery (ER) for elective total hip or total knee replacement has become common practice. The aim of this study is to evaluate the impact of ER on transfusion rates and incidence of venous thromboembolism (VTE). Methods. A comprehensive review was undertaken of all patients who underwent primary hip or knee arthroplasty surgery electively between January 2011 and December 2013 at our institution. ER was implemented in August 2012, thus creating two cohorts: the traditional protocol (TP) group and the ER group. Outcome measurements of length of stay, postoperative transfusion, thromboembolic complications, and number of readmissions were assessed. Main Findings. 1262 patients were included. The TP group contained a total of 632 patients and the ER group contained 630 patients. Postoperative transfusion rate in the ER group was reduced with 45% (P≤0.05). There was no statistical difference in postoperative VTE complications. The length of stay was reduced from 5.5 days to 4.8 days (P<0.05). Conclusions. There was no difference in the number of readmissions. ER has contributed to a significant decrease in transfusions after elective arthroplasty surgery, with no increase in the incidence of thromboembolic events. Furthermore, it has significantly reduced inpatient length of stay.

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Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2014.12.042 ◽

2015 ◽

Vol 220 (4) ◽

pp. 430-443 ◽

Cited By ~ 192

Author(s):

Robert H. Thiele ◽

Kathleen M. Rea ◽

Florence E. Turrentine ◽

Charles M. Friel ◽

Taryn E. Hassinger ◽

...

Keyword(s):

Colorectal Surgery ◽

Length Of Stay ◽

Enhanced Recovery ◽

Direct Costs ◽

Enhanced Recovery Protocol

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Enhanced recovery after surgery (ERAS) in clinical practice

Anaesthesia, Pain & Intensive Care ◽

10.35975/apic.v24i3.1287 ◽

2020 ◽

Vol 24 (3) ◽

Author(s):

Robert Leger ◽

Jon Livelsberger ◽

Ashish Sinha

Keyword(s):

Clinical Practice ◽

Length Of Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Evidence Based ◽

Wide Spread ◽

Postsurgical Complications ◽

Protocol Compliance ◽

Care Practices ◽

Multidisciplinary System

‘Enhanced Recovery After Surgery’ (ERAS) protocols are an evidence-based, multidisciplinary system for patient care that— since its emergence in 2001— has shown remarkable efficacy in reducing surgical complications, shortening length of stay (LoS), and the incidence of hospital re-admission. Unfortunately, wide spread acceptance of ERAS has been slow, as it conflicts with some traditional perioperative care practices. However, with protocol compliance >70%, studies have shown significant reduction in mortality and postsurgical complications, with 30-50% reduction in LoS and approximately a 50% reduction in complications.

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931 Deep Inferior Epigastric Perforator (DIEP) Flap: Impact of Early Drain Removal on Seroma Formation Rate and Duration of Inpatient Stay

British Journal of Surgery ◽

10.1093/bjs/znab259.706 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

K Grigg ◽

R Clancy ◽

C Lewis ◽

P Jackson

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Formation Rate ◽

Seroma Formation ◽

Diep Flap ◽

Complication Rates ◽

Post Surgery ◽

Drain Removal ◽

Significant Difference ◽

The Mean

Abstract Aim Donor site seroma can follow deep inferior epigastric flap (DIEP) harvest. Post-surgery gradient technology (GTC) garments are worn by DIEP patients postoperatively following drain removal to reduce seroma formation. Early drain removal was considered a contributing factor to increased seroma formation rate. From June 2018 drain removal regardless of output was instigated at day two post-surgery. Prior to this, drains were removed when less than 30mls over 24 hours. We aim to assess the seroma rate post DIEP harvest with early drain removal. Method Retrospective review of prospectively managed database between June 2018 to May 2020. Surgical complications and length of stay in hospital were recorded. Results 200 patients underwent DIEP flap breast reconstruction. The mean age of patients was 52 years (range 28-73). There was no significant difference in seroma complication rate between those who had drains removed on day 3 compared with day 2 ((1.02% (1/98) vs. (0.98% (1/102); p = 1). The mean length of stay in hospital for the 1st cohort was 3.86 days and for the 2nd cohort was 3.23 days. There were no complications related to drain removal. Conclusions Our data suggests that drain removal after 2 days postoperatively with DIEP reconstruction does not affect seroma complication rates. Moreover, it leads to a shorter hospital stay. These conclusions are in keeping with enhanced recovery protocols and an early drain removal surgical process could be advised.

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Preoperative Versus Postoperative Use of Transversus Abdominis Plane Block With Nonliposomal Bupivacaine on Postoperative Narcotic Use: A Retrospective Study.

10.21203/rs.3.rs-131723/v1 ◽

2021 ◽

Author(s):

Richard Kalu ◽

Peter Boateng ◽

Lauren Carrier ◽

Jaime Garzon ◽

Amy Tang ◽

...

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Tertiary Care ◽

Transversus Abdominis ◽

Tap Block ◽

Transversus Abdominis Plane ◽

Readmission Rates ◽

Recovery Protocols ◽

Opioid Medications ◽

Colorectal Resections

Abstract Background: Enhanced recovery protocols optimize pain control via multimodal approaches that include transversus abdominis plane (TAP) block. The aim of this study was to evaluate the effect of preoperative vs postoperative nonliposomal bupivacaine TAP block on postoperative narcotic use after colorectal surgery.Methods: A retrospective cohort study comparing postoperative narcotic use in patients who received preoperative (n = 240) vs postoperative (n = 22) nonliposomal TAP blocks. The study was conducted in a single tertiary care institution and included patients who underwent colorectal resections between August 2018 and January 2020. The study measured narcotics use in the postoperative and follow-up periods, operative details, length of stay, reoperation, and readmission rates.Results: Patients who received postoperative nonliposomal bupivacaine TAP blocks were less likely to require postoperative patient-controlled analgesia (PCA) (59.1% vs 83.3%; p = 0.012) and opioid medications on discharge (6.4% vs 16.9%; p = 0.004) relative to patients who received preoperative TAP. When needed, a significantly smaller amount of opioid was prescribed to the postoperative group (84.5 vs 32.0 mg, p = 0.047). No significant differences were noted in the duration of postoperative PCA use, amount of oral narcotic use, and length of stay.Conclusions: Nonliposomal bupivacaine TAP block administered postoperatively was associated with significantly lower need for postoperative PCA and discharge narcotics. Given the overall short length of stay for the 2 groups, further study is needed to justify the additional cost of liposomal bupivacaine TAP blocks for patients undergoing colorectal resections.

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