Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study (Preprint)

BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS We divided our study into 4 phases—phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post–CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post–CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre–CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.

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

World Journal of Surgery ◽

10.1007/s00268-020-05926-z ◽

2021 ◽

Author(s):

Basile Pache ◽

David Martin ◽

Valérie Addor ◽

Nicolas Demartines ◽

Martin Hübner

Keyword(s):

Missing Data ◽

Large Scale ◽

Urinary Catheter ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Length Of Hospital Stay ◽

Prospective Audit ◽

Audit System ◽

Validation Criteria ◽

Eras Protocol

Abstract 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.

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ENHANCED RECOVERY (ERAS) AFTER LIVER SURGERY:COMPARATIVE STUDY IN A BRAZILIAN TERCIARY CENTER

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/0102-672020180001e1424 ◽

2019 ◽

Vol 32 (1) ◽

Cited By ~ 3

Author(s):

Uirá Fernandes TEIXEIRA ◽

Marcos Bertozzi GOLDONI ◽

Fábio Luiz WAECHTER ◽

José Artur SAMPAIO ◽

Florentino Fernandes MENDES ◽

...

Keyword(s):

Enhanced Recovery ◽

Surgical Stress ◽

Length Of Hospital Stay ◽

Early Mobilization ◽

Oral Feeding ◽

Control Group ◽

Colonic Surgery ◽

Early Oral Feeding ◽

Tertiary Center ◽

Eras Protocol

ABSTRACT Background: After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations. Aim: To analyze the implementation of ERAS protocols for liver surgery in a tertiary center. Methods: Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol. Results: There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group. Conclusion: Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.

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ERAS Improves Postoperative Recovery in Children

10.21203/rs.3.rs-736991/v1 ◽

2021 ◽

Author(s):

Tingmei Wu ◽

Haiwen Li ◽

Huixia Zhou ◽

Xuemei Hao ◽

Xiaojun Wang ◽

...

Keyword(s):

Inflammatory Cytokine ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Final Analysis ◽

Postoperative Recovery ◽

Controlled Study ◽

Control Group ◽

Robot Assisted ◽

Cytokine Levels ◽

Eras Protocol

Abstract Objective: Enhanced recovery after surgery (ERAS) protocols are established in adults but not fully evaluated in children. This study investigated whether an ERAS protocol improved recovery and influenced postoperative inflammatory cytokine levels in children undergoing surgery for hydronephrosis. Methods: This randomized controlled study included patients who underwent robot-assisted laparoscopic surgery for hydronephrosis at Bayi Children's Hospital (Beijing, China) between October 2018 and September 2019. Patients were randomized to an ERAS group (perioperative ERAS protocol) or control group (standard perioperative management). Outcomes related to postoperative recovery and inflammatory cytokine levels were evaluated. Results: The final analysis included 18 patients in each group. Five patients (27.78%) in each group experienced postoperative complications (abdominal pain, nausea and vomiting, subcutaneous emphysema or fever). The ERAS group had a shorter time to first postoperative flatus than the control group (25 vs. 49 hours; P =0.009), although the time for abdominal drainage flow to reach ≤20 mL/day, time to urinary catheter removal and length of hospital stay did not differ significantly between groups. Preoperative plasma cytokine levels were comparable between groups. Compared with the control group, the ERAS group had a higher IL-6 level on postoperative day 2 ( P <0.05) and a lower concentration of IL-1β on postoperative days 1 and 2 ( P <0.05). Postoperative levels of CRP, TNFα and IL-10 did not differ significantly between groups. Conclusions: ERAS may accelerate postoperative recovery and modulate the postoperative inflammatory response in pediatric patients undergoing robot-assisted laparoscopic pyeloplasty for hydronephrosis.

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129 Compliance with The ERAS Protocol Amongst Colorectal Surgery Junior Doctors at Gloucester Royal Hospital

British Journal of Surgery ◽

10.1093/bjs/znab259.008 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

L Brennan

Keyword(s):

Colorectal Surgery ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Intravenous Fluid ◽

Junior Doctors ◽

Intravenous Fluids ◽

Elective Colorectal Surgery ◽

Royal Hospital ◽

Elective Surgical Procedures ◽

Eras Protocol

Abstract Background Enhanced recovery after surgery (ERAS) is an evidence-based protocol aiming to expedite recovery following elective surgical procedures. ERAS has shown to reduce the length of hospital stay, complications, readmissions, and costs. The junior doctor’s role in ERAS centres around admission, preoperative nutritional care, and ERAS compliance. This audit aimed to review prescribing of perioperative nutritional drinks (NutriciaPreop© and Fortisips) and intravenous fluids for patients undergoing elective colorectal surgery at Gloucester Royal Hospital. Method An 80% standard was set for this audit. A full audit cycle was completed. Drug and intravenous fluid charts were analysed for correct prescribing of NutriciaPreop© and intravenous fluids pre-operatively, and peri operative Fortisips. Improvement measures included ward posters and education to incoming junior doctors. Results Initial data collection showed that 70% of patients received a correct intravenous fluid prescription pre-operatively. 24% of patients were prescribed NutriciaPreop© and 18% were prescribed Fortisips. During re-auditing intravenous fluids were correctly prescribed in 80% of patients, NutriciaPreop© in 67% of patients and Fortisips in 60%. Conclusions This audit emphasises the importance of good quality inductions for junior doctors and how simple measures improve prescribing of essential peri-operative nutrition. Additionally, the value of multidisciplinary team involvement in junior doctor training has been highlighted.

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The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair

Surgical Endoscopy ◽

10.1007/s00464-019-07233-8 ◽

2019 ◽

Vol 34 (10) ◽

pp. 4638-4644 ◽

Cited By ~ 6

Author(s):

Walker Ueland ◽

Seth Walsh-Blackmore ◽

Michael Nisiewicz ◽

Daniel L. Davenport ◽

Margaret A. Plymale ◽

...

Keyword(s):

Hernia Repair ◽

Hospital Stay ◽

Ventral Hernia ◽

Ventral Hernia Repair ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Length Of Hospital Stay ◽

Eras Protocol

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A Pilot Study of Enhance Recovery after Surgery (ERAS) for Liver Resection

IIUM Medical Journal Malaysia ◽

10.31436/imjm.v16i2.323 ◽

2020 ◽

Vol 16 (2) ◽

Author(s):

Jarmin R ◽

Mohamad IS ◽

Ahmad AW ◽

Othman H ◽

Zuhdi Z ◽

...

Keyword(s):

Liver Resection ◽

Postoperative Complications ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Postoperative Recovery ◽

Modern Approach ◽

Full Diet ◽

Tube Removal ◽

Major Resection ◽

Eras Protocol

Background: Morbidity post hepatectomy still remain persistent throughout decades compared to other surgery. Modern approach have been introduced to improve safety and reduce morbidity whilst at the same time enhance patient recovery. Thus, enhanced recovery after surgery or fast track recovery program for liver resection was initiated. Objective: The aim of this study was to achieve discharge by postoperative day 3 for minor resection and day 5 for major resection. Design and Setting: This is a prospective study conducted in Hospital Universiti Kebangsaan Malaysia (HUKM) from September 2014 till April 2015. Material and Methods: All patients undergoing open liver resection were included in the study. They were then managed post operatively according to ERAS protocol that was drawn up based on previous studies. Patient’s demographics data, intra operative parameters, postoperative complications and adherence to postoperative recovery protocol were recorded. Results: Seventeen patients (7 major and 10 minor resection) were recruited. The mean length of hospital stay for minor resection was 5.9 and major resection was 9.6 .With regards to the targets, 4 out of 10 (40%)patients in minor resection group and 4 out 7 (57.1%) in the major group were discharged on time. 9 patients had postoperative complications with no mortality recorded. In terms of the ERAS protocol targets, the PCA morphine discontinuation target was achieved in 15 patients (88.3%) ,nasogastric tube removal (13 patients -76.5%) , urinary cathether removal (6 patients - 35.3%), abdominal drains removal (9 patients-52.9%) and resumption of full diet was achieved by 82.4% (14 patients). Conclusion: From these overall achievement, most of our targets have been met and this shows that our ERAS protocol is safe to be applied to patient undergoing hepatectomy. Limitations: Some patients had achieved their target but not discharged for unknown reason.

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Enhanced Recovery After Surgery can Improve Patient Outcomes and Reduce Hospital Cost of Gastrectomy for Cancer in the West: A Propensity-Score-Based Analysis

Annals of Surgical Oncology ◽

10.1245/s10434-021-10079-x ◽

2021 ◽

Author(s):

Jacopo Weindelmayer ◽

Valentina Mengardo ◽

Angela Gasparini ◽

Michele Sacco ◽

Lorena Torroni ◽

...

Keyword(s):

Propensity Score ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Neoadjuvant Treatment ◽

Multivariable Analysis ◽

Hospital Costs ◽

Length Of Hospital Stay ◽

The West ◽

Median Reduction ◽

Eras Protocol

Abstract Background Data on ERAS for gastrectomy are scarce, and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their clinical condition and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center. Methods We conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate, and compliance with ERAS items. A propensity score (PS) was built on confounding variables. Results Compliance with ERAS items after the program was ≥ 70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in the ERAS group. PS-based multivariable analysis confirmed a significant, 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not change significantly. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted to a median reduction of 1 day and €775, respectively. Conclusions ERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality, or readmission.

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Impact of enhanced recovery after surgery protocol compliance on patients’ outcome in benign hysterectomy and establishment of a predictive nomogram model

BMC Anesthesiology ◽

10.1186/s12871-021-01509-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yiwei Shen ◽

Feng Lv ◽

Su Min ◽

Gangming Wu ◽

Juying Jin ◽

...

Keyword(s):

Patient Satisfaction ◽

Postoperative Complications ◽

Length Of Stay ◽

Postoperative Complication ◽

Patient Experience ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Early Mobilization ◽

Urinary Drainage ◽

Eras Protocol

Abstract Background Enhanced recovery after surgery (ERAS) pathways have been shown to improve clinical outcomes after surgery. Considering the importance of patient experience for patients with benign surgery, this study evaluated whether improved compliance with ERAS protocol modified for gynecological surgery which recommended by the ERAS Society is associated with better clinical outcomes and patient experience, and to determine the influence of compliance with each ERAS element on patients’ outcome after benign hysterectomy. Methods A prospective observational study was performed on the women who underwent hysterectomy between 2019 and 2020. A total of 475 women greater 18 years old were classified into three groups according to their per cent compliance with ERAS protocols: Group I: < 60% (148 cases); Group II:≥60 and < 80% (160 cases); Group III: ≥80% (167 cases). Primary outcome was the 30-day postoperative complications. Second outcomes included QoR-15 questionnaire scores, patient satisfaction on a scale from 1 to 7, and length of stay after operation. After multivariable binary logistic regression analyse, a nomogram model was established to predict the incidence of having a postoperative complication with individual ERAS element compliance. Results The study enrolled 585 patients, and 475 completed the follow-up assessment. Patients with compliance over 80% had a significant reduction in postoperative complications (20.4% vs 41.2% vs 38.1%, P < 0.001) and length of stay after surgery (4 vs 5 vs 4, P < 0.001). Increased compliance was also associated with higher patient satisfaction and QoR-15 scores (P < 0.001),. Among the five dimensions of the QoR-15, physical comfort (P < 0.05), physical independence (P < 0.05), and pain dimension (P < 0.05) were better in the higher compliance groups. Minimally invasive surgery (MIS) (P < 0.001), postoperative nausea and vomiting (PONV) prophylaxis (P < 0.001), early mobilization (P = 0.031), early oral nutrition (P = 0.012), and early removal of urinary drainage (P < 0.001) were significantly associated with less complications. Having a postoperative complication was better predicted by the proposed nomogram model with high AUC value (0.906) and sensitivity (0.948) in the cohort. Conclusions Improved compliance with the ERAS protocol was associated with improved recovery and better patient experience undergoing hysterectomy. MIS, PONV prophylaxis, early mobilization, early oral intake, and early removal of urinary drainage were of concern in reducing postoperative complications. Trial registration Chinese Clinical Trial Registry, ChiCTR1800019178. Registered on 30/10/2018.

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Enhanced recovery after surgery (ERAS) pathway for primary hip and knee arthroplasty: study protocol for a randomized controlled trial

Trials ◽

10.1186/s13063-019-3706-8 ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Jingyi Li ◽

Haibei Zhu ◽

Ren Liao

Keyword(s):

Randomized Controlled Trial ◽

Clinical Practice ◽

Knee Arthroplasty ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Controlled Trial ◽

Early Mobilization ◽

Quality Of Healthcare ◽

Randomized Controlled ◽

Aging Populations

Abstract Background With the substantially growing trend of the aging populations in China and the rest of the world, the number of total hip and total knee arthroplasty (THA and TKA) cases are increasing dramatically. It is important to develop practical strategies to improve the quality of healthcare and better outcome for patients undergoing THA and TKA. Enhanced recovery after surgery (ERAS) pathways have been reported to promote earlier recovery and be beneficial for patients. We propose the hypothesis that the ERAS pathway could reduce the length of stay (LOS) in hospital for patients undergoing primary THA or TKA. Methods/Design This trial is a prospective, open-labelled, multi-centered, randomized controlled trial that will test the superiority of the ERAS pathway in term of LOS in hospital for the patients undergoing primary THA or TKA compared to current non-ERAS clinical practice. A total of 640 patients undergoing primary THA or TKA will be randomly allocated to either ERAS pathway (ERAS group) or conventional care according to individual participating center (non-ERAS group). The primary outcome is the total LOS in hospital; the secondary outcomes include postoperative LOS, all-cause mortality by 30 days after operation, in-hospital complications, early mobilization, postoperative pain control, total in-hospital cost, and readmission rate by 30 days after discharge from the hospital. Discussion This trial is designed to evaluate the superiority of the ERAS pathway to conventional non-ERAS clinical practice in reducing the LOS. The results may provide new insight into the clinical applications of the ERAS pathway for THA and TKA. Trial registration National Institutes of Health Clinical Trials Registry, NCT03517098. Registered on 4 May 2018.

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Prevalence and Consequences of Preoperative Weight Loss in Gynecologic Surgery

Nutrients ◽

10.3390/nu11051094 ◽

2019 ◽

Vol 11 (5) ◽

pp. 1094 ◽

Cited By ~ 1

Author(s):

Basile Pache ◽

Fabian Grass ◽

Martin Hübner ◽

Amaniel Kefleyesus ◽

Patrice Mathevet ◽

...

Keyword(s):

Weight Loss ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Preoperative Weight Loss ◽

Nutritional Screening ◽

Preoperative Weight ◽

Eras Protocol ◽

Extensive Surgery

Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00–5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15–4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented.

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