Skip to main content
SpringerLink
Log in

ERAS, length of stay and private insurance: a retrospective study

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Hospital discharge after colorectal resection within an Enhanced Recovery After Surgery (ERAS) program occurs earlier compared to standard-care postoperative pathways but often later than what objective criteria of “readiness for discharge” could allow. The aim of this study was to analyse reasons and risk factors of such discharge delay.

Methods

All elective patients admitted for colorectal resection at the regional Hospital of Lugano in 2014 and 2015 were included. The postoperative day on which patients fulfilled consensus agreed criteria (according to Fiore) for readiness for discharge (POD-F) and the effective day of discharge (POD-D) were determined. We analysed the reasons for discharge delay (POD-D>POD-F) and performed univariate and multivariate analysis to determine risk factors.

Results

One hundred thirty-eight patients were included in the study. Median POD-F was 5 (2–48) days, POD-D was 6 (3–50) days. In 94 patients, POD-D occurred later than POD-F with a median delay of 1 (1–11) days. Reasons for discharge delay were insufficient social support in 13 (14%), patient’s preference in 39 (41%) and medical team preference in 41 (44%). Private insurance (OR 2.61, 95%CI 1.08–6.34, p = 0.034) and patient discharged on a day other than Monday (OR 2.94, 95%CI 1.16–7.14, p = 0.023) were independent predictors for discharge delay.

Conclusion

Even when objective criteria for readiness for discharge have been fulfilled, patients and/or doctors often do not feel comfortable with hospital discharge at this time point. Length of stay, even within an ERAS program, is still influenced by several non-medical factors and is therefore not a precise surrogate marker of outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Khan SA, Ullah S, Ahmed J, Wilson TR, McNaught C, Hartley J, MacFie J (2013) Influence of enhanced recovery after surgery pathways and laparoscopic surgery on health-related quality of life. Color Dis 15:900–907

    Article  CAS  Google Scholar 

  2. Kisialeuski M, Pędziwiatr M, Matłok M et al (2015) Enhanced recovery after colorectal surgery in elderly patients. Wideochir Inne Tech Maloinwazyjne 10:30–36

    PubMed  PubMed Central  Google Scholar 

  3. Pędziwiatr M, Pisarska M, Kisielewski M, Matłok M, Major P, Wierdak M, Budzyński A, Ljungqvist O (2016) Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery? Med Oncol 33:25

    Article  Google Scholar 

  4. Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colo-rectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440

    Article  Google Scholar 

  5. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38:1531–1541

    Article  Google Scholar 

  6. Lv L, Shao YF, Zhou YB (2012) The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Color Dis 27:1549–1554

    Article  Google Scholar 

  7. Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, McLeod RS (2009) Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13:2321–2329

    Article  Google Scholar 

  8. Pecorelli N, Hershorn O, Baldini G, Fiore JF, Stein BL, Liberman AS, Charlebois P, Carli F, Feldman LS (2017) Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc 31:1760–1771

    Article  Google Scholar 

  9. Fiore JF Jr, Browning L, Bialocerkowski A, Gruen RL, Faragher IG, Denehy L (2012) Hospital discharge criteria following colorectal surgery: a sistematic review. Color Dis 14:270–281

    Article  Google Scholar 

  10. Castelino T, Fiore JF Jr, Niculiseanu P, Landry T, Augustin B, Feldman LS et al (2016) The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review. Surgery 159:991–100

    Article  Google Scholar 

  11. Maessen J, Dejong CH, Hausel J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94:224–231

    Article  CAS  Google Scholar 

  12. Fiore JF Jr, Bialocerkowski A, Browning L, Faragher IG, Denehy L (2012) Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique. Dis Colon Rectum 55:416–423

    Article  Google Scholar 

  13. Ngui NK, Hitos K, Ctercteko G (2011) Preoperative factors prolonging the length of stay in elective colorectal surgery. ANZ J Surg 81:624–628

    Article  Google Scholar 

  14. Levy BF, Scott MJ, Fawcett WJ et al (2009) 23-hour-stay laparoscopic colectomy. Dis Colon Rectum 52:1239–1243

    Article  CAS  Google Scholar 

  15. Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 86:227–230

    Article  CAS  Google Scholar 

  16. Delaney CP (2008) Outcome of discharge within 24 to 72 hours after laparoscopic colorecal surgery. Dis Colon Rectum 51:181–185

    Article  Google Scholar 

  17. Smart NJ, White P, Allison AS, Ockrim JB, Kennedy RH, Francis NK (2012) Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model. Color Dis 14:e727–e734

    Article  CAS  Google Scholar 

  18. Gillissen F, Hoff C, Maessen JM et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg 37:1082–1093

    Article  Google Scholar 

  19. Boulind CE, Yeo M, Burkill C, Witt A, James E, Ewings P, Kennedy RH, Francis NK (2012) Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery. Color Dis 14:e103–e110

    Article  CAS  Google Scholar 

  20. Cologne KG, Byers S, Rosen DR et al (2016) Factors associated with a short (< 2 days) or long (> 10 days) length of stay after colectomy: a multivariate analysis of over 400 patients. Am Surg 82:960–963

    PubMed  Google Scholar 

  21. Schmelzer TM, Mostafa G, Lincourt AE et al (2008) Factors affecting length of stay following colonic resection. J Surg Res 146:195–201

    Article  Google Scholar 

  22. Francis NK, Luther A, Salib E, Allanby L, Messenger D, Allison AS, Smart NJ, Ockrim JB (2015) The use of artificial neural networks to predict delayed discharge and readmission in enhanced recovery following laparoscopic colorectal cancer surgery. Tech Coloproctol 19:419–428

    Article  CAS  Google Scholar 

  23. Fiore JF Jr, Faragher IG, Bialocerkowski A et al (2013) Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery. World J Surg 37:2927–2934

    Article  Google Scholar 

  24. Slieker JC, Clerc D, Hahnloser D, Demartines N, Hübner M (2017) Prospective evaluation of discharge trends after colorectal surgery within an Enhanced Recovery after Surgery pathway. Dig Surg 34:298–304

    Article  Google Scholar 

  25. Maessen JM, Dejong CH, Kessels AG et al (2008) Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg 32:971–975

    Article  CAS  Google Scholar 

  26. Ihedioha U, Esmail F, Lloyd G et al (2015) Enhanced recovery programmes in colorectal surgery are less enhanced later in the week: an observational study. JRMS open 6:2054270414562983

    Google Scholar 

  27. Romain B, Grass F, Addor V et al (2016) Impact of weekday surgery on application of enhanced recovery pathway: a retrospective cohort study. BMJ Open 6(10):e011067

    Article  Google Scholar 

  28. Coolsen MM, Bakens M, van Dam RM et al (2015) Implementing an enhanced recovery program after pancreaticoduodenectomy in elderly patients: is it feasible? World J Surg 39:251–258

    Article  Google Scholar 

  29. Dejong CH, van Dam RM (2014) Enhanced recovery programs in liver surgery. World J Surg 38:2683–2684

    Article  CAS  Google Scholar 

  30. Feldman LS, Lee L, Fiore J Jr (2015) What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways? Can J Anaesth 62:120–130

    Article  Google Scholar 

  31. Madani A, Fiore JF Jr, Wang Y, Bejjani J, Sivakumaran L, Mata J, Watson D, Carli F, Mulder DS, Sirois C, Ferri LE, Feldman LS (2015) An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery 158:899–908 discussion 908-1

    Article  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Esther De Krujif for the statistical analysis of the data.

Author information

Authors and Affiliations

  1. Ospedale Regionale di Locarno, Via Ospedale 1, 6600, Locarno, Switzerland

    Diana A. Celio

  2. Department of Anaesthesiology, Regional Hospital of Lugano, Via Tesserete 46, 6903, Lugano, Switzerland

    Roberto Poggi

  3. Regional Hospital of Lugano, Via Tesserete 46, 6903, Lugano, Switzerland

    Mike Schmalzbauer

  4. Department of Surgery, Regional Hospital of Lugano, Via Tesserete 46, 6903, Lugano, Switzerland

    Raffaele Rosso, Pietro Majno & Dimitri Christoforidis

Authors
  1. Diana A. Celio
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roberto Poggi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mike Schmalzbauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Raffaele Rosso
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pietro Majno
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Dimitri Christoforidis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Diana A. Celio.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the ethics committee of Ticino (2019–00941 /CE 3482) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

In accordance with the ethics committee of Ticino, Switzerland, an individual informed consent of all participants was not considered necessary.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Celio, D.A., Poggi, R., Schmalzbauer, M. et al. ERAS, length of stay and private insurance: a retrospective study. Int J Colorectal Dis 34, 1865–1870 (2019). https://doi.org/10.1007/s00384-019-03391-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-019-03391-2

Keywords

Search

Navigation