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Newly implemented enhanced recovery pathway positively impacts hospital length of stay

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Abstract

Background

Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes.

Methods

This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations—laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway.

Results

The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04).

Conclusions

A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.

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References

  1. Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606–617

    Article  CAS  PubMed  Google Scholar 

  2. Kolozsvari NO, Capretti G, Kaneva P, Neville A, Carli F, Liberman S, Chalebois P, Stein B, Vassiliou MC, Fried GM, Feldman LS (2013) Impact of an enhanced recovery program on short-term outcomes after scheduled laparoscopic colon resection. Surg Endosc 27(1):133–138

    Article  PubMed  Google Scholar 

  3. Varadhan KK, Lobo DN, Ljungqvist O (2010) Enhanced recovery after surgery: the future of improving surgical care. Crit Care Clin 26:527–547

    Article  PubMed  Google Scholar 

  4. Wind J, Polle SW, Fung Kon Jin PHP, Dejong CHC, von Meyenfeldt MF, Ubbink DT, Gouma DJ, Bemelman WA (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809

    Article  CAS  PubMed  Google Scholar 

  5. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840

    Article  PubMed  Google Scholar 

  6. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA (2007) A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 245(6):867–872

    Article  PubMed  PubMed Central  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  PubMed  Google Scholar 

  8. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev (2):CD007635. doi:10.1002/14651858.CD007635.pub2

  9. Gillissen F, Hoff C, Maessen JMC, Winkens B, Teeuwen JHFA, von Meyenfeldt MF, Dejong CHC (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  PubMed  Google Scholar 

  10. Lawrence JK, Keller DS, Samia H, Ermlich B, Brady KM, Nobel T, Stein SL, Delaney CP (2013) Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using enhanced recovery pathways. J Am Coll Surg 216:390–394

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  12. Kim DW, Kang SB, Lee SY, Oh HK, In MH (2013) Early rehabilitation programs after laparoscopic colorectal surgery: evidence and criticism. World J Gastroenterol 19(46):8543–8551

    Article  PubMed  PubMed Central  Google Scholar 

  13. Miller TE, Thacker JK, White WD, Mantyn C, Migaly J, Jin J, Roche AM, Eisenstein EL, Edwards R, Anstrom KJ, Moon RE, Gan TJ, Enhanced Recovery Study Group (2014) Reduced length of hospital stay after implementation of an Enhanced Recovery Protocol. Anesth Analg 118:1052–1061

    Article  PubMed  Google Scholar 

  14. Lassen K, Soop M, Nygren J, Cox BW, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KCH, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CHC, for the Enhanced Recovery After Surgery (ERAS) Group (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144:961–969

    Article  PubMed  Google Scholar 

  15. (MSQC-PSO) MSQCPSO (2014) MSQC 2.0 data collection manual. Accessed 20 Jan 2015

  16. Dellinder RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, The Surviving Sepsis Campaign Guidelines including the Pediatric Subgroup (2013) Surviving sepsis. Crit Care Med 41:580–637

    Article  Google Scholar 

  17. Walter CJ, Collin J, Dumville JC, Drew PJ, Monson JR (2009) Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis 11:344–353

    Article  CAS  PubMed  Google Scholar 

  18. Chestovich PJ, Ay Lin, Yoo J (2013) Fast-track pathways in colorectal surgery. Surg Clin North Am 248(93):21–32

    Article  Google Scholar 

  19. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N (2009) A fast-track program reduces complications and length of hospital stay after colorectal surgery. Gastroenterology 136:842–847

    Article  PubMed  Google Scholar 

  20. Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J (2012) Guidelines for peri-operative care in elective rectal/pelvic surgery: enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr 31:801–816

    Article  CAS  PubMed  Google Scholar 

  21. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA, LAFA Study Group (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery. Ann Surg 254:868–875

    Article  PubMed  Google Scholar 

  22. Lee TG, Kang SB, Kim DW, Hong S, Heo SC, Park KJ (2011) Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum 54:21–28

    Article  PubMed  Google Scholar 

  23. Li P, Fang F, Cai JX, Tang D, Li QG, Wang DR (2013) Fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for colorectal malignancy: a meta-analysis. World J Gastroenterol 19:9119–9126

    Article  PubMed  PubMed Central  Google Scholar 

  24. Zhuang CL, Ye XY, Zhang XD, Chen BC, Yu Z (2013) Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 56:667–678

    Article  PubMed  Google Scholar 

  25. Archibald LH, Ott MJ, Gale CM, Zhang J, Stat M, Peters MS, Stroud GK (2011) Enhanced recovery after colon surgery in a community hospital system. Dis Colon Rectum 54:840–845

    Article  PubMed  Google Scholar 

  26. Greco M, Capretti G, Beretta L, Genna 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  PubMed  Google Scholar 

  27. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, Umapathi BA, Kron IL, Sawyer RG, Hedrick TL (2015) Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg 220(4):430–443

    Article  PubMed  Google Scholar 

  28. DeBarros M, Steele S (2013) Perioperative protocols in colorectal surgery. Clin Colon Rectal Surg 26:139–145

    Article  PubMed  PubMed Central  Google Scholar 

  29. Tam MS, Kaoutzanis C, Mullard AJ, Regenbogen SE, Franz MG, Hendren S, Kraphol G, Vandewarker JF, Lampman RM, Cleary RK (2015) A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery. Surg Endosc. doi:10.1007/s00464-105-4218-6

    Google Scholar 

  30. Bhama AR, Obias V, Welch KB, Vandewarker JF, Cleary RK (2015) A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons—National Surgical Improvement Program (ACS-NSQIP) database. Surg Endosc. doi:10.1007/s00464-015-4381-9PMID26169638

    PubMed  Google Scholar 

  31. Tiefenthal M, Asklid D, Hjern F, Matthiessen P, Gustafsson UO (2015) Laparoscopic and open right-sided colonic resection in daily routine practice. A prospective multicentre study within an ERAS protocol. Colorectal Dis. doi:10.1111/codi.13082

    Google Scholar 

  32. Dhruva RPH, Howells S, Haray PN (2015) Does an enhanced recovery programme add value to laparoscopic colorectal resections? Int J Colorectal Dis 30(11):1473–1477

    Article  Google Scholar 

  33. Lindsetmo RO, Champagne B, Delaney CP (2009) Laparoscopic rectal resections and fast-track surgery: What can be expected? Am J Surg 197:408–412

    Article  PubMed  Google Scholar 

  34. Chen CC, Huang IP, Wang C, Liu MC, Jian JJ, Cheng SH (2011) Is it appropriate to apply the enhanced recovery program to patients undergoing laparoscopic rectal surgery? Surg Endosc 25:1477–1483

    Article  PubMed  Google Scholar 

  35. Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist Soop M, Ramirez J (2013) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37:285–305

    Article  CAS  PubMed  Google Scholar 

  36. Stottmeier S, Harling H, Wille-Jørgensen P, Balleby L, Kehlet H (2012) Postoperative morbidity after fast-track laparoscopic resection of rectal cancer. Colorectal Dis 14:769–775

    Article  CAS  PubMed  Google Scholar 

  37. Khreiss W, Huebner M, Cima RR, Dozois ER, Chua HK, Pemberton JH, Harmsen WS, Larson DW (2014) Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Dis Colon Rectum 57:557–563

    Article  PubMed  Google Scholar 

  38. Bragg D, El-Sharkawy AM, Psaltis E, Maxwell-Armstrong CA, Lobo DN (2015) Postoperative ileus: recent developments in pathophysiology and management. Clin Nutr 34:367–376

    Article  PubMed  Google Scholar 

  39. Harbaugh CM, Al-Holou SN, Drews JD, Shah MM, Terjimanian MN, Cai S, Campbell DA Jr, Englesbe MJ (2013) A statewide, community-based assessment of alvimopan’s effect on surgical outcomes. Ann Surg 257:427–432

    Article  PubMed  Google Scholar 

  40. Obokhare ID, Champagne B, Stein SL, Krpata D, Delaney CP (2011) The effect of alvimopan on recovery after laparoscopic segmental colectomy. Dis Colon Rectum 54:743–746

    Article  PubMed  Google Scholar 

  41. Hendren S, Morris AM, Zhang W, Dimick J (2011) Early discharge and hospital readmission after colectomy for cancer. Dis Colon Rectum 54:1362–1367

    Article  PubMed  Google Scholar 

  42. Kiran RP, Delaney CP, Senagore AJ, Steel M, Garafalo T, Fazio VW (2004) Outcomes and prediction of hospital readmission after intestinal surgery. J Am Coll Surg 198:977–983

    Article  Google Scholar 

  43. Rossi G, Vaccarezza H, Vaccaro CA, Mentz RE, Im V, Alvarez A, Quintana GO (2013) Two-day hospital stay after laparoscopic colorectal surgery under an Enhanced Recovery after Surgery (ERAS) pathway. World J Surg 37:2483–2489

    Article  PubMed  PubMed Central  Google Scholar 

  44. Zhao JH, Sun JX, Gao P, Chen XW, Song YX, Huang XZ, Xu HM, Wang ZN (2014) Fast-track surgery versus traditional perioperative care in laparoscopic colorectal cancer surgery: a meta-analysis. BMC Cancer 14:607

    Article  PubMed  PubMed Central  Google Scholar 

  45. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF (2014) Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. BJS 101:172–188

    Article  CAS  Google Scholar 

  46. Francis NK, Mason J, Salib E, Allanby L, Messenger D, Allison AS, Smart NJ, Ockrim JB (2015) Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme. Colorectal Dis 17(7):O148–O154. doi:10.1111/codi.13002

    Article  CAS  PubMed  Google Scholar 

  47. Cannesson M (2015) The perioperative surgical home: an innovative clinical care delivery model. J Clin Anesth 27:185–187

    Article  PubMed  Google Scholar 

  48. Wennström B, Stromberg MW, Modin M, Skullman S (2010) Patient symptoms after colonic surgery in the era of enhanced recovery—a long-term follow up. J Clin Nurs 19:666–672

    Article  PubMed  Google Scholar 

  49. Group EC (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261(6):1153–1159

    Article  Google Scholar 

  50. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2011) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Arch Surg 46:571–576

    Article  Google Scholar 

  51. Patel SS, Floyd A, Doorly MG, Ortega AE, Ault GT, Kaiser AM, Senagore A (2012) Current controversies in the management of colon cancer. Curr Probl Surg 49(7):398–460

    Article  PubMed  Google Scholar 

  52. Aasa A, Hovback M, Berterô CM (2013) The importance of preoperative information for patient participation in colorectal surgery care. J Clin Nurs 22:1604–1612

    Article  PubMed  Google Scholar 

  53. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, Kim DJ, Vassiliou MC, Feldman LS (2013) Impact of a trimodal prehabilitation program on funtional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 27:1072–1082

    Article  PubMed  Google Scholar 

  54. Hübner M, Lovely JK, Huebner M, Slettedahl SW, Jacob AK, Larson DW (2013) Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications. J Am Coll Surg 216:1124–1134

    Article  PubMed  Google Scholar 

  55. Futier E, Constantin JM, Petit A, Kwiatkowski F, Flamien R, Slim K, Sapin V, Jaber S, Bazin JE (2010) Conservative vs. restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg 145:1193–1200

    Article  PubMed  Google Scholar 

  56. Keller D, Stein SL (2013) Facilitating return of bowel function after colorectal surgery: alvimopan and gum chewing. Clin Colon Rectal Surg 26:186–190

    Article  PubMed  PubMed Central  Google Scholar 

  57. Keller D, Delaney CP (2013) The role of enhanced recovery pathways in the setting of minimally invasive colorectal surgery. Semin Colorectal Surg 24(1):7–13

    Article  Google Scholar 

  58. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG (2010) A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 123:61–70

    PubMed  Google Scholar 

  59. Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J (2014) Prospective study of a colorectal enhanced recovery after surgery in a community hospital. JAMA 149(9):955–961

    Google Scholar 

  60. Stowers MDJ, Lemanu DP, Hill AG (2015) Health economics in Enhanced Recovery After Surgery programs. Can J Anesth 62(2):219–230. doi:10.1007/s12630-014-0272-0

    Article  PubMed  Google Scholar 

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Acknowledgments

Mark E. Cowen, MD; SJMH ERP Committee.

Funding

This study was funded by a grant from Blue Cross Blue Shield of Michigan Foundation.

Author contributions

TM, TL, JF, KC, KE, RL, JZ, JB, KM, JV, and RKC contributed to concept and design; KC and JFV helped in the acquisition of data; TM, JF, KC, and RKC analyzed/interpreted the data; TM, TL, JF, KC, and RKC drafted the article; JF, KC, and RKC revised the article; and final approval was given by TM, TL, JF, KC, KE, RL, JZ, JB, KM, JV, and RKC.

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Authors and Affiliations

  1. Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA

    Thomas D. Martin, Talya Lorenz, Jane Ferraro, Richard M. Lampman, Karen L. Emery, Joan E. Zurkan, Jami L. Boyd, Karin Montgomery, Rachel E. Lang, James F. Vandewarker & Robert K. Cleary

  2. Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA

    Kevin Chagin

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  1. Thomas D. Martin
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  2. Talya Lorenz
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  3. Jane Ferraro
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Correspondence to Robert K. Cleary.

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Disclosures

Dr. Cleary has received honoraria from Intuitive Surgical (daVinci) for Colon and Rectal Surgery Residency instruction in robotics. Thomas D. Martin, Talya Lorenz, Jane Ferraro, Kevin Chagin, Richard M. Lampman, Karen L. Emery, Joan E. Zurkan, Jami L. Boyd, Karin Montgomery, Rachel E. Lang, and James F. Vandewarker have anything to disclose.

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Martin, T.D., Lorenz, T., Ferraro, J. et al. Newly implemented enhanced recovery pathway positively impacts hospital length of stay. Surg Endosc 30, 4019–4028 (2016). https://doi.org/10.1007/s00464-015-4714-8

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