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Liao C, Lai X, Zhong J, Zeng W, Zhang J, Deng W, Shu J, Zhong H, Cai L, Liao R. Reducing the length of hospital stay for patients undergoing primary total knee arthroplasty by application of enhanced recovery after surgery (ERAS) pathway: a multicenter, prospective, randomized controlled trial. Eur J Med Res 2025; 30:385. [PMID: 40369602 PMCID: PMC12079852 DOI: 10.1186/s40001-025-02647-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Accepted: 04/29/2025] [Indexed: 05/16/2025] Open
Abstract
BACKGROUND The proportion of elderly patients undergoing Total knee arthroplasty (TKA) is growing. Optimizing and accelerating postoperative recovery for TKA patients is critical in clinical practice. Enhanced Recovery After Surgery (ERAS) is a protocol involving a series of evidence-based perioperative optimization strategies to minimize surgical stress and expedite recovery, and a multidisciplinary ERAS pathway was established jointly by anesthesiologists and orthopedic surgeons in this study. The authors hypothesized that application of the ERAS pathway can reduce the length of hospital stay (LOS) for patients undergoing primary TKA. MATERIALS AND METHODS This multicenter, prospective, randomized controlled trial was conducted from February 1, 2021 to January 31, 2023, and included patients undergoing elective primary TKA. 320 patients were randomly assigned to either the ERAS group (practice according to the ERAS pathway) or the control group (without ERAS pathway implementation) in a 1:1 ratio. The primary outcome was the total LOS in hospital. RESULTS LOS in the ERAS group was 5.92 ± 1.16 days, significantly shorter than the 8.17 ± 1.76 days in the control group (p < 0.001). Postoperative LOS and time to independent ambulation were significantly shorter in the ERAS group compared to the control group (p < 0.001). On postoperative day 1, significantly less participants reported pain both in rest and during mobilization in the ERAS group than the control group (p < 0.001). The incidences of thirst and postoperative nausea and vomiting (PONV) was significantly reduced in the ERAS group compared to the control group (16.8% vs. 88.6%, and 2.6% vs. 24.7%, respectively, p < 0.001). No perioperative deaths or reoperations within 30 days occurred in either group. CONCLUSION The application of an ERAS pathway for primary TKA significantly reduces LOS, alleviates postoperative pain, and lowers the incidence of adverse events compared to perioperative management without ERAS pathway implementation. TRIAL REGISTRATION The National Institutes of Health Clinical Trials Registry, NCT03517098. Registered on April 24, 2018.
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Affiliation(s)
- Chenxi Liao
- Department of Anesthesia and Operation Center, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, No.37 Guo Xue Lane, Chengdu, 610041, China
| | - Xingning Lai
- Department of Anesthesia and Operation Center, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, No.37 Guo Xue Lane, Chengdu, 610041, China
| | - Jie Zhong
- Department of Anesthesia and Operation Center, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, No.37 Guo Xue Lane, Chengdu, 610041, China
| | - Wencong Zeng
- Department of Anesthesiology, Huizhou First Hospital, No.20 Jiangbei Sanxin South Road, Huizhou, 516001, China
| | - Jiannan Zhang
- Department of Anesthesiology, No. 8, Wuxi Traditional Chinese Medicine Hospital Affiliated to Nanjing University of Chinese Medicine, Zhongnan West Road, Wuxi, 214071, China
| | - Wanxin Deng
- Department of Anesthesiology, The First People's Hospital of Longquanyi District, Chengdu, 610100, China
| | - Jiayun Shu
- Department of Anesthesiology, Xindu District People's Hospital of Chengdu, No.199 Yuying Road South Section, Chengdu, 610599, China
| | - Haobo Zhong
- Department of Orthopedics, Huizhou First Hospital, No.20 Jiangbei Sanxin South Road, Huizhou, 516001, China
| | - Liangyu Cai
- Department of Anesthesiology, No. 8, Wuxi Traditional Chinese Medicine Hospital Affiliated to Nanjing University of Chinese Medicine, Zhongnan West Road, Wuxi, 214071, China
| | - Ren Liao
- Department of Anesthesia and Operation Center, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, No.37 Guo Xue Lane, Chengdu, 610041, China.
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Polková M, Koliba P, Kabele P, Dubová O, Hodyc D, Škodová MK, Zikán M, Sládková P, Tichá M, Brtnický T. How can we reduce healthcare costs by using Enhanced Recovery After Surgery more effectively in different groups of gynaecological patients? A single-centre experience. J Eval Clin Pract 2025; 31:e14196. [PMID: 39420795 PMCID: PMC12021305 DOI: 10.1111/jep.14196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 09/16/2024] [Accepted: 09/30/2024] [Indexed: 10/19/2024]
Abstract
INTRODUCTION The objective of this study was to assess the impact of the Enhanced Recovery After Surgery (ERAS) programme implementation on treatment costs at a university-type centre, using the DRG scheme. MATERIALS AND METHODS Retrospective analysis of patients' data in a group of 604 individuals enroled in the study. We evaluated three groups of patients according to the ERAS clinical protocol (CP): (1) CP oncogynaecology, (2) CP simple hysterectomy, (3) CP laparoscopy. The study aimed to evaluate the impact on the length of stay (LOS), savings in bed-days, and the reduction in direct treatment costs. Three parameters-antibiotic consumption, blood derivative consumption and laboratory test costs-were chosen to compare direct treatment costs. The statistical significance of the difference in the observed parameters was tested by a two-sample unpaired t test with unequal variances at the 0.05 significance level. RESULTS We analysed data from 604 patients. In all three groups, the length of stay (LOS) was significantly reduced. The most significant reduction was observed in the CP oncogynaecology group, where the LOS was reduced from 11.1 days to 6.8 days (2022) and 7.6 days (2023) compared to 2019 (p < 0.05). Furthermore, there was a notable reduction in inpatient bed-days, which resulted in the capacity being made available to admit additional patients. A statistically significant reduction in direct costs was observed in the group of CP hysterectomy (antibiotic use) and in the CP laparoscopy (laboratory test costs). CONCLUSIONS The implementation of the ERAS principles resulted in a number of significant positive economic impacts-reduction in the LOS and a corresponding increase in bed capacity for new patients. Additionally, direct treatment costs, including those related to antibiotic use or laboratory testing were reduced. The Czech Republic's acute healthcare system, like the majority of European healthcare systems, is financed by the DRG system. This flat-rate payment per patient encourages hospital management to seek cost-reduction strategies. The results of our study indicate that fast-track protocols represent a potential viable approach to reducing the cost of treatment while simultaneously meeting the recommendations of evidence-based medicine.
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Affiliation(s)
- Markéta Polková
- Department of Gynaecology and Obstetrics, 1st Faculty of Medicine and Bulovka University HospitalCharles UniversityPragueCzech Republic
| | - Peter Koliba
- Department of Gynaecology and Obstetrics, 1st Faculty of Medicine and Bulovka University HospitalCharles UniversityPragueCzech Republic
| | - Pavel Kabele
- Department of Gynaecology and Obstetrics, 1st Faculty of Medicine and Bulovka University HospitalCharles UniversityPragueCzech Republic
| | - Oľga Dubová
- Department of Gynaecology and Obstetrics, 1st Faculty of Medicine and Bulovka University HospitalCharles UniversityPragueCzech Republic
| | | | | | - Michal Zikán
- Department of Gynaecology and Obstetrics, 1st Faculty of Medicine and Bulovka University HospitalCharles UniversityPragueCzech Republic
| | - Petra Sládková
- Physiotherapy and Medical Rehabilitation DepartmentBulovka University HospitalPragueCzech Republic
| | - Marie Tichá
- Physiotherapy and Medical Rehabilitation DepartmentBulovka University HospitalPragueCzech Republic
| | - Tomáš Brtnický
- Department of Gynaecology and Obstetrics, 1st Faculty of Medicine and Bulovka University HospitalCharles UniversityPragueCzech Republic
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Özbay T, Şanlı D, Springer JE. An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery. Acta Chir Belg 2024; 124:396-405. [PMID: 38445819 DOI: 10.1080/00015458.2024.2327813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Although ERAS protocols have many benefits, there are some deficiencies in their understanding and implementation by healthcare professionals. The present study was conducted to investigate the compliance of the current perioperative practices of healthcare professional with the ERAS protocols and to assess barriers to the implementation of ERAS protocols in colorectal surgery. METHODS This cross-sectional descriptive study conducted in the surgical clinics and operating rooms of a training and research hospital between January 2020 and September 2020 included 110 physician and nurse members of surgical teams. Data were collected using the Questionnaire for Evaluating the Use of the ERAS Protocol and Identifying Barriers to Implementation in Colorectal Surgery. RESULTS The compliance of the current perioperative practices by healthcare professionals with the ERAS protocols ranged between 15.5% (routinely leaving nasogastric tubes in situ following colorectal resection) and 61.8% (being aware of the concept of balanced analgesia). Variables such as the healthcare professional's profession, title, years in practice and colorectal surgery experience led to a difference between them in terms of their compliance of the practices with the ERAS protocols (p < 0.05). Based on the healthcare professionals' comments about barriers to the implementation of the ERAS protocol, themes such as education, teamwork, communication and lack of resources were created. CONCLUSION Healthcare professionals' compliance level of the current perioperative practices with the ERAS protocols was mostly low. Barriers to the implementation of the ERAS protocols had a multi-factor structure that concerns the multidisciplinary team.
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Affiliation(s)
- Turna Özbay
- Department of Nursing, Graduate School of Health Sciences, Izmir Katip Celebi University, Izmir, Türkiye
| | - Deniz Şanlı
- Department of Surgical Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Türkiye
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Blumenthal RN, Locke AR, Ben-Isvy N, Hasan MS, Wang C, Belanger MJ, Minhaj M, Greenberg SB. A Retrospective Comparison Trial Investigating Aggregate Length of Stay Post Implementation of Seven Enhanced Recovery After Surgery (ERAS) Protocols between 2015 and 2022. J Clin Med 2024; 13:5847. [PMID: 39407911 PMCID: PMC11477442 DOI: 10.3390/jcm13195847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 09/21/2024] [Accepted: 09/29/2024] [Indexed: 10/20/2024] Open
Abstract
(1) Introduction: Enhanced Recovery After Surgery (ERAS) protocols can create a cultural shift that will benefit patients by significantly reducing patient length of stay when compared to an equivalent group of surgical patients not following an ERAS protocol. (2) Methods: In this retrospective study of 2236 patients in a multi-center, community-based healthcare system, matching was performed based on a multitude of variables related to demographics, comorbidities, and surgical outcomes across seven ERAS protocols. These cohorts were then compared pre and post ERAS protocol implementation. (3) Results: ERAS protocols significantly reduced hospital length of stay from 3.0 days to 2.1 days (p <0.0001). Additional significant outcomes included reductions in opioid consumption from 40 morphine milligram equivalents (MMEs) to 20 MMEs (p <0.001) and decreased pain scores on postoperative day zero (POD 0), postoperative day one (POD 1), and postoperative day two (POD 2) when stratified into mild, moderate, and severe pain (p <0.001 on all three days). (4) Conclusions: ERAS protocols aggregately reduce hospital length of stay, pain scores, and opioid consumption.
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Affiliation(s)
- Rebecca N. Blumenthal
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
- Department of Anesthesiology and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Andrew R. Locke
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Noah Ben-Isvy
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Muneeb S. Hasan
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Chi Wang
- Department of Biostatistics, Endeavor Health, Evanston, IL 60201, USA
| | - Matthew J. Belanger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Mohammed Minhaj
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
- Department of Anesthesiology and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Steven B. Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
- Department of Anesthesiology and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
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Nian J, Li Z, Chen P, Ye P, Liu C. Enhanced recovery after surgery versus conventional postoperative care in patients undergoing hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 310:515-524. [PMID: 38836927 DOI: 10.1007/s00404-024-07475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/11/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE Hysterectomy is a common gynecological surgery associated with significant postoperative discomfort and extended hospital stays. Enhanced recovery after surgery (ERAS), a multidisciplinary approach, has emerged as a strategy aimed at improving perioperative outcomes and promoting faster patient recovery and satisfaction. This meta-analysis aimed to evaluate the impact of ERAS protocols on clinical outcomes, such as hospital stay length, readmission rates, and postoperative complications, in patients undergoing gynecological hysterectomy. METHODS Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted. Databases including PubMed, Embase, and Cochrane library were searched for relevant studies published up to January 31, 2023. A total of seventeen studies were selected based on predefined eligibility and exclusion criteria. Meta-analysis was carried out using a random-effects model with the STATA SE 14.0 software, focusing on outcomes like length of hospital stay, postoperative complications, and readmission rates. RESULTS ERAS protocols significantly reduced the length of hospital stays and incidence of postoperative complications such as ileus, without increasing readmission rates or the level of patient-reported pain. Notable heterogeneity was observed among included studies, attributed to the variation in patient populations and the specificity of the documented study protocols. CONCLUSION The findings underscore the effectiveness of ERAS protocols in enhancing recovery trajectories in gynecological hysterectomy patients. This reinforces the imperative for broader, standardized adoption of ERAS pathways as an evidence-based approach, fostering a safer and more efficient perioperative care paradigm.
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Affiliation(s)
- Jinxia Nian
- Operating Room, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350001, China
| | - Zhenming Li
- Operating Room, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350001, China
| | - Pinying Chen
- Operating Room, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350001, China
| | - Peiying Ye
- Central Sterile Supply Department, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350001, China.
| | - Chenyin Liu
- Nursing Department, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350001, China.
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Akay E, Irmak K, Incebıyık R, Sağlam F, Mutlu EB. Comparing Wound Healing and Infection Risk Between Early and Late Dressing Removal After Abdominal Hysterectomy. Cureus 2024; 16:e62535. [PMID: 39022459 PMCID: PMC11253562 DOI: 10.7759/cureus.62535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION This study evaluates the effects of dressing timing after abdominal hysterectomy on wound healing and infection risk. It highlights the potential for early dressing removal to accelerate healing and underscores the need for clear guidelines in wound care that align with the ERAS (Enhanced Recovery After Surgery) protocol. METHODS Using a prospective, randomized, double-blind design, this research was carried out at Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey. The objective was to investigate the impact of early dressing removal on wound healing and infection rates after elective abdominal hysterectomy. RESULTS Demographic parameters such as age, height, weight, and body mass index (BMI) were found to have no significant impact on wound healing. Patients whose dressings were removed early had shorter hospital stays. No significant differences were observed between the two groups in terms of wound complications and hospital readmission rates. CONCLUSIONS Early dressing removal after abdominal hysterectomy was observed to positively affect wound healing and facilitate earlier hospital discharge. However, no significant differences were found in hospital readmission rates between the two groups. These findings suggest that the dressing timing can be more flexible within the ERAS protocol and does not have a decisive impact on postoperative complications.
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Affiliation(s)
- Emrullah Akay
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
| | - Kübra Irmak
- Obstetrics and Gynecology, Istinye University, Istanbul, TUR
| | - Ravza Incebıyık
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
| | - Fatma Sağlam
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
| | - Enes Burak Mutlu
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
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Erkan C, Inal HA, Uysal A. Intra- and post-operative outcomes of the Enhanced Recovery after Surgery (ERAS) Program in laparoscopic hysterectomy. Arch Gynecol Obstet 2024; 309:2751-2759. [PMID: 38584246 DOI: 10.1007/s00404-024-07469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/10/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE To investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on perioperative and post-operative outcomes in laparoscopic hysterectomies (LHs) performed for benign gynecological diseases. METHODS This prospective study was conducted with randomized 100 participants who underwent LH between 1 January and 31 December, 2022. A standard care protocol was applied to 50 participants (Group 1, control) and the ERAS protocol to the other 50 (Group 2, study). Length of hospitalization was compared between the groups as the primary outcome, and the duration of the operation, the amount of bleeding, post-operative nausea-vomiting, gas discharge time, visual analog scale (VAS) pain scores, and complications as the secondary outcomes. RESULTS No statistically significant difference was seen between the groups in terms of sociodemographic characteristics, medical history, operation indications, surgical procedures applied in addition to hysterectomy, operative time, pre-operative and post-operative hemoglobin levels, amount of bleeding, or drain use (p > 0.05). However, a statistically significant difference was observed in terms of nausea (60% vs. 26%, p = 0.001), vomiting (28% vs. 10%, p = 0.040), duration of gassing (17.74 ± 6.77 vs. 14.20 ± 7.05 h, p = 0.012), length of hospitalization (41.78 ± 12.17 vs. 34.12 ± 10.90 h, p = 0.001), analgesic requirements (4.62 ± 1.36 vs. 3.34 ± 1.27 h, p < 0.001), or VAS scores at the 1st (5.86 ± 1.21 vs. 4.58 ± 1.31, p < 0.001), 6th (5.16 ± 1.12 vs. 4.04 ± 1.08, p < 0.001), 12th (4.72 ± 1.12 vs. 3.48 ± 1.12, p < 0.001), 18th (4.48 ± 1.21 vs. 3.24 ± 1.34, p < 0.001), and 24th (4.08 ± 1.29 vs. 3.01 ± 1.30, p < 0.001) hours. CONCLUSION The findings of this study show that the ERAS protocol has a positive effect on peri- and post-operative outcomes in LH. Further prospective studies are now needed to confirm the validity of the results.
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Affiliation(s)
- Caglar Erkan
- Department of Obstetrics and Gynecology, Antalya Training and Research Hospital, Varlık Mh. Kazım Karabekir Cd., 07100, Antalya, Turkey
| | - Hasan Ali Inal
- Department of Obstetrics and Gynecology, Antalya Training and Research Hospital, Varlık Mh. Kazım Karabekir Cd., 07100, Antalya, Turkey.
| | - Aysel Uysal
- Department of Obstetrics and Gynecology, Antalya Training and Research Hospital, Varlık Mh. Kazım Karabekir Cd., 07100, Antalya, Turkey
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Nelson G. Enhanced Recovery in Gynecologic Oncology Surgery-State of the Science. Curr Oncol Rep 2023; 25:1097-1104. [PMID: 37490193 DOI: 10.1007/s11912-023-01442-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/26/2023]
Abstract
PURPOSEOF REVIEW The purpose of this review is to describe the state of the science of enhanced recovery after surgery (ERAS) in gynecologic oncology. RECENT FINDINGS Over the last 5 years, there is mounting evidence supporting ERAS in gynecologic oncology surgery. Despite this, surveys have found suboptimal uptake of ERAS, and stakeholders have highlighted the difficulty of ERAS implementation as a major barrier. To address this, the core components required for a successful ERAS implementation program (protocol, ERAS team, audit system) are reviewed. ERAS developments specific to gynecologic oncology are also discussed, including same-day discharge initiatives for minimally invasive surgery, implications of telemedicine, and methods to increase uptake of ERAS in low- and middle-income countries. ERAS is a surgical quality improvement program with strong evidence supporting its effectiveness in gynecologic oncology. Efforts are required to address ERAS implementation barriers to increase uptake globally, especially in low-income settings.
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Affiliation(s)
- Gregg Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, 1331 29 St NW, Calgary, Alberta, T2N 4N2, Canada.
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Tresch C, Lallemant M, Ramanah R. Enhanced Recovery after Pelvic Organ Prolapse Surgery. J Clin Med 2023; 12:5911. [PMID: 37762852 PMCID: PMC10532386 DOI: 10.3390/jcm12185911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
The objective of this study was to review on the influence of enhanced rehabilitation in pelvic organ prolapse surgery outcomes, specifically focusing on length of hospital stay, hospital costs, pain, morbidity, and patient satisfaction. Following the PRISMA model and using PubMed as a source, eight articles pertaining to prolapse surgery and two articles concerning vaginal hysterectomies were selected, all published between 2014 and 2021. These studies revealed no significant difference in terms of operating time, intra- and post-operative complications, intra-operative blood loss and post-operative pain scores before and after the introduction of the ERAS program. Only one study noted a difference in readmission rates. There was, however, a noticeable decrease in intra-operative and post-operative intravenous intakes, opioid administration, length of stay, and overall hospital costs with the adoption of ERAS. Additionally, with ERAS, patients were able to mobilize more rapidly, and overall patient satisfaction significantly improved.
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Affiliation(s)
- Caroline Tresch
- Service de Gynécologie-Obstétrique, Université de Franche-Comté, CHU de Besançon, 25000 Besançon, France;
| | - Marine Lallemant
- Service de Gynécologie-Obstétrique, Université de Franche-Comté, CHU de Besançon, 25000 Besançon, France;
| | - Rajeev Ramanah
- Service de Gynécologie, Université de Franche-Comté, CHU de Besançon, 25000 Besançon, France;
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Ackert KE, Bauerle W, Pellegrino AN, Stoltzfus J, Pateman S, Graves D, Graul A, Taylor N, Zighelboim I. Implementation of an enhanced recovery after surgery (ERAS) protocol for total abdominal hysterectomies in the division of gynecologic oncology: a network-wide quality improvement initiative. J Osteopath Med 2023; 123:493-498. [PMID: 37318833 DOI: 10.1515/jom-2022-0204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/23/2023] [Indexed: 06/17/2023]
Abstract
CONTEXT Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease length of stay and postoperative opioid usage in colorectal and bariatric surgeries performed at large academic centers. Hysterectomies are the second most common surgical procedure among women in the United States. Hysterectomies performed in an open fashion, or total abdominal hysterectomies (TAHs), account for a large portion of procedures performed by gynecologic oncologists secondary to current oncology guidelines and surgical complexity. Implementation of an ERAS protocol for gynecologic oncology TAHs is one way in which patient outcomes may be improved. OBJECTIVES An ERAS protocol for gynecologic oncology surgeries performed in a community hospital was instituted with the goal to optimize patient outcomes preoperatively. The primary outcome of interest was to reduce patient opioid usage. Secondary outcomes included compliance with the ERAS protocol, length of stay, and cost. Thirdly, this study aimed to demonstrate the unique challenges of implementing a large-scale protocol across a community network. METHODS An ERAS protocol was implemented in 2018, with multidisciplinary input from the Departments of Gynecologic Oncology, Anesthesia, Pharmacy, Nursing, Information Technology, and Quality Improvement to develop a comprehensive ERAS order set. This was implemented across a 12-site hospital system network that consisted of both urban and rural hospital settings. A retrospective review of patient charts was performed to assess measured outcomes. Parametric and nonparametric tests were utilized for statistical analysis with p<0.05 denoting statistical significance. If the p value was >0.05 and <0.09, this was considered a trend toward significant. RESULTS A total of 124 patients underwent a TAH utilizing the ERAS protocol during 2018 and 2019. The control arm consisted of 59 patients who underwent a TAH prior to the ERAS protocol intervention, which was the standard of care in 2017. After 2 years of implementation of the ERAS protocol intervention, we found that 48 % of the ERAS patients had minimal opioid requirements after surgery (oral morphine equivalent [OME] range 0-40) with decreased postoperative opioid requirements in the ERAS group (p=0.03). Although not statistically significant, utilization of the ERAS protocol for gynecologic oncology TAHs trended toward shorter hospital length of stay from 5.18 to 4.17 days (p=0.07). The median total hospital costs per patient also showed a nonsignificant decrease in cost from $13,342.00 in the non-ERAS cohort and $13,703.00 in the ERAS cohort (p=0.8). CONCLUSIONS A large-scale quality improvement (QI) initiative is feasible utilizing a multidisciplinary team to implement an ERAS protocol for TAHs in the division of Gynecologic Oncology with promising results. This large-scale QI result was comparable to studies that conducted quality-improvement ERAS initiatives at single academic institutions and should be considered within community networks.
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Affiliation(s)
- Kathleen E Ackert
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Wayne Bauerle
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Anna Ng Pellegrino
- Department of Anesthesia, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Jill Stoltzfus
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Shaun Pateman
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Dan Graves
- Department of Anesthesia, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Ashley Graul
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nicholas Taylor
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Israel Zighelboim
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
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Kohn JR, Frost AS, Tambovtseva A, Hunt M, Clark K, Wilson C, Borahay MA. Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors. Int J Gynaecol Obstet 2023; 161:616-623. [PMID: 36436911 PMCID: PMC10121734 DOI: 10.1002/ijgo.14593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/28/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy. METHODS The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates. RESULTS A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges. CONCLUSION Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.
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Affiliation(s)
- Jaden R. Kohn
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anja S. Frost
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Megan Hunt
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Mostafa A. Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
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12
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Enhanced Recovery After Surgery Patients Are Prescribed Fewer Opioids at Discharge: A Propensity-score Matched Analysis. Ann Surg 2023; 277:e287-e293. [PMID: 34225295 DOI: 10.1097/sla.0000000000005042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to compare discharge opioid prescriptions pre- and post-ERAS implementation. SUMMARY OF BACKGROUND DATA ERAS programs decrease inpatient opioid use, but their relationship with postdischarge opioids remains unclear. METHODS All patients undergoing hysterectomy between October 2016 and November 2020 and pancreatectomy or hepatectomy between April 2017 and November 2020 at 1 tertiary care center were included. For each procedure, ERAS was implemented during the study period. PSM was performed to compare pre - versus post-ERAS patients on discharge opioids (number of pills and oral morphine equivalents). Patients were matched on age, sex, race, payor, American Society of Anesthesiologists score, prior opioid use, and procedure. Sensitivity analyses in open versus minimally invasive surgery cohorts were performed. RESULTS A total of 3983 patients were included (1929 pre-ERAS; 2054 post-ERAS). Post-ERAS patients were younger (56.0 vs 58.4 years; P < 0.001), more often female (95.8% vs 78.1%; P < 0.001), less often white (77.2% vs 82.0%; P < 0.001), less often had prior opioid use (20.1% vs 28.1%; P < 0.001), and more often underwent hysterectomy (91.1% vs 55.7%; P < 0.001). After PSM, there were no significant differences between cohorts in baseline characteristics. Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs 22.0 pills; P < 0.001) and lower oral morphine equivalents (129.4 mg vs 167.6 mg; P < 0.001) than pre-ERAS patients. Sensitivity analyses confirmed these findings [open (18.8 pills vs 25.4 pills; P < 0.001 \ 138.9 mg vs 198.7 mg; P < 0.001); minimally invasive surgery (17.2 pills vs 21.1 pills; P < 0.001 \ 127.1 mg vs 160.1 mg; P < 0.001). CONCLUSIONS Post-ERAS patients were prescribed significantly fewer opioids at discharge compared to matched pre-ERAS patients.
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Robella M, Tonello M, Berchialla P, Sciannameo V, Ilari Civit AM, Sommariva A, Sassaroli C, Di Giorgio A, Gelmini R, Ghirardi V, Roviello F, Carboni F, Lippolis PV, Kusamura S, Vaira M. Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis. Cancers (Basel) 2023; 15:cancers15030570. [PMID: 36765534 PMCID: PMC9913706 DOI: 10.3390/cancers15030570] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.
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Affiliation(s)
- Manuela Robella
- Unit of Surgical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Torino, Italy
- Correspondence: ; Tel.: +39-338-382-4104
| | - Marco Tonello
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Paola Berchialla
- Center for Biostatistics, Epidemiology and Public Health (C-BEPH), Deptartment of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
| | - Veronica Sciannameo
- Center for Biostatistics, Epidemiology and Public Health (C-BEPH), Deptartment of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
| | | | - Antonio Sommariva
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Cinzia Sassaroli
- Abdominal Oncology Department, Fondazione Giovanni Pascale, IRCCS, 80131 Naples, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Roberta Gelmini
- SC Chirurgia Generale d’Urgenza ed Oncologica, AOU Policlinico di Modena, 41125 Modena, Italy
| | - Valentina Ghirardi
- UOC Ovarian Carcinoma Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery, and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Fabio Carboni
- Peritoneal Tumours Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | | | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale Tumori IRCCS Milano, 20133 Milano, Italy
| | - Marco Vaira
- Unit of Surgical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Torino, Italy
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14
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O'Neill AM, Calpin GG, Norris L, Beirne JP. The impact of enhanced recovery after gynaecological surgery: A systematic review and meta-analysis. Gynecol Oncol 2023; 168:8-16. [PMID: 36356373 DOI: 10.1016/j.ygyno.2022.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery programs have become the gold standard of care in many surgical specialities. OBJECTIVES This updated systematic review and meta-analysis aims to evaluate how an ERAS program can impact outcomes across both benign and oncological gynaecological surgery to inform standard surgical practice. SEARCH STRATEGY An electronic search of the SCOPUS, Embase and PubMed Medline databases was performed for relevant studies assessing the use of ERAS in patients undergoing gynaecological surgery compared with those without ERAS. SELECTION CRITERIA The studies included were all trials using ERAS programs in gynaecological surgery with a clearly outlined protocol which included at least four items from the most recent guidelines and recorded one primary outcome. DATA COLLECTION AND ANALYSIS Meta-analysis was performed on two primary endpoints; post-operative length of stay and readmission rate and one secondary endpoint; rates of ileus. Further subgroup analyses was performed to compare benign and oncological surgeries. MAIN RESULTS Forty studies (7885 patients) were included in the meta-analysis; 15 randomised controlled trials and 25 cohort studies. 21 studies (4333 patients) were included in meta-analyses of length of stay. Patients in the ERAS group (2351 patients) had a shortened length of stay by 1.22 days (95% CI: -1.59 - -0.86, P < 0.00001) compared to those in the control group (1982 patients). Evaluation of 27 studies (6051 patients) in meta-analysis of readmission rate demonstrated a 20% reduction in readmission rate (OR: 0.80, 95% CI: 0.65-0.97). Analysis of our secondary outcome, demonstrated a 47% reduction in rate of ileus compared to the control group. CONCLUSIONS ERAS pathways significantly reduce length of stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery.
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Affiliation(s)
- Alice M O'Neill
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Gavin G Calpin
- Department of Surgery, University Hospital Galway, Newcastle Road, Galway, Ireland
| | - Lucy Norris
- Department of Obstetrics and Gynaecology, Trinity St. James' Cancer Institute, Trinity Centre for Health Sciences, St. James' Hospital, Dublin 8, Ireland
| | - James P Beirne
- Department of Gynaecological Oncology, Trinity St. James' Cancer Institute, St. James' Hospital, Dublin 8, Ireland
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YAYLA A, ESKİCİ V, AY E, ÖZER N, KURT G. Ameliyat Öncesi ve Sonrası Dönemde Yapılan Uygulamaların ERAS Protokolüne Uygunluğunun Değerlendirilmesi. İSTANBUL GELIŞIM ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2022. [DOI: 10.38079/igusabder.980901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Amaç: Bu çalışma, ameliyat öncesi ve sonrası dönemde yapılan uygulamaların ERAS (Enhanced Recovery After Surgery) protokolüne uygunluğunun değerlendirilmesi amacıyla yapılmıştır.Yöntem: Tanımlayıcı-kesitsel nitelikte tasarlanan araştırma, Ocak – Temmuz 2019 tarihleri arasında bir üniversitenin Sağlık Araştırma ve Uygulama Merkezinin cerrahi kliniklerinde yürütülmüştür. Ameliyatı planlanan, çalışmaya katılmayı kabul eden 863 hasta araştırma örneklemini oluşturmuştur. Veriler, araştırmacılar tarafından literatür doğrultusunda hazırlanan anket formu, Vizüel Analog Skala ve Bulantı Sayısal Ölçeği ile yüz yüze görüşme yöntemiyle toplanmıştır. Veriler, SPSS 20.0 paket programında tanımlayıcı istatistikler kullanılarak değerlendirilmiştir.Bulgular: Çalışmadaki hastaların tamamının ameliyat öncesi dönemde oral karbonhidrat almadığı, ameliyat öncesi aç kalma sürelerinin 10,55±6,91 saat olduğu ve hastalara premedikasyon uygulanmadığı belirlenmiştir. Hastaların ameliyat sonrası; ilk sıvı alma zamanı ortalamasının 10,45±15,44 saat, ilk katı gıda alma zamanı ortalamasının 18,70±29,23 saat olduğu, ilk mobilizasyon süresinin 19,02±21,39 saat, nazogastrik sonda kalış süresi ortalamasının 29,33±28,80 saat, drenin kalış süresi ortalamasının 54,30±28,06 saat, üriner kateter kalış süresi ortalamasının 49,51±27,40 saat olduğu saptanmıştır.Sonuç: Çalışma sonucunda ERAS protokollerine uyumun istenilen düzeyde olmadığı ve sağlık çalışanlarına ERAS’la uyumlu olmayan uygulamalarla ilgili eğitim verilmesi önerilebilir.
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16
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Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial. J Am Acad Orthop Surg 2022; 30:e833-e841. [PMID: 35312650 DOI: 10.5435/jaaos-d-21-00960] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/11/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty. METHODS We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake. RESULTS Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements. CONCLUSION This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively. CLINICAL TRIALS REGISTRY NCT03380754.
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17
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Trad ATA, Tamhane P, Weaver AL, Baker MV, Visscher SL, Borah BJ, Kalogera E, Gebhart JB, Trabuco EC. Impact of enhanced recovery implementation in women undergoing abdominal sacrocolpopexy. Int J Gynaecol Obstet 2022; 159:727-734. [PMID: 35598156 DOI: 10.1002/ijgo.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/30/2022] [Accepted: 05/17/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of Enhanced Recovery After Surgery (ERAS) with and without liposomal bupivacaine (LB) on opioid use, hospital length of stay (LOS), costs, and morbidity of women undergoing sacrocolpopexy. METHODS Retrospective cohort of women who underwent abdominal sacrocolpopexy between April 1, 2009 and November 30, 2017. Costs for relevant healthcare services were determined by assigning 2017 charges multiplied by 2017 Medicare Cost Report's cost to charge ratios. Outcomes were compared among periods with multivariable regression models adjusted for age, American Society of Anesthesiologists score, and concurrent hysterectomy and posterior repair. RESULTS Patients were subdivided into pre-ERAS (G1, n = 128), post-ERAS (G2, n = 83), and post-ERAS plus LB (G3, n = 91). The proportion of patients needing opioids during postoperative days 0-2 was significantly less for G3 (75.8%) compared with G1 (97.7%) and G2 (92.8%); P < 0.001). The median morphine equivalent units (MEU) with interquartile ranges, mean LOS, and adjusted mean standardized costs were significantly lower in G3 compared with the other two groups (35 [20-75] vs. 67 [31-109], and 60 [30-122] MEUs; 1.8 vs. 2.3 vs. 2.9 days; and $2391, $2975, and $3844, for G3, G2, and G1, respectively; P < 0.001). CONCLUSION Implementation of an ERAS pathway led to significant decreases in opioid use, LOS, and costs. Supplementation with LB further improved these measures.
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Affiliation(s)
| | - Prajakta Tamhane
- Department of Family Medicine, Reid Health, Richmond, Indiana, USA
| | - Amy L Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary V Baker
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - John B Gebhart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Emanuel C Trabuco
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Martin F, Vautrin N, Elnar AA, Goetz C, Bécret A. Evaluation of the impact of an enhanced recovery after surgery (ERAS) programme on the quality of recovery in patients undergoing a scheduled hysterectomy: a prospective single-centre before-after study protocol (RAACHYS study). BMJ Open 2022; 12:e055822. [PMID: 35393312 PMCID: PMC8990258 DOI: 10.1136/bmjopen-2021-055822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 03/18/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The enhanced recovery after surgery (ERAS) programmes following hysterectomies have been studied since 2010, and their positive effects on clinical or economic criteria are now well established. However, the benefits on health outcomes, especially rapid recovery after surgery from patients' perspective is lacking in literature, leading to develop scores supporting person-centred and value-based care such as patient-reported outcome measures. The aim of this study is to assess the impact of an ERAS programme on patients' well-being after undergoing hysterectomy. METHODS AND ANALYSIS This is an observational, prospective single-centre before-after clinical trial. 148 patients are recruited and allocated into two groups, before and after ERAS programme implementation, respectively. The ERAS programme consists in optimising factors dealing with early rehabilitation, such as preoperative patient education, multimodal pain management, early postoperative fluid taken and mobilisation. A self-questionnaire quality of recovery-15 (QoR-15) on the preoperative day 1 (D-1), postoperative day 0 evening (D0) and the postoperative day 1 (D+1) is completed by patients. Patients scheduled to undergo hysterectomy, aged 18 years and above, whose physical status are classified as American Society of Anesthesiologists score 1-3 and who are able to return home after being discharged from hospital and contact their physician or the medical department if necessary are recruited for this study. The total duration of inclusion is 36 months. The primary outcome is the difference in QoR-15 scores measured on D+1 which will be compared between the 'before' and the 'after' group, using multiple linear regression model. ETHICS AND DISSEMINATION Approval was obtained from the Ethical Committee (Paris, France). Subjects are actually being recruited after giving their oral agreement or non-objection to participate in this clinical trial and following the oral and written information given by the anaesthesiologist practitioner.Trial registration number: ClinicalTrials.gov: NCT04268576 (Pre-result).
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Affiliation(s)
- Flora Martin
- Anesthesiology, CHR Metz-Thionville, Metz, France
- Faculté de médecine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | | | | | - Christophe Goetz
- Clinical Research Support Unit, CHR Metz-Thionville, Metz, France
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Foulon A, Fauvet R, Villefranque V, Bourdel N, Simonet T, Sylvestre CL, Canlorbe G, Azaïs H. Definition, general principles and expected benefits of Enhanced Recovery in Surgery. J Gynecol Obstet Hum Reprod 2022; 51:102373. [DOI: 10.1016/j.jogoh.2022.102373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
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Chau JPC, Liu X, Lo SHS, Chien WT, Hui SK, Choi KC, Zhao J. Perioperative enhanced recovery programmes for women with gynaecological cancers. Cochrane Database Syst Rev 2022; 3:CD008239. [PMID: 35289396 PMCID: PMC8922407 DOI: 10.1002/14651858.cd008239.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015. OBJECTIVES To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes. SEARCH METHODS We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty. MAIN RESULTS We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.
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Affiliation(s)
- Janita Pak Chun Chau
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xu Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sze Ki Hui
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Jie Zhao
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Tanner LD, Chen HY, Chauhan SP, Sibai BM, Ghebremichael SJ. Enhanced recovery after scheduled cesarean delivery: a prospective pre-post intervention study. J Matern Fetal Neonatal Med 2021; 35:9170-9177. [PMID: 34957893 DOI: 10.1080/14767058.2021.2020237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess whether an early recovery after surgery (ERAS) pathway after scheduled cesarean delivery was associated with a reduction in postoperative length of stay compared with standard perioperative care. METHODS This was a prospective pre- and post-intervention study. Women were included if they were between 18 and 45 years of age and delivered a singleton, term, non-anomalous fetus via scheduled cesarean delivery by a provider within an academic practice. The ERAS pathway consisted of 23 evidence-based components regarding preoperative, intraoperative, and postoperative care. The primary outcome was the rate of postoperative length of stay of 3 or more days. Secondary outcomes included total postoperative narcotic use, postoperative complications, 30-day hospital readmission rates, and quality of recovery questionnaire scores. RESULTS A total of 116 women were included. There were no significant differences in patient characteristics between the pre- and post-implementation groups in the post-implementation group, surgery time was longer (78.3 ± 27.8 vs 59.1 ± 19.2 min, p < .001) and blood loss volume was higher (910.3 ± 405.1 vs 729.1 ± 202.0, p = .003), compared to pre-implementation group. An ERAS pathway was not associated in a significant reduction in postoperative length of stay of 3 or more days (70.7% vs 75.9%, p = .529). It was also not significantly associated with a difference in postoperative narcotic use, maximum pain score, transfusion, postoperative complications or hospital readmission rates. CONCLUSION An early recovery after surgery pathway after scheduled cesarean delivery was not associated with a reduction in postoperative length of stay or narcotic use, though the recovery scores were better after implementation.
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Affiliation(s)
- Lisette D Tanner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Han-Yang Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Baha M Sibai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Semhar J Ghebremichael
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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22
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Enhanced recovery after posterior deep infiltrating endometriosis surgery: a national study. Fertil Steril 2021; 117:376-383. [PMID: 34949453 DOI: 10.1016/j.fertnstert.2021.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the impact of the implementation of a national enhanced recovery after surgery (ERAS) program for posterior deep infiltrating endometriosis (DIE) surgery on the length of hospital stay, the rate of postoperative complications, and readmission within 30 days. DESIGN Comparative exposed/nonexposed observational study. SETTING Study based on the French national medicoeconomic database of the Program of Medicalization of Information System. PATIENTS Seven hundred and sixty-four women who underwent DIE surgery were involved and matched (1:3 ratio) into two groups: ERAS group for the year 2019 and non-ERAS group for the year 2015. INTERVENTIONS Surgical management for posterior DIE. MAIN OUTCOME MEASURES The length of hospital stay, the rate of postoperative complications during the initial hospital stay, and readmission within 30 days. RESULTS The ERAS group included 191 women, and the non-ERAS group included 573 women. The mean length of hospital stay was shorter in the ERAS group than in the non-ERAS group (4.28 ± 3.80 days vs. 5.42 ± 4.04 days, respectively). The rate of postoperative abdominal or pelvic pain syndromes was lower in the ERAS group than in the non-ERAS group (5/191 (2.62%) vs. 48/573 (8.38%), respectively; relative risk, 0.31 [0.125-0.7969]). The rate of postoperative complication and the rate of readmission within 30 days were not different between the two groups. CONCLUSIONS The implementation of ERAS has a significant positive impact on patient outcomes after DIE surgery. The length of hospital stay and abdominal or pelvic pain syndromes were reduced without increasing complications or readmission within 30 days.
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Shen Y, Lv F, Min S, Wu G, Jin J, Gong Y, Yu J, Qin P, Zhang Y. Impact of enhanced recovery after surgery protocol compliance on patients' outcome in benign hysterectomy and establishment of a predictive nomogram model. BMC Anesthesiol 2021; 21:289. [PMID: 34809583 PMCID: PMC8607678 DOI: 10.1186/s12871-021-01509-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
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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Affiliation(s)
- Yiwei Shen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Feng Lv
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Gangming Wu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Juying Jin
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Yao Gong
- Department of Gynecology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Yu
- Department of Gynecology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peipei Qin
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Ying Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
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Lee SS, Chern JY, Frey MK, Comfort A, Lee J, Roselli N, Boyd LR. Enhanced recovery Pathways in gynecologic surgery: Are they safe and effective in the elderly? Gynecol Oncol Rep 2021; 38:100862. [PMID: 34621945 PMCID: PMC8479239 DOI: 10.1016/j.gore.2021.100862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/01/2021] [Accepted: 09/13/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare perioperative outcomes of the elderly versus non-elderly patients on ERPs undergoing laparotomy for gynecologic surgery. METHODS From January 2016 to June 2017, patients undergoing elective laparotomies for gynecologic surgery were enrolled in a perioperative ERP protocol. Outcomes were compared between the elderly (age ≥ 70 years) and the non-elderly (age ≤ 69 years). Primary outcomes were length of stay and perioperative complication rates. Comparisons were performed using chi-squared tests or Fisher's exact tests for categorical data and Student's t-test or Wilcoxon rank-sum tests for continuous variables, with p < 0.05 for significance. RESULTS One hundred eighty-nine patients were enrolled in the study, including 16 patients ≥ 70 years old. The median age was 75 years for the elderly and 45 years for the non-elderly. Elderly patients were more likely to have more complex surgery and longer operative times (absolute median difference of 39 min). Despite the increasing complexity of surgical procedures for elderly patients, there were no statistically significant differences in serious inpatient complications (Clavien-Dindo score 3A or greater), pain and nausea scores, 30-day complications and readmission rates. Elderly patients had a longer median length of stay compared to non-elderly patients by one day (p < 0.001), however, this was not statistically significant on multivariate analysis. CONCLUSION In our series, elderly patients on the ERP had similar rates of complications and readmission when compared to non-elderly patients, despite undergoing more complex surgeries. This suggests that ERP may be feasible and safe in the elderly population undergoing elective gynecologic laparotomy.
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Affiliation(s)
- Sarah S. Lee
- New York University School of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York, NY, United States
| | - Jing-Yi Chern
- Moffitt Cancer Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Tampa, FL, United States
| | - Melissa K. Frey
- Weill Cornell Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York, NY, United States
| | - Ashley Comfort
- Boston University Medical Center, Department of Obstetrics and Gynecology, Boston, MA, United States
| | - Jessica Lee
- University of Texas Southwestern Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Dallas, TX, United States
| | - Nicole Roselli
- New York University School of Medicine, Department of Obstetrics and Gynecology
| | - Leslie R. Boyd
- New York University School of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York, NY, United States
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25
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Sisodia RC, Ellis D, Hidrue M, Linov P, Cavallo E, Bryant AS, Wakamatsu M, del Carmen MG. Cohort study of impact on length of stay of individual enhanced recovery after surgery protocol components. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2021; 3:e000087. [PMID: 35047804 PMCID: PMC8749327 DOI: 10.1136/bmjsit-2021-000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/09/2021] [Indexed: 11/05/2022] Open
Abstract
Objective The goal of this study was to explore which enhanced recovery after surgery (ERAS) bundle items were most associated with decreased length of stay after surgery, most likely associated with decreased length of stay after surgery. Design A cohort study. Setting Large tertiary academic medical centre. Participants The study included 1318 women undergoing hysterectomy as part of our ERAS pathway between 1 February 2018 and 30 January 2020 and a matched historical cohort of all hysterectomies performed at our institution between 3 October 2016 and 30 January 2018 (n=1063). Intervention The addition of ERAS to perioperative care. This is a cohort study of all patients undergoing hysterectomy at an academic medical centre after ERAS implementation on 1 February 2018. Compliance and outcomes after ERAS roll out were monitored and managed by a centralised team. Descriptive statistics, multivariate regression, interrupted time series analysis were used as indicated. Main outcome measures Impact of ERAS process measure adherence on length of stay. Results After initiation of ERAS pathway, 1318 women underwent hysterectomy. There were more open surgeries after ERAS implementation, but cohorts were otherwise balanced. The impact of process measure adherence on length of stay varied based on surgical approach (minimally invasive vs open). For open surgery, compliance with intraoperative antiemetics (−30%, 95% CI −18% to 40%) and decreased postoperative fluid administration (−12%, 95% CI −1% to 21%) were significantly associated with reduced length of stay. For minimally invasive surgery, ambulation within 8 hours of surgery was associated with reduced length of stay (−53%, 95% CI −55% to 52%). Conclusions While adherence to overall ERAS protocols decreases length of stay, the specific components of the bundle most significantly impacting this outcome remain elusive. Our data identify early ambulation, use of antiemetics and decreasing postoperative fluid administration to be associated with decreased length of stay.
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Affiliation(s)
- Rachel C. Sisodia
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dan Ellis
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Hidrue
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela Linov
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elena Cavallo
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Allison S. Bryant
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - May Wakamatsu
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcela G. del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
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Bahadur A, Kumari P, Mundhra R, Ravi AK, Chawla L, Mahamood M M, Kumari P, Chaturvedi J. Evaluate the Effectiveness of Enhanced Recovery After Surgery Versus Conventional Approach in Benign Gynecological Surgeries: A Randomized Controlled Trial. Cureus 2021; 13:e16527. [PMID: 34430137 PMCID: PMC8378282 DOI: 10.7759/cureus.16527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 01/22/2023] Open
Abstract
Objective This study aimed to evaluate the effectiveness of enhanced recovery after surgery (ERAS) model versus conventional approach in benign gynecological surgeries (incorporating various routes of surgery). Methods This was a randomized controlled trial wherein patients undergoing gynecological surgery for benign indications from January 2019 to July 2020 were recruited and randomized into ERAS and conventional protocol groups using block randomization. The intended primary outcome was to compare the median length of hospital stay in both groups. “Fit for discharge” criteria were used to assess the length of stay as patients who belonged to hilly terrain with limited transportation facilities stayed for a longer duration. Results A total of 180 patients were recruited and 90 each was randomized into ERAS and conventional protocol groups. The difference in length of hospital stay between ERAS (36 hours, range 24-96 hours) and conventional group (72 hours, range: 24-144 hours) was significant (p<0.01). A statistically significant difference was noted in the time for recovery of bowel function and tolerance for diet in the ERAS group. No significant difference in complications and readmission (within 30 days) rate was seen between the two groups. Quality of life as assessed by the World Health Organization Quality of Life Brief Version (WHO-QOL BREF) on the day of discharge and day 30 was higher in the ERAS group in physical and psychological domains, while no difference was seen in environmental and social domains. Conclusion This study as an institutional experience strengthens the existing evidence regarding the efficacy of ERAS in reducing hospital stay and improving quality of life compared to the conventional perioperative management protocol.
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Affiliation(s)
- Anupama Bahadur
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Payal Kumari
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Rajlaxmi Mundhra
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Anoosha K Ravi
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Latika Chawla
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Mahima Mahamood M
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Purvashi Kumari
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Jaya Chaturvedi
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
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Smith MJ, Lee J, Brodsky AL, Figueroa MA, Stamm MH, Giard A, Luker N, Friedman S, Huncke T, Jain SK, Pothuri B. Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway. J Minim Invasive Gynecol 2021; 28:2052-2059.e3. [PMID: 34139329 DOI: 10.1016/j.jmig.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m2 undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP. DESIGN A retrospective cohort study. SETTING An academic teaching hospital. PATIENTS A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m2) undergoing robotic hysterectomy. INTERVENTIONS The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls. MEASUREMENTS AND MAIN RESULTS Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room). CONCLUSION The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.
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Affiliation(s)
- Maria J Smith
- Department of Obstetrics and Gynecology, NYU Langone Health (Dr. Smith), New York, NY
| | - Jessica Lee
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Texas Southwestern Medical Center (Drs. Lee), Dallas, TX
| | - Allison L Brodsky
- Department of Obstetrics and Gynecology, University of California San Diego (Drs. Brodsky), San Diego, CA
| | - Melissa A Figueroa
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Matthew H Stamm
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Audra Giard
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Nadia Luker
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Steven Friedman
- Department of Population Health, NYU Langone Health (Mr. Friedman)
| | - Tessa Huncke
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Sudheer K Jain
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, NYU Langone Health (Dr. Pothuri).
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Joshi TV, Bruce SF, Grim R, Buchanan T, Chatterjee-Paer S, Burton ER, Sorosky JI, Shahin MS, Edelson MI. Implementation of an enhanced recovery protocol in gynecologic oncology. Gynecol Oncol Rep 2021; 36:100771. [PMID: 34036136 PMCID: PMC8134956 DOI: 10.1016/j.gore.2021.100771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/19/2021] [Accepted: 04/24/2021] [Indexed: 12/18/2022] Open
Abstract
Enhanced recovery in gynecologic oncology decreased narcotic usage. Shorter length of hospital stay was also observed in the ERAS cohort. ERAS produced early return of bowel function. The ERAS cohort received less perioperative blood transfusions. A compliance analysis is integral to successful implementation of ERAS. Enhanced Recovery after Surgery (ERAS) is an evidence-based approach that aims to reduce narcotic use and maintain anabolic balance to enable full functional recovery. Our primary aim was to determine the effect of ERAS on narcotic usage among patients who underwent exploratory laparotomy by gynecologic oncologists. We characterized its effect on length of stay, intraoperative blood transfusions, bowel function, 30-day readmissions, and postoperative complications. A retrospective cohort study was performed at Abington Hospital-Jefferson Health in gynecologic oncology. Women who underwent an exploratory laparotomy from 2011 to 2016 for both benign and malignant etiologies were included before and after implementation of our ERAS protocol. Patients who underwent a bowel resection were excluded. A total of 724 patients were included: 360 in the non-ERAS and 364 in the ERAS cohort. An overall reduction in narcotic usage, measured as oral morphine milliequivalents (MMEs) was observed in the ERAS relative to the non-ERAS group, during the entire hospital stay (MME 34 versus 68, p < 0.001 and within 72 h postoperatively (MME 34 versus 60, p < 0.005). A shorter length of stay and earlier return of bowel function were also observed in the ERAS group. No differences in 30-day readmissions (p = 0.967) or postoperative complications (p = 0.328) were observed. This study demonstrated the benefits of ERAS in Gynecologic Oncology. A significant reduction of postoperative narcotic use, earlier return of bowel function and a shorter postoperative hospital stay was seen in the ERAS compared to traditional perioperative care.
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Affiliation(s)
- Tanvi V Joshi
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Shaina F Bruce
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Rod Grim
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Tommy Buchanan
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Sudeshna Chatterjee-Paer
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Elizabeth R Burton
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Joel I Sorosky
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Mark S Shahin
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Mitchell I Edelson
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
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Karaman S, Karaman T, Deveci H, Ozsoy AZ, Delibas IB. Effect of transcutaneous electrical nerve stimulation on quality of recovery and pain after abdominal hysterectomy. J Anaesthesiol Clin Pharmacol 2021; 37:85-89. [PMID: 34103829 PMCID: PMC8174447 DOI: 10.4103/joacp.joacp_207_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/24/2019] [Accepted: 10/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background and Aims: Transcutaneous electrical nerve stimulation (TENS) is a noninvasive complementary therapy for postoperative pain management. The effect of TENS on quality of recovery (QoR) and pain treatment in the early postoperative period is not well documented. The aim of this study was to evaluate the effect of TENS on postoperative QoR and pain in patients who had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO). Material and Methods: Fifty-two patients were randomized into two groups: control (sham TENS treatment) and TENS (TENS treatment). QoR, dynamic pain, and static pain were evaluated after surgery. Results: The QoR score was significantly higher in the TENS group as compared with that in the control group (P = 0.029). Pain scores during coughing (dynamic pain) were significantly less in TENS group compared to control group (P <0.001). However, there was no between-group difference in pain scores at rest (static pain) or total analgesic consumption (P = 0.63 or P = 0.83, respectively). Conclusion: TENS may be a valuable tool to improve patients' QoR and dynamic pain scores after TAH + BSO.
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Affiliation(s)
- Serkan Karaman
- Department of Anesthesiology and Reanimation, School of Medicine, Tokat Gaziosmanpasa University, Tokat, Turkey
| | - Tuğba Karaman
- Department of Anesthesiology and Reanimation, School of Medicine, Tokat Gaziosmanpasa University, Tokat, Turkey
| | - Hulya Deveci
- Department of Physical Therapy and Rehabilitation, School of Medicine, Tokat Gaziosmanpasa University, Tokat, Turkey
| | - Asker Z Ozsoy
- Department of Gynecology and Obstetrics, School of Medicine, Tokat Gaziosmanpasa University, Tokat, Turkey
| | - Ilhan B Delibas
- Department of Gynecology and Obstetrics, School of Medicine, Tokat Gaziosmanpasa University, Tokat, Turkey
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Ercolino A, Droghetti M, Schiavina R, Bianchi L, Chessa F, Mineo Bianchi F, Barbaresi U, Angiolini A, Casablanca C, Mottaran A, Molinaroli E, Pultrone C, Dababneh H, Bertaccini A, Brunocilla E. Postoperative outcomes of Fast-Track-enhanced recovery protocol in open radical cystectomy: comparison with standard management in a high-volume center and Trifecta proposal. Minerva Urol Nephrol 2020; 73:763-772. [PMID: 33200895 DOI: 10.23736/s2724-6051.20.03843-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We aimed at comparing perioperative outcomes in patients submitted to radical cystectomy followed by Fast Track (FT) protocol or standard management, and propose a definition of Trifecta, to improve standardized quality assessment for RC. METHODS We considered 191 patients submitted to RC between January 2017 and January 2019. Patients followed FT or standard management according to surgeon's preference. Preoperative and intraoperative characteristics, alongside with postoperative outcomes were compared between the two groups. Trifecta was defined as follows: in-hospital stay (HS) ≤ 10 days, time to defecation (TtD) below the overall mean and no major (≥ Clavien-Dindo grade III) complications. Finally, Trifecta achievement rates were assessed in both groups. RESULTS Seventy-five patients (39%) followed the FT protocol and 116 (61%) standard management. The two groups were homogeneous for preoperative, intraoperative and pathological characteristics. Patients in the FT group had shorter TtD (5 vs. 6 days P=0.006), HS (12 vs. 14 days P=0.008) and lower readmission rate (8% vs. 19% P=0.04). Early complication rates and grades were similar, while less late complications were found in FT group (6.7% vs. 21.6% P=0.006). Trifecta achievement rate was higher for FT group (31% vs. 8% P<0.001). Single-item failure percentages for HS, TtD and major grade complications were respectively 90%, 60% and 19%, with no difference between the two groups. CONCLUSIONS FT protocol can safely consent faster bowel recovery and earlier discharge after RC, plus reducing readmission rates. Using a Trifecta incorporating essential perioperative outcomes, could improve standardized quality assessment for RC.
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Affiliation(s)
- Amelio Ercolino
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Droghetti
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy - .,University of Bologna, Bologna, Italy
| | - Francesco Chessa
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | | | - Umberto Barbaresi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Angiolini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlo Casablanca
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Angelo Mottaran
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Molinaroli
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristian Pultrone
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Hussam Dababneh
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Bertaccini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Eugenio Brunocilla
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
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Kilpiö O, Härkki PSM, Mentula MJ, Väänänen A, Pakarinen PI. Recovery after enhanced versus conventional care laparoscopic hysterectomy performed in the afternoon: A randomized controlled trial. Int J Gynaecol Obstet 2020; 151:392-398. [DOI: 10.1002/ijgo.13382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/17/2020] [Accepted: 09/16/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Olga Kilpiö
- Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Päivi S. M. Härkki
- Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Maarit J. Mentula
- Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Antti Väänänen
- Department of Anesthesiology and Intensive Care University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Päivi I. Pakarinen
- Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
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Bernard L, McGinnis JM, Su J, Alyafi M, Palmer D, Potts L, Nancekivell KL, Thomas H, Kokus H, Eiriksson LR, Elit LM, Jimenez WGF, Reade CJ, Helpman L. Thirty-day outcomes after gynecologic oncology surgery: A single-center experience of enhanced recovery after surgery pathways. Acta Obstet Gynecol Scand 2020; 100:353-361. [PMID: 33000463 DOI: 10.1111/aogs.14009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/16/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The purpose of the study is to evaluate the impact of an enhanced recovery after surgery (ERAS) program implemented in a Gynecologic Oncology population undergoing a laparotomy at a Canadian tertiary care center. MATERIAL AND METHODS Prospectively collected data, using the American College of Surgeons' National Surgical Quality Improvement Program dataset (ACS NSQIP), was used to compare 30-day postoperative outcomes of gynecologic oncology patients undergoing a laparotomy before and after the 2018 implementation of an ERAS program in a Canadian regional cancer center. Patient demographics, surgical variables and postoperative outcomes of 187 patients undergoing surgery in 2019 were compared with those of 441 patients undergoing surgery between January 2016 and December 2017. Student's t, Mann-Whitney U and Chi-square tests, as well as multivariate linear and logistic regressions were used to evaluate baseline characteristics and 30-day postoperative complications. RESULTS Length of stay was significantly shortened in the study population after introducing the ERAS protocol, from a mean of 4.7 (SD = 3.8) days to a mean of 3.8 (SD = 3.2) days (P = .0001). The overall complication rate decreased from 24.3% to 16% (P = .02). Significant decreases in the rates of postoperative infections (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.31-0.99) and cardiovascular complications (adjusted OR 0.27, 95% CI 0.09-0.79) were noted, without a significant increase in readmission rate (adjusted OR 0.50, 95% CI 0.21-1.07). CONCLUSIONS Introducing an ERAS program for gynecologic oncology patients undergoing laparotomy was effective in shortening length of stay and the overall complication rate without a significant increase in readmission. Advocacy for broader implementation of ERAS among gynecologic oncology services and ongoing discussion on challenges and opportunities in the implementation process are warranted to improve patient outcomes and experiences.
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Affiliation(s)
- Laurence Bernard
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Justin M McGinnis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jane Su
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Alyafi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Delia Palmer
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Leonard Potts
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kelly-Lynn Nancekivell
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Heidi Thomas
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Heather Kokus
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Lua R Eiriksson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Lorraine M Elit
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Waldo G F Jimenez
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Clare J Reade
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Limor Helpman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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AlAshqar A, Goktepe ME, Kilic GS, Borahay MA. Predictors of the cost of hysterectomy for benign indications. J Gynecol Obstet Hum Reprod 2020; 50:101936. [PMID: 33039600 DOI: 10.1016/j.jogoh.2020.101936] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hysterectomy is a commonly performed procedure with widely variable costs. As gynecologists divert from invasive to minimally invasive approaches, many factors come into play in determining hysterectomy cost and efforts should be sought to minimize it. Our objective was to identify the predictors of hysterectomy cost. MATERIALS AND METHODS This was a retrospective cohort study where women who underwent hysterectomy for benign conditions at the University of Texas Medical Branch from 2009 to 2016 were identified. We obtained and analyzed demographic, operative, and financial data from electronic medical records and the hospital finance department. RESULTS We identified 1,847 women. Open hysterectomy was the most frequently practiced (35.8 %), followed by vaginal (23.7 %), laparoscopic (23.6 %), and robotic (16.9 %) approaches. Multivariate regression demonstrated that hysterectomy charges can be significantly predicted from surgical approach, patient's age, operating room (OR) time, length of stay (LOS), estimated blood loss, insurance type, fiscal year, and concomitant procedures. Charges increased by $3,723.57 for each day increase in LOS (P <0.001), by $76.02 for each minute increase in OR time (P <0.001), and by $48.21 for each one-year increase in age (P 0.037). Adjusting for LOS and OR time remarkably decreased the cost of open and robotic hysterectomy, respectively when compared with the vaginal approach. CONCLUSION Multiple demographic and operative factors can predict the cost of hysterectomy. Healthcare providers, including gynecologists, are required to pursue additional roles in proper resource management and be acquainted with the cost drivers of therapeutic interventions. Future efforts and policies should target modifiable factors to minimize cost and promote value-based practices.
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Affiliation(s)
- Abdelrahman AlAshqar
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States; Department of Obstetrics and Gynecology, Kuwait University, Kuwait City, Kuwait
| | - Metin E Goktepe
- Medical Student, The University of Texas Medical Branch in Galveston, TX, United States
| | - Gokhan S Kilic
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch in Galveston, TX, United States
| | - Mostafa A Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States.
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Smith AE, Heiss K, Childress KJ. Enhanced Recovery After Surgery in Pediatric and Adolescent Gynecology: A Pilot Study. J Pediatr Adolesc Gynecol 2020; 33:403-409. [PMID: 32061749 DOI: 10.1016/j.jpag.2020.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in adult gynecology as well as adult and pediatric colorectal and urologic surgery with reduction in narcotic use, complications, return to the system (RTS), length of stay (LOS), and improved patient satisfaction. There are no studies evaluating the use of ERAS in pediatric and adolescent gynecology (PAG). The goals of this study are to present initial patient outcomes using ERAS in PAG patients undergoing intra-abdominal gynecologic surgery to prove efficacy, patient satisfaction, and decreased narcotic use. DESIGN As a quality improvement measure in perioperative care, an ERAS protocol including preoperative, intraoperative, and postoperative components and a follow-up patient telephone call for pain assessment was implemented for all intra-abdominal gynecologic procedures. A retrospective study on implementation of ERAS components, outcomes, and patient satisfaction was then performed in participants meeting inclusion criteria. SETTING Large academic children's hospital. PARTICIPANTS Patients <25 years of age who underwent laparoscopic (LSC) or open abdominal (XLAP) gynecologic surgery using an ERAS protocol by the PAG service over a 12-month period. INTERVENTIONS An ERAS protocol including preoperative, intraoperative, and postoperative components and follow-up patient telephone call for pain assessment was implemented for all major gynecologic surgeries performed by the PAG service. MAIN OUTCOME MEASURES Patient satisfaction with the perioperative ERAS protocol along with components including pain management, narcotic use, LOS, RTS, and postoperative complications for various intra-abdominal gynecologic procedures. RESULTS A total of 40 participants met inclusion criteria for the study. Thirty-four (85%) participants underwent LSC procedures and six (15%) underwent XLAP. Of the LSC patients, 95% were discharged on postoperative day 0, and all XLAP patients and one LSC patient were discharged on postoperative day 1. In all, 95% of patients were discharged from the hospital requiring only non-narcotic ERAS medications. There were no readmissions or postoperative complications. All patients were satisfied with their postoperative pain control at their follow-up telephone call and clinic visit. CONCLUSION Implementation of a pediatric-specific ERAS protocol in children and adolescents undergoing gynecologic surgery is feasible and safe, and leads to less narcotic use without an increase in complications or decrease in patient satisfaction.
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Affiliation(s)
| | - Kurt Heiss
- Division of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA; Department of Surgery, Emory University, Atlanta, GA
| | - Krista J Childress
- Division of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA; Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Emory University, Atlanta, GA.
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Jaloun HE, Lee IK, Kim MK, Sung NY, Turkistani SAA, Park SM, Won DY, Hong SH, Kye BH, Lee YS, Jeon HM. Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery. Ann Coloproctol 2020; 36:264-272. [PMID: 32674557 PMCID: PMC7508488 DOI: 10.3393/ac.2020.03.25] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/25/2020] [Indexed: 01/25/2023] Open
Abstract
Purpose Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes. Methods Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database. Results The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively). Conclusion ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.
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Affiliation(s)
- Heba Essam Jaloun
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Ki Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Na Young Sung
- Cancer Information & Education Branch, National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Suhail Abdullah Al Turkistani
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Min Park
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Youn Won
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae Myung Jeon
- Department of General Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
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Enhanced recovery after surgery in minimally invasive gynecologic surgery surgical patients: one size fits all? Curr Opin Obstet Gynecol 2020; 32:248-254. [DOI: 10.1097/gco.0000000000000634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Barreras González JE, Díaz Ortega I, Castillo Sánchez Y, Pereira Fraga JG, López Milhet AB. Laparoscopic Hysterectomy for 2780 Patients: In Havana's National Center for Minimally Invasive Surgery. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Israel Díaz Ortega
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Yuderkis Castillo Sánchez
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Jorge Gerardo Pereira Fraga
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Ana Bertha López Milhet
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
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Comparison of enhanced recovery protocol with conventional care in patients undergoing minor gynecologic surgery. Wideochir Inne Tech Maloinwazyjne 2020; 15:220-226. [PMID: 32117508 PMCID: PMC7020716 DOI: 10.5114/wiitm.2019.85464] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/29/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Data regarding the role of the enhanced recovery after surgery (ERAS) protocol in improving postoperative outcomes and postoperative compliance in patients undergoing gynecological surgery, in particular, minor laparoscopic and hysteroscopic gynecological procedures, are limited. Aim To investigate the impact of the ERAS protocol on time to ambulation, length of stay (LOS), readmissions and postoperative complications in patients undergoing minor gynecological surgical procedures. Material and methods A total of 104 patients undergoing minor laparoscopic and hysteroscopic gynecological procedures were randomized to the ERAS protocol or conventional care. Time to defecation, ambulation, and solid food intake, bleeding and LOS were recorded for each patient. Results The amount of intravenous fluid administered in the perioperative (p < 0.001) and postoperative period (p < 0.001) was significantly higher in the conventional care group than in the ERAS group. In addition, time to first defecation (p < 0.001), time to eating solid food (p < 0.001), and time to ambulation (p = 0.008) were shorter in the ERAS group compared to the conventional care group. Length of stay was also significantly shorter in the ERAS group than in the conventional care group (p < 0.001). Conclusions Implementation of ERAS protocols provides shorter LOS, less fluid intake, early return of bowel function and early mobilization without an increase in complication rate in women undergoing minor laparoscopic or hysteroscopic gynecologic surgery.
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Rimmer MP, Henderson I, Keay SD, Khan KS, Al Wattar BH. Early versus delayed urinary catheter removal after hysterectomy: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 247:55-60. [PMID: 32065990 DOI: 10.1016/j.ejogrb.2020.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES In bladder drainage, an essential part of post-hysterectomy care, the optimal timing for removing the urinary catheter is unclear. Our objective was to evaluate the risks and benefits of early (<6 h) vs delayed (>6 h) catheter removal post-hysterectomy. STUDY DESIGN A systematic review searching MEDLINE, EMBASE and Cochrane CENTRAL from inception till May 2019 for randomised trials of women undergoing hysterectomy. We reported on urinary retention, positive urine culture, urinary tract infection (UTI) (defined by symptoms and/or antibiotic use), post-operative pyrexia, time to ambulation, and length of hospital stay. We assessed risk of bias in included trials and used a random-effect model to generate risk ratios (RR) for dichotomous outcomes and weighted mean differences (WMD) for continuous outcomes, with 95 % confidence intervals (CI). RESULTS Of 1020 potentially relevant citations, we included 10 randomised trials (1120 women). Four trials had low risk of bias for randomisation and allocation concealment while five had low risk for outcome assessment and selective reporting. Compared to delayed removal, women in the early catheter removal group had a higher risk of urinary retention and needing re-catheterisation (10 RCTs, RR 3.61, 95 %CI 1.21-9.21, I2 = 56 %). There was some reduction in the risk of post-operative UTI (6 RCTs, RR 0.42, 95 %CI 0.18 to 0.96, I2 = 0 %), but we did not find a significant difference in post-operative pyrexia (6 RCTs, RR 0.73, 95 %CI 0.43-1.24, I2 = 18 %) or positive urine cultures (6 RCTs, RR of 0.56, 95 %CI 0.27-1.12, I2 = 55 %). There was no significant difference in the average time to ambulation (3RCTs, WMD -4.6, 95 %CI -9.16 to -0.18, I2 = 98 %) and length of hospital stay (3RCTs, WMD -1.05, 95 %CI -2.42 to 0.31, I2 = 98 %). Our meta-regression on the provision of prophylactic antibiotics did not show a significant effect on the reported outcomes. Our analysis was limited by our inability to adjust for potential effect modifiers such as the surgical route. CONCLUSIONS Early removal of the urinary catheter <6 h post-hysterectomy seems to increase the risk of urinary retention and needing re-catheterisation, but may reduce post-operative UTI.
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Affiliation(s)
- Michael P Rimmer
- MRC Centre for Reproductive Health, Queens Medical Research Institute, Edinburgh BioQuarter, University of Edinburgh, UK
| | - Ian Henderson
- Warwick Medical School, Warwick University, Coventry, UK; University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, UK
| | - Stephen D Keay
- University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, UK
| | - Khalid S Khan
- Department of Preventive Medicine and Public Health, University of Granada, 18071 Granada, Spain
| | - Bassel H Al Wattar
- Warwick Medical School, Warwick University, Coventry, UK; University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, UK.
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Harrison RF, Li Y, Guzman A, Pitcher B, Rodriguez-Restrepo A, Cain KE, Iniesta MD, Lasala JD, Ramirez PT, Meyer LA. Impact of implementation of an enhanced recovery program in gynecologic surgery on healthcare costs. Am J Obstet Gynecol 2020; 222:66.e1-66.e9. [PMID: 31376395 DOI: 10.1016/j.ajog.2019.07.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/16/2019] [Accepted: 07/26/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Enhanced recovery programs have been associated with improved outcomes after gynecologic surgery. There are limited data on the effect of enhanced recovery programs on healthcare costs or healthcare service use. OBJECTIVE The purpose of this study was to evaluate differences in hospital charges for women who undergo surgery for a suspected gynecologic cancer that is managed in an enhanced recovery program as compared with conventional perioperative care. STUDY DESIGN We performed a retrospective cohort study of women who underwent open abdominal surgery for a suspected gynecologic cancer before and after the implementation of an enhanced recovery after surgery program. Consecutive patients from May to October 2014 and from November 2014 to November 2015 comprised the conventional perioperative care (before enhanced recovery after surgery) and enhanced recovery after surgery cohorts, respectively. Patients were excluded if they underwent surgery with a multidisciplinary surgical team or minimally invasive surgery. All technical and professional charges were ascertained for all healthcare services from the day of surgery until postoperative day 30. Charges for adjuvant treatment were excluded. Charges were classified according to the type of clinical service provided. The primary outcome was the difference in total hospital charges between the pre-enhanced recovery after surgery and the enhanced recovery after surgery groups. Secondary outcomes were between group differences in hospital charges within clinical service categories. RESULTS A total of 271 patients were included in the analysis (58 patients in the pre-enhanced recovery after surgery and 213 patients in the enhanced recovery after surgery cohort). A total of 70,177 technical charges and 6775 professional charges were identified and classified. The median hospital charge for a patient decreased 15.6% in the enhanced recovery after surgery group compared with the pre-enhanced recovery after surgery group (95% confidence interval, 5-24.5%; P=.008). Patients in the enhanced recovery after surgery group also had lower charges for laboratory services (20% lower; 95% confidence interval, 0--39%; P=.04), pharmacy services (30% lower; 95% confidence interval, 14--41%; P<.001), room and board (25% lower; 95% confidence interval, 20--47%; P=.005), and material goods (64% lower; 95% confidence interval, 44--81%; P<.001). No differences in charges were observed for perioperative services, diagnostic procedures, emergency department care, transfusion-related services, interventional radiology procedures, physical/occupational therapy, outpatient care, or other services. CONCLUSION Hospital charges and healthcare service use were lower for enhanced recovery patients compared with patients who received conventional perioperative care after open surgery for a suspected gynecologic cancer. Enhanced recovery programs may be considered to be high value in healthcare because they provide improved outcomes while lowering resource use.
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Li J, Zhu H, Liao R. Enhanced recovery after surgery (ERAS) pathway for primary hip and knee arthroplasty: study protocol for a randomized controlled trial. Trials 2019; 20:599. [PMID: 31640757 PMCID: PMC6805414 DOI: 10.1186/s13063-019-3706-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/06/2019] [Indexed: 02/05/2023] Open
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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Affiliation(s)
- Jingyi Li
- Department of Dermatovenereology, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Haibei Zhu
- Division of Anaesthesiology & Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Ren Liao
- Department of Anesthesiology, West China Hospital of Sichuan University, 37 Guoxue Lane, Chengdu, 610041, China.
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Wijk L, Udumyan R, Pache B, Altman AD, Williams LL, Elias KM, McGee J, Wells T, Gramlich L, Holcomb K, Achtari C, Ljungqvist O, Dowdy SC, Nelson G. International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery. Am J Obstet Gynecol 2019; 221:237.e1-237.e11. [PMID: 31051119 DOI: 10.1016/j.ajog.2019.04.028] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/17/2019] [Accepted: 04/24/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. OBJECTIVE To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. STUDY DESIGN The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. RESULTS Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4-11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90-0.95; P<.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82-0.93; P<.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients. CONCLUSION Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation.
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Affiliation(s)
- Lena Wijk
- Department of Obstetrics and Gynecology, Örebro University Hospital, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Sweden
| | - Basile Pache
- Department of Obstetrics and Gynecology, Lausanne University Hospital, Lausanne, Switzerland
| | - Alon D Altman
- Winnipeg Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Laura L Williams
- Gynecologic Oncology of Middle Tennessee, HCA Centennial Hospital, Nashville, TN
| | - Kevin M Elias
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Jake McGee
- London Health Sciences Centre, London, ON, Canada
| | | | | | - Kevin Holcomb
- Clinical Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| | - Chahin Achtari
- Gynecology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Olle Ljungqvist
- Department of Surgery, Örebro University Hospital, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
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Pache B, Joliat GR, Hübner M, Grass F, Demartines N, Mathevet P, Achtari C. Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery. Gynecol Oncol 2019; 154:388-393. [DOI: 10.1016/j.ygyno.2019.06.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
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Lambaudie E, Mathis J, Zemmour C, Jauffret-Fara C, Mikhael ET, Pouliquen C, Sabatier R, Brun C, Faucher M, Mokart D, Houvenaeghel G. Prediction of early discharge after gynaecological oncology surgery within ERAS. Surg Endosc 2019; 34:1985-1993. [PMID: 31309314 DOI: 10.1007/s00464-019-06974-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/01/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Enhanced recovery after surgery programs (ERAS) have been proven to decrease the length of hospital stay without increasing readmission rates or complications. However, the patient and operative characteristics that improve the chance of a successful early hospital discharge are not well established. The aim of this study was to design a nomogram which could be used before surgery, using the characteristics of patients, to establish who could benefit from early discharge (POD ≤ 2 days). METHODS This observational study has been prospectively conducted. All the included patients were referred for surgical treatment of gynecologic cancer. We defined two sub-groups of patients on surgical procedure characteristics: isolated procedures (hysterectomy or lymphadenectomy) and combined procedures (at least the association of two procedures). RESULTS 230 patients were enrolled during the study protocol. 83.9% of patients were treated with a minimally invasive surgery (MIS). 159 patients (69.1%) were discharged on or before POD 2. On multivariate analysis, the surgical approach (open surgery vs. laparoscopy, OR 0.02 (95% CI [0-0.07]), p < 0.001) and the type of surgery (combined procedure versus isolated procedure, OR 0.41 (95% CI [0.18-0.91]), p = 0.028) were found to be significant predictors of increased hospital stay. A nomogram has been built for the purpose of predicting eligible patients for early post-operative discharge based on the multivariate analysis results (AUC = 0.86, 95% CI [0.81-0.92]). CONCLUSION The use of MIS for isolated procedures in oncologic indications constitutes an independent factor of early discharge in a setting of ERAS. These promising preliminary results still require to be validated on a prospective cohort.
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Affiliation(s)
- Eric Lambaudie
- Department of Surgery, Paoli Calmettes Institute, Marseille, France. .,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France. .,Department of Surgical Oncology, Institut Paoli Calmettes, 232 Bd. Sainte-Marguerite, 13009, Marseille, France.
| | - Jérome Mathis
- Department of Surgery, Paoli Calmettes Institute, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Innovation, Biostatistics and Methodology Unit, Paoli Calmettes Institute, Marseille, France.,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | | | | | - Camille Pouliquen
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Renaud Sabatier
- Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France.,Department of Medical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Clément Brun
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Marion Faucher
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Djamel Mokart
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Gilles Houvenaeghel
- Department of Surgery, Paoli Calmettes Institute, Marseille, France.,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
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Pache B, Jurt J, Grass F, Hübner M, Demartines N, Mathevet P, Achtari C. Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance? Int J Gynecol Cancer 2019; 29:810-815. [PMID: 30898937 DOI: 10.1136/ijgc-2019-000268] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/19/2019] [Accepted: 02/25/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes. METHODS Retrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification. RESULTS A total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I-V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001). CONCLUSIONS Compliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.
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Affiliation(s)
- Basile Pache
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Service of Gynecology, Department "Femme-Mère-Enfant, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jonas Jurt
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Fabian Grass
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Patrice Mathevet
- Service of Gynecology, Department "Femme-Mère-Enfant, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Chahin Achtari
- Service of Gynecology, Department "Femme-Mère-Enfant, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Renaud MC, Bélanger L, Lachapelle P, Grégoire J, Sebastianelli A, Plante M. Effectiveness of an Enhanced Recovery After Surgery Program in Gynaecology Oncologic Surgery: A Single-Centre Prospective Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:436-442. [DOI: 10.1016/j.jogc.2018.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/31/2018] [Indexed: 11/30/2022]
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Kalogera E, Glaser GE, Kumar A, Dowdy SC, Langstraat CL. Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review. J Minim Invasive Gynecol 2019; 26:288-298. [DOI: 10.1016/j.jmig.2018.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022]
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Enhanced Recovery after Surgery in Gynecology: A Review of the Literature. J Minim Invasive Gynecol 2019; 26:327-343. [DOI: 10.1016/j.jmig.2018.12.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/14/2023]
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Nazzani S, Bandini M, Preisser F, Mazzone E, Marchioni M, Tian Z, Stubinski R, Clementi MC, Saad F, Shariat SF, Montanari E, Briganti A, Carmignani L, Karakiewicz PI. Postoperative paralytic ileus after major oncological procedures in the enhanced recovery after surgery era: A population based analysis. Surg Oncol 2019; 28:201-207. [PMID: 30851901 DOI: 10.1016/j.suronc.2019.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 12/03/2018] [Accepted: 01/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been developed and implemented as of 2001 and may have significantly reduced several complication types including paralytic ileus. However, no formal analyses targeted paralytic ileus rates after contemporary major surgical oncology procedures. We examined temporal trends of paralytic ileus following ten major oncological surgical procedures. The effect of paralytic ileus on length of stay (LOS) and total hospital charges was examined. Univariable and multivariable linear and logistic regression analyses were used. METHODS Between 2003 and 2013, we retrospectively identified patients, who underwent prostatectomy, colectomy, cystectomy, mastectomy, gastrectomy, hysterectomy, nephrectomy, oophorectomy, lung resection or pancreatectomy within the Nationwide Inpatient Sample. A total of 3 431 602 patients were included in our analyses. Annual paralytic ileus rate differences after major oncological surgical procedures were evaluated using linear regression. Multivariable logistic regression analyses were used to test for paralytic ileus rates determinants, as well as on the effect of paralytic ileus rates on LOS and hospital charges. RESULTS Paralytic ileus rates ranged from 0.1% (mastectomy) to 23.2% (cystectomy) after ten examined major oncological surgical procedures. Overall annual paralytic ileus rates did not change [estimated annual percentage change (EAPC)+0.1%, p = 0.7]. Multivariable logistic regression derived predicted probabilities (PP) of paralytic ileus were highest for cystectomy (PP: 26.1%) and colectomy (PP: 17.15%) and were lowest for lung resection (PP: 2.22%) and mastectomy (PP: 0.16%). In analyses predicting LOS above the 75th percentile, paralytic ileus effect after mastectomy (OR: 14.66) and prostatectomy (OR: 13.21) ranked, as highest and second highest respectively. In analyses predicting hospital charges above the 75th percentile, paralytic ileus effect after mastectomy (OR: 2.21) and oophorectomy (OR: 1.99) ranked as highest and second highest respectively. CONCLUSIONS Despite implementation of ERAS protocols paralytic ileus rates have not decreased over time. Gastrointestinal procedures are among the highest contributors of paralytic ileus. Moreover, procedures with short LOS represent the strongest relative contributors to LOS increases and increases in hospitalization costs.
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Affiliation(s)
- Sebastiano Nazzani
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CR-CHUM), Institut du Cancer de Montréal, Montréal, Québec, Canada; Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.
| | - Marco Bandini
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CR-CHUM), Institut du Cancer de Montréal, Montréal, Québec, Canada; Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy, Vita-Salute San Raffaele University, Milan, Italy
| | - Felix Preisser
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CR-CHUM), Institut du Cancer de Montréal, Montréal, Québec, Canada; Martini Klinik, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elio Mazzone
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CR-CHUM), Institut du Cancer de Montréal, Montréal, Québec, Canada; Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy, Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Marchioni
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Department of Urology, SS Annunziata Hospital, "G.D'Annunzio" University of Chieti, Chieti, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Robert Stubinski
- Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Maria Chiara Clementi
- Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CR-CHUM), Institut du Cancer de Montréal, Montréal, Québec, Canada
| | | | - Emanuele Montanari
- Department of Urology, IRCCS Fondazione Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Carmignani
- Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CR-CHUM), Institut du Cancer de Montréal, Montréal, Québec, Canada
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Johnson K, Razo S, Smith J, Cain A, Soper K. Optimize patient outcomes among females undergoing gynecological surgery: A randomized controlled trial. Appl Nurs Res 2019; 45:39-44. [PMID: 30683249 DOI: 10.1016/j.apnr.2018.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/27/2018] [Accepted: 12/08/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Optimizing early education in gynecological procedures utilizing an Enhanced Recovery after Surgery (ERAS) program and a bundle concept may optimize patient outcomes after surgery. PURPOSE Evaluate whether an ERAS bundle compared to standard education can affect length of stay, 30 day readmission, and patient satisfaction among patients undergoing gynecologic surgery. DESIGN Prospective, comparative, randomized design SETTING: 28 bed Medical Surgical Unit SAMPLE/INTERVENTION: 50 patients undergoing hysterectomy, 25 who received post-operative evidence based bundle/standard education, and 25 who received standard education packet. Bundle components included 1) early mobilization, 2) early transition to oral pain medication, 3) early feeding, and 4) chewing gum. A follow-up phone call was made in two to three days following discharge for both groups utilizing teach-back. RESULTS 84% (n = 21) patients in the bundle group were discharged in one day. There were no 30 day readmissions for both groups. Twenty two (88%) participants met the bundle components 100% of the time. For the indicator "walking helped with recovery" 100% (n = 25) responded "very good to excellent" for bundle group and 96% (n = 24) responded "very good to excellent" for standard group. Twenty three (92%) of the bundle group felt that that overall nursing care received was very good to excellent and 24 (96%) of the general group felt that overall nursing care received was very good to excellent. CONCLUSION Optimizing peri-operative education using a bundle approach to provide evidence based interventions can minimize risk and enhance early recovery for females undergoing gynecological surgery.
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Affiliation(s)
- Kari Johnson
- Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States.
| | - Sherry Razo
- Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States.
| | - Jeannie Smith
- Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States.
| | - Alex Cain
- Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States.
| | - Kathi Soper
- Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States.
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