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Carr F, Mathura P, Symon J. Ending PJ paralysis for hospitalised patients: a quality improvement initiative. BMJ Open Qual 2025; 14:e003195. [PMID: 40258639 PMCID: PMC12015703 DOI: 10.1136/bmjoq-2024-003195] [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: 10/28/2024] [Accepted: 03/22/2025] [Indexed: 04/23/2025] Open
Abstract
INTRODUCTION PJ paralysis refers to the negative effects experienced by hospitalised patients who remain inactive and dressed in hospital clothing, and is a serious problem, affecting one-third of hospitalised older adults. This study evaluated the impact of a multicomponent hospital-based intervention to get patients out of bed, dressed in non-hospital attire, and moving around/mobilised. METHODS A 3-month quality improvement initiative was conducted at one hospital unit in Western Canada, which aimed for 50% of all patients to be dressed in their own clothing by midday, sitting up in a chair for all meals and mobilising to activities. Healthcare providers, patients and family members received PJ paralysis education, and a new patient dress code care standard and physician patient care order were implemented. Measures included: daily percentage of patients dressed and up for meals, weekly mobilisation rates, patient and provider satisfaction, and complication rates. Descriptive statistics were completed. RESULTS From July to October 2019, 70 patients participated. Approximately 14.3% of patients were dressed in their own clothing daily, 6.4% were sitting for all three meals, and the weekly mean number of patients mobilising to activities was 0.9 (SD 0.7) and mobilising for other reasons was 4.5 (SD 1.3). Five physician care orders were written. A trend was observed towards decreased falls, with minimal change in the number of staff, nursing assessment time and complication rates. Patient feedback revealed improvement in their self-identity. CONCLUSION Alleviating PJ paralysis in hospitalised older patients requires a complex multifactorial approach. Despite not achieving the project aim, the intervention demonstrated positive impacts without complications or additional workload, and ease of implementation suggests feasibility and (potential) long-term sustainability. Further research is needed to explore the experiences and perceptions of patients and healthcare providers to identify facilitators and barriers, which may aid in enhancing and implementing future interventions.
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Affiliation(s)
- Frances Carr
- Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
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Bertocchi E, Brunelli D, Squaranti T, Campagnola D, Camparsi S, Tessari R, Menestrina N, Gentile I, Sanfilippo L, De Santis N, Guerriero M, Ruffo G. Cost Saving Analysis of an Enhanced Recovery After Surgery (ERAS) Program for Elective Colorectal Surgery in an ERAS Qualified and Training Center. World J Surg 2025; 49:850-858. [PMID: 40056394 PMCID: PMC11994153 DOI: 10.1002/wjs.12548] [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: 09/23/2024] [Revised: 02/13/2025] [Accepted: 02/24/2025] [Indexed: 03/10/2025]
Abstract
BACKGROUND To ascertain the costs of implementing an enhanced recovery after surgery (ERAS) protocol in elective colorectal surgery throughout all perioperative phases in an Italian ERAS Qualified and Training Center. METHODS Consecutive patients who had undergone elective colorectal surgery in 2022, the first year of our facility being an ERAS Qualified Center (n 204; ERAS group), were compared to a control group (n 203; pre-ERAS group) that had undergone elective colorectal surgery in 2017, the last year before the internal ERAS implementation. The primary endpoint was the cost-effectiveness of the ERAS protocol as determined by evaluating perioperative costs. Secondary endpoints were postoperative clinical outcomes. RESULTS In the ERAS group, fewer postoperative complications (p < 0.001), a shorter length of stay (LOS) (p < 0.001), and a decreased 30-day readmission rate (p 0.047) were reported. The mean cost saving for elective colorectal surgery in the ERAS setting was about €3676.73 per patient. The preoperative costs in the ERAS group were 45% higher than in the control group. The intraoperative phase showed a small but significant decrease in costs (-€324.04, SD 1683.81, and p 0.002). The postoperative phase also had a significant decrease in costs (-€3439.30, SD 6903.07, and p < 0.001), which was especially apparent in patients with severe complications. CONCLUSIONS Despite significantly increased costs in the preoperative phase, the ERAS protocol, when highly complied with, may lead to significantly decreased patient pathway costs due to a reduction of postoperative complications, a shorter LOS, and the more targeted use of medication and blood transfusions.
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Affiliation(s)
- Elisa Bertocchi
- General Surgery UnitIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Davide Brunelli
- Hospital Health DirectionIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Thomas Squaranti
- Planning and ControlIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Diego Campagnola
- Planning and ControlIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Sara Camparsi
- Planning and ControlIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Roberto Tessari
- Hospital Pharmacy UnitIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Nicola Menestrina
- Department of Anesthesia, Intensive Care and Pain TherapyIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Irene Gentile
- General Surgery UnitIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Lorenza Sanfilippo
- Section of BiostatisticsIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Nicoletta De Santis
- Section of BiostatisticsIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Massimo Guerriero
- Section of BiostatisticsIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
| | - Giacomo Ruffo
- General Surgery UnitIRCCS Sacro Cuore Don Calabria HospitalNegrar di ValpolicellaItaly
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Mihailescu AA, Gradinaru S, Kraft A, Blendea CD, Capitanu BS, Neagu SI. Enhanced rehabilitation after surgery: principles in the treatment of emergency complicated colorectal cancers - a narrative review. J Med Life 2025; 18:179-187. [PMID: 40291936 PMCID: PMC12022730 DOI: 10.25122/jml-2025-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2025] [Accepted: 03/24/2025] [Indexed: 04/30/2025] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are used in elective colorectal surgeries and have shown improved recovery for many patients. However, using these protocols in emergency colorectal surgery, especially in complicated cases of obstructive colorectal cancer, is still debated. This review examined the ERAS principles that can be adapted for emergencies. We reviewed the literature on applying ERAS principles in emergency colorectal cancer surgery. We analyzed key strategies used before, during, and after surgery. The aim of ERAS in emergency colorectal surgery is to reduce physical stress from urgent surgical conditions. Before surgery, the focus should be on early patient recovery, managing blood sugar levels, and providing patient education when possible. Minimally invasive techniques, careful fluid management, and effective pain relief during surgery are intraoperative key points. After surgery, early feeding, patient mobilization, and minimizing the use of medical devices are encouraged. Studies have shown that using ERAS in emergencies can lower mortality, reduce hospital stays, and influence patient recovery rates, although it may lead to higher initial costs. Still, following ERAS in emergencies is inconsistent due to logistical issues and patient health changes. More people are starting to recognize the benefits of ERAS in obstructive colorectal cancer surgery. Although there is less evidence compared to elective procedures, new studies suggest that organized steps for care can improve patient outcomes. Further research is needed to improve ERAS emergency protocols and identify patients suitable for this approach so that healthcare resources can be used better.
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Key Words
- APACHE II, Acute Physiology and Chronic Health Evaluation
- ASA, American Society of Anesthesiologists
- ELPQuiC, Emergency Laparotomy Pathway Quality Improvement Care
- ERAS, Enhanced Recovery After Surgery
- GDFT, Goal-Directed Fluid Therapy
- MAP, Mean Arterial Pressure
- NGT, Nasogastric Tube
- P-POSSUM, Portsmouth-POSSUM
- PECS, Pectoral Nerve Block
- PONV, Postoperative Nausea and Vomiting
- POSSUM, Physiological and Operative Severity Score for the Enumeration of Mortality
- SIRS, Systemic Inflammatory Response Syndrome
- SSR, Surgical Stress Response
- TAP, Transversus Abdominis Plane
- complicated colorectal cancer
- emergency colorectal surgery
- multimodal rehabilitation
- perioperative care
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Affiliation(s)
- Alexandra-Ana Mihailescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Anesthesiology and Critical Care, Foisor Clinical Hospital of Orthopedics, Traumatology, and Osteoarticular Tuberculosis, Bucharest, Romania
| | - Sebastian Gradinaru
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
- Department of General Surgery, Ilfov County Emergency Clinical Hospital, Bucharest, Romania
| | - Alin Kraft
- Department of General Surgery, General Doctor Aviator Victor Atanasiu National Aviation and Space Medicine Institute, Bucharest, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Corneliu-Dan Blendea
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
- Department of Recovery, Physical Medicine and Balneology, Ilfov County Emergency Clinical Hospital, Bucharest, Romania
| | - Bogdan-Sorin Capitanu
- Department of Orthopedics, Foisor Clinical Hospital of Orthopedics, Traumatology and Osteoarticular Tuberculosis, Bucharest, Romania
| | - Stefan Ilie Neagu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Albalawi HIH, Alyoubi RKA, Alsuhaymi NMM, Aldossary FAK, Mohammed G AA, Albishi FM, Aljeddawi J, Najm FAO, Najem NA, Almarhoon MMA. Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery. Cureus 2024; 16:e76123. [PMID: 39840197 PMCID: PMC11745840 DOI: 10.7759/cureus.76123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2024] [Indexed: 01/23/2025] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Neda Ahmed Najem
- General Practice, Fakeeh College of Medical Sciences, Jeddah, SAU
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Ciftci Y, Radomski SN, Johnson BA, Johnston FM, Greer JB. Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2024; 31:7987-7997. [PMID: 39230850 DOI: 10.1245/s10434-024-15945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/17/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown. PATIENTS AND METHODS We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables. RESULTS Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period. CONCLUSIONS The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.
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Affiliation(s)
- Yusuf Ciftci
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blake A Johnson
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Hey G, Mehkri Y, Mehkri I, Boatright S, Duncan A, Patel K, Gendreau J, Chandra V. Enhanced Recovery After Surgery Pathways in Pediatric Spinal Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 190:329-338. [PMID: 39089650 DOI: 10.1016/j.wneu.2024.07.170] [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: 05/22/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Pediatric spinal fusion surgery is a complex procedure that poses challenges in perioperative management. The enhanced recovery after surgery (ERAS) approach is an evidence-based, multidisciplinary strategy to optimize patient care in an individualized, multidisciplinary way. Despite the benefits of ERAS protocol implementation, the role of ERAS in pediatric spine surgery remains understudied. This systematic review and meta-analysis aims to evaluate the current literature regarding pediatric spinal surgery ERAS protocols and their ability to decrease the length of stay, pain, time-to-stand, and complications. METHODS A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Statistical analyses were performed using Cochrane's RevMan (version 5.4). RESULTS Seventeen studies totaling 2733 patients were included in this analysis. Patients treated in an ERAS protocol had significant reductions in length of stay (P < 0.001), time-to-stand (P < 0.001), total complications (P = 0.02), and estimated blood loss (P = 0.001). CONCLUSIONS ERAS protocol implementation can significantly enhance outcomes for pediatric patients receiving spinal surgery. Consequently, ERAS protocols have the potential to lower healthcare expenses, increase access, and set a new standard of care. Future research should be conducted to expand pediatric ERAS protocols to a diverse range of spinal pathologies and assess the long-term advantages of this practice.
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Affiliation(s)
- Grace Hey
- University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Yusuf Mehkri
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ilyas Mehkri
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Avery Duncan
- Mercer University, School of Medicine, Savannah, Georgia, USA
| | - Karina Patel
- Mercer University, School of Medicine, Savannah, Georgia, USA
| | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Vyshak Chandra
- Lillian S. Wells Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Ruiz Torres I, Serrano AB, Juez LD, Ballestero Pérez A, Ocaña Jiménez J, Die Trill J, Fernandez Cebrian JM, García Pérez JC. Cost-benefit analysis and short-term outcomes after implementing an ERAS protocol for colorectal surgery: a propensity score-matched analysis. Tech Coloproctol 2024; 28:130. [PMID: 39311960 DOI: 10.1007/s10151-024-02997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 08/09/2024] [Indexed: 10/23/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has become increasingly popular in the post-operative management of abdominal surgery. Published data suggest that patients on ERAS protocols have fewer minor and major complications, and highlight a reduction in medical morbidity (such as urinary and respiratory infections). Limited data is available on surgical complications. The aim of the study was to evaluate the impact of the ERAS protocol on post-operative complications and length of hospital stay. Furthermore, we aimed to determine the impact of this protocol on cost-effectiveness. MATERIAL AND METHODS From January 2016 to December 2022, 532 colectomies for colorectal cancer (CRC) were performed. A prospective observational study was conducted in a tertiary hospital on the cohort of patients, aged 18 years and older, operated on for non-urgent colorectal cancer. The impact on post-operative complications, hospital stay and economic impact was analysed in two groups: patients managed under ERAS and non-ERAS protocol. A propensity score-matching analysis was performed between the two groups. RESULTS After propensity score matching 1:1, each cohort included 71 patients, and clinicopathological characteristics were well balanced in terms of tumour type, surgical technique and surgical approach. ERAS patients experienced fewer infectious complications and a shorter postoperative stay (p < 0.001). In particular, they had an 8.5% reduction in anastomotic dehiscence (p = 0.012) and surgical wound infections (p = 0.029). After analysis of medical complications, no statistically significant differences were identified in urinary tract infections, pneumonia, gastrointestinal bleeding or sepsis. ERAS protocol was more efficient and cost-effective than the control group, with an overall savings of 37,673.44€. CONCLUSIONS The implementation of an enhanced recovery protocol for elective colorectal surgery in a tertiary hospital was cost-effective and associated with a reduction in post-operative complications, especially infectious complications.
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Affiliation(s)
- I Ruiz Torres
- Department of Anaesthesia, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - A B Serrano
- Department of Anaesthesia, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - L D Juez
- Department of General Surgery and Digestive System, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ctra. Colmenar, Km 9,1., 28034, Madrid, Spain.
| | - A Ballestero Pérez
- Department of General Surgery and Digestive System, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ctra. Colmenar, Km 9,1., 28034, Madrid, Spain
| | - J Ocaña Jiménez
- Department of General Surgery and Digestive System, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ctra. Colmenar, Km 9,1., 28034, Madrid, Spain
| | - J Die Trill
- Department of General Surgery and Digestive System, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ctra. Colmenar, Km 9,1., 28034, Madrid, Spain
- Universidad de Alcalá (UAH), Madrid, Spain
| | - J M Fernandez Cebrian
- Department of General Surgery and Digestive System, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ctra. Colmenar, Km 9,1., 28034, Madrid, Spain
- Universidad de Alcalá (UAH), Madrid, Spain
| | - J C García Pérez
- Department of General Surgery and Digestive System, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ctra. Colmenar, Km 9,1., 28034, Madrid, Spain
- Universidad de Alcalá (UAH), Madrid, Spain
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Zeng Z, Lu X, Sun Y, Xiao Z. Exploring thirst incidence and risk factors in patients undergoing general anesthesia after extubation based on ERAS principles: a cross sectional study. BMC Anesthesiol 2024; 24:287. [PMID: 39138388 PMCID: PMC11321221 DOI: 10.1186/s12871-024-02676-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 08/07/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND This study aims to comprehend the levels of dry mouth and thirst in patients after general anesthesia, and to identify the factors influencing them. METHODS The study included all patients transferred to the Post Anesthesia Care Unit (PACU) at the Second Affiliated Hospital of Dalian Medical University between August 2021 and November 2021 after undergoing general anesthesia. A thirst numeric rating scale was utilized to conduct surveys, enabling the assessment of thirst incidence and intensity. Statistical analysis was performed to explore patient thirst levels and the associated factors. RESULTS The study revealed a thirst incidence rate of 50.8%. Among the thirst intensity ratings, 71.4% of patients experienced mild thirst, 23.0% reported moderate thirst, and 5.6% expressed severe thirst. Single-factor statistical analysis of potential risk factors among the enrolled cases indicated that gender, history of coronary heart disease, surgical duration, intraoperative fluid volume, intraoperative blood loss, intraoperative urine output, and different surgical departments were linked to post-anesthetic thirst in patients undergoing general anesthesia. Multifactorial Logistic regression analysis highlighted age, gender, history of coronary heart disease, fasting duration, and intraoperative fluid volume as independent risk factors for post-anesthetic thirst in patients undergoing general anesthesia. Moreover, age, gender, history of coronary heart disease, and intraoperative fluid volume were also identified as risk factors for varying degrees of thirst. CONCLUSION The incidence and intensity of post-anesthetic thirst after general anesthesia are relatively high. Their occurrence is closely associated with age, gender, history of coronary heart disease, fasting duration, and intraoperative fluid volume.
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Affiliation(s)
- Zhihe Zeng
- Department of Anesthesiology, the Second Affiliated Hospital of Dalian Medical University, Dalian, 116027, China
| | - Xinge Lu
- Department of Anesthesiology, the Second Affiliated Hospital of Dalian Medical University, Dalian, 116027, China
- Department of Anesthesiology, Shanghai East Hospital Affiliated to Tongji University, Shanghai, China
| | - Ye Sun
- Department of Anesthesiology, the Second Affiliated Hospital of Dalian Medical University, Dalian, 116027, China
| | - Zhaoyang Xiao
- Department of Anesthesiology, the Second Affiliated Hospital of Dalian Medical University, Dalian, 116027, China.
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Ciftci Y, Radomski SN, Johnson BA, Johnston FM, Greer JB. Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes. Ann Surg Oncol 2024; 31:5390-5399. [PMID: 38777898 DOI: 10.1245/s10434-024-15320-x] [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: 09/19/2023] [Accepted: 04/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. PATIENTS AND METHODS We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables. RESULTS Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001]. CONCLUSIONS CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.
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Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blake A Johnson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Ciftci Y, Radomski SN, Johnston FM, Greer JB. ASO Author Reflections: One Size Does Not Fit All-Enhanced Recovery After Surgery in CRS-HIPEC. Ann Surg Oncol 2024; 31:5400-5401. [PMID: 38789616 DOI: 10.1245/s10434-024-15427-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Dyas AR, Stuart CM, Bronsert MR, Kelleher AD, Bata KE, Cumbler EU, Erickson CJ, Blum MG, Vizena AS, Barker AR, Funk L, Sack K, Abrams BA, Randhawa SK, David EA, Mitchell JD, Weyant MJ, Scott CD, Meguid RA. Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Health Care System. Ann Surg 2024; 279:1062-1069. [PMID: 38385282 PMCID: PMC11087203 DOI: 10.1097/sla.0000000000006243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. BACKGROUND The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported. METHODS This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders. RESULTS There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05). CONCLUSIONS Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.
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Affiliation(s)
- Adam R. Dyas
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Christina M. Stuart
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R. Bronsert
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alyson D. Kelleher
- Department of Quality and Safety, University of Colorado School of Medicine, Aurora, CO
| | - Kyle E. Bata
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ethan U. Cumbler
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Matthew G. Blum
- Department of Surgery, UCHealth Memorial Hospital, Colorado Springs, CO
| | - Annette S. Vizena
- Department of Anesthesiology, UCHealth Poudre Valley Hospital. Fort Collins, CO
| | - Alison R. Barker
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Lauren Funk
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Karishma Sack
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Benjamin A. Abrams
- Department of Anesthesiology and Critical Care, University of Colorado School of Medicine, Aurora, CO
| | - Simran K. Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth A. David
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - John D. Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Christopher D. Scott
- Department of Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert A. Meguid
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Lin V, Poulsen JK, Juvik AF, Roikjær O, Gögenur I, Fransgaard T. The implementation of an inflammatory bowel disease-specific enhanced recovery after surgery protocol: an observational cohort study. Tech Coloproctol 2024; 28:58. [PMID: 38796600 PMCID: PMC11127850 DOI: 10.1007/s10151-024-02933-3] [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: 01/11/2024] [Accepted: 04/14/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND The implementation of Enhanced Recovery After Surgery (ERAS) protocols has resulted in improved postoperative outcomes in colorectal cancer surgery. The evidence regarding feasibility and impact on outcomes in surgery for inflammatory bowel disease (IBD) is limited. METHODS We performed a retrospective observational cohort study, comparing patient trajectories before and after implementing an IBD-specific ERAS protocol at Zealand University Hospital. We assessed the occurrence of serious postoperative complications of Clavien-Dindo grade 3 or higher as our primary outcome, with postoperative length of stay in days and rate of readmissions as secondary outcomes, using χ2, Mann-Whitney test, and odds ratios adjusted for sex and age. RESULTS From 2017 to 2023, 394 patients were operated on for IBD and included in our study. In the ERAS cohort, 39/250 patients experienced a postoperative complication of Clavien-Dindo grade 3 or higher compared to 27/144 patients in the non-ERAS cohort (15.6% vs. 18.8%, p = 0.420) with an adjusted odds ratio of 0.73 (95% CI 0.42-1.28). There was a significantly shorter postoperative length of stay (median 4 vs. 6 days, p < 0.001) in the ERAS cohort compared to the non-ERAS cohort. Readmission rates remained similar (22.4% vs. 16.0%, p = 0.125). CONCLUSIONS ERAS in IBD surgery was associated with faster patient recovery, but without an impact on the occurrence of serious postoperative complications and rate of readmissions.
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Affiliation(s)
- V Lin
- Center for Surgical Science, Zealand University Hospital Koge, Lykkebækvej 1, 4600, Køge, Denmark.
| | - J K Poulsen
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark
| | - A F Juvik
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark
| | - O Roikjær
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark
| | - I Gögenur
- Center for Surgical Science, Zealand University Hospital Koge, Lykkebækvej 1, 4600, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - T Fransgaard
- Center for Surgical Science, Zealand University Hospital Koge, Lykkebækvej 1, 4600, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Bisagni P, D'Abrosca V, Tripodi V, Armao FT, Longhi M, Russo G, Ballabio M. Cost saving in implementing ERAS protocol in emergency abdominal surgery. BMC Surg 2024; 24:70. [PMID: 38389067 PMCID: PMC10885507 DOI: 10.1186/s12893-024-02345-y] [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: 01/01/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution. METHODS A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed. RESULTS 50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient. CONCLUSIONS ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.
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Affiliation(s)
- Pietro Bisagni
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia.
- Università degli Studi Statale di Milano, Milano, Italy.
| | - Vera D'Abrosca
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
| | - Vincenzo Tripodi
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
| | - Francesca Teodora Armao
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
- Università degli Studi Statale di Milano, Milano, Italy
| | - Marco Longhi
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
| | - Gianluca Russo
- Department of Emergency, Ospedale Maggiore di Lodi, Lodi, Italy
- Università degli Studi Statale di Milano, Milano, Italy
| | - Michele Ballabio
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
- Università degli Studi Statale di Milano, Milano, Italy
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Mazni Y, Syaiful RA, Ibrahim F, Jeo WS, Putranto AS, Sihardo L, Marbun V, Lalisang AN, Putranto R, Natadisastra RM, Sumariyono S, Nugroho AM, Manikam NRM, Karimah N, Hastuty V, Sutisna EN, Widiati E, Mutiara R, Wardhani RK, Liastuti LD, Lalisang TJM. The enhanced recovery after surgery (ERAS) protocol implementation in a national tertiary-level hospital: a prospective cohort study. Ann Med Surg (Lond) 2024; 86:85-91. [PMID: 38222714 PMCID: PMC10783346 DOI: 10.1097/ms9.0000000000001609] [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: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Successful colorectal surgery is determined based on postoperative mortality and morbidity rates, complication rates, and cost-effectiveness. One of the methods to obtain an excellent postoperative outcome is the enhanced recovery after surgery (ERAS) protocol. This study aims to see the effects of implementing an ERAS protocol in colorectal surgery patients. Methods Eighty-four patients who underwent elective colorectal surgery at National Tertiary-level Hospital were included between January 2021 and July 2022. Patients were then placed into ERAS (42) and control groups (42) according to the criteria. The Patients in the ERAS group underwent a customized 18-component ERAS protocol and were assessed for adherence. Postoperatively, both groups were monitored for up to 30 days and assessed for complications and readmission. The authors then analyzed the length of stay and total patient costs in both groups. Results The length of stay in the ERAS group was shorter than the control group [median (interquartile range) 6 (5-7) vs. 13 (11-19), P<0.001], with a lower total cost of [USD 1875 (1234-3722) vs. USD 3063 (2251-4907), P<0.001]. Patients in the ERAS group had a lower incidence of complications, 10% vs. 21%, and readmission 5% vs. 10%, within 30 days after discharge than patients in the control group; however, the differences were not statistically significant. The adherence to the ERAS protocol within the ERAS group was 97%. Conclusion Implementing the ERAS protocol in colorectal patients reduces the length of stay and total costs.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Rudi Putranto
- Division of Psychosomatic and Palliative Care, Department of Internal Medicine
| | | | | | | | - Nurul Ratna Mutu Manikam
- Department of Nutrition, Faculty of Medicine, Universitas Indonesia—Dr. Cipto Mangunkusumo Hospital
| | - Nurrul Karimah
- Dr. Cipto Mangunkusumo General Hospital
- Nutrition and Food Production Installation Unit, Cipto Mangunkusumo, National General Hospital
| | - Vyanty Hastuty
- Dr. Cipto Mangunkusumo General Hospital
- Nutrition and Food Production Installation Unit, Cipto Mangunkusumo, National General Hospital
| | | | | | - Rina Mutiara
- Dr. Cipto Mangunkusumo General Hospital
- Nutrition and Food Production Installation Unit, Cipto Mangunkusumo, National General Hospital
| | - Rizky Kusuma Wardhani
- Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo, National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Yoon SH, Lee HJ. Challenging issues of implementing enhanced recovery after surgery programs in South Korea. Anesth Pain Med (Seoul) 2024; 19:24-34. [PMID: 38311352 PMCID: PMC10847003 DOI: 10.17085/apm.23096] [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: 08/02/2023] [Revised: 10/25/2023] [Accepted: 12/22/2023] [Indexed: 02/08/2024] Open
Abstract
This review discusses the challenges of implementing enhanced recovery after surgery (ERAS) programs in South Korea. ERAS is a patient-centered perioperative care approach that aims to improve postoperative recovery by minimizing surgical stress and complications. While ERAS has demonstrated significant benefits, its successful implementation faces various barriers such as a lack of manpower and policy support, poor communication and collaboration among perioperative members, resistance to shifting away from outdated practices, and patient-specific risk factors. This review emphasizes the importance of understanding these factors to tailor effective strategies for successful ERAS implementation in South Korea's unique healthcare setting. In this review, we aim to shed light on the current status of ERAS in South Korea and identify key barriers. We hope to encourage Korean anesthesiologists to take a leading role in adopting the ERAS program as the standard for perioperative care. Ultimately, our goal is to improve the surgical outcomes of patients using this proactive approach.
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Affiliation(s)
- Soo-Hyuk Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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Süsstrunk J, Mijnssen R, von Strauss M, Müller BP, Wilhelm A, Steinemann DC. Enhanced recovery after surgery (ERAS) in colorectal surgery: implementation is still beneficial despite modern surgical and anesthetic care. Langenbecks Arch Surg 2023; 409:5. [PMID: 38091109 DOI: 10.1007/s00423-023-03195-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols have shown beneficial outcomes in the last 20 years. Nevertheless, simultaneously implemented technical improvements such as minimally invasive access or modified anesthesia care may play a crucial role in optimizing patient outcome. The aim of the study was to investigate the effect of ERAS implementation in a highly specialized colorectal center. METHODS This is a propensity score matched single-center study comparing the short-term outcomes of patients undergoing elective colorectal surgery in a society-indepedent ERAS program from January 2021 to August 2022 to standard perioperative care from January 2019 to December 2020. RESULTS Four hundred fifty-six patients were included in the propensity score matched analysis with 228 patients per group (ERAS vs. standard care). Minimally invasive access was used in 80.2% vs. 77.6% (p = 0.88), and there were 16.6% vs. 18.8% (p = 0.92) rectal procedures in the ERAS and standard care group, respectively. Major complications occurred in 10.1% vs. 11.4% (p = 0.65) and anastomotic leakage demanding operative revision in 2.2% vs. 2.6% (p = 0.68) in the ERAS and standard care group, respectively. ERAS lead to a lower number of non-surgical complications compared to standard care (57 vs. 79; p = 0.02). Mean length of stay (LOS) and mean costs per case were lower in ERAS compared to standard care (9.2 ± 5.6 days vs. 12.7 ± 7.4 days, p < 0.01; costs 33,727 ± 15,883 USD vs. 40,309 ± 29,738 USD, p < 0.01). CONCLUSION The implementation of an ERAS protocol may lead to a reduction of LOS, costs, and a lower number of non-surgical complications even in a highly specialized colorectal unit using modern surgical and anesthetic care. ( ClinialTrials.gov number NCT05773248).
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Affiliation(s)
- Julian Süsstrunk
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland.
| | - Remo Mijnssen
- Medical Faculty, University of Basel, 4001, Basel, Switzerland
| | - Marco von Strauss
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland
- Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland
| | - Beat Peter Müller
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland
- Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland
| | - Alexander Wilhelm
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland
- Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland
- Surgical Outcome Research Center Basel, University Hospital Basel, 4002, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland
- Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland
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Muetterties CE, Taylor JM, Kaeding DE, Morales RR, Nguyen AV, Kwan L, Tseng CY, Delong MR, Festekjian JH. Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5444. [PMID: 38098953 PMCID: PMC10721129 DOI: 10.1097/gox.0000000000005444] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/11/2023] [Indexed: 12/17/2023]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center. Methods The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls. Results The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant. Conclusion Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.
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Affiliation(s)
- Corbin E. Muetterties
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Diana E. Kaeding
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Ricardo R. Morales
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Anissa V. Nguyen
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Lorna Kwan
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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18
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Liu J, Zheng QQ, Wu YT. Effect of enhanced recovery after surgery with multidisciplinary collaboration on nursing outcomes after total knee arthroplasty. World J Clin Cases 2023; 11:7745-7752. [DOI: 10.12998/wjcc.v11.i32.7745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND There is a lack of studies on the effects of enhanced recovery after surgery (ERAS) with multidisciplinary collaboration on the nursing outcomes of total knee arthroplasty (TKA).
AIM To explore the effect of ERAS with multidisciplinary collaboration on nursing outcomes after TKA.
METHODS We retrospectively analyzed the clinical data of 80 patients who underwent TKA at a tertiary hospital between January 2021 and December 2022. The patients were divided into two groups according to the nursing mode: the ERAS group (n = 40) received ERAS with multidisciplinary collaboration, and the conventional group (n = 40) received routine nursing. The following indicators were compared between the two groups: length of hospital stay, hospitalization cost, intraoperative blood loss, hemoglobin level 24 h after surgery, visual analog scale (VAS) score for pain, range of motion (ROM) of the knee joint, Hospital for Special Surgery (HSS) knee score, and postoperative complications.
RESULTS The ERAS group had a significantly shorter length of hospital stay, lower hospitalization cost, less intraoperative blood loss, higher hemoglobin level 24 h after surgery, lower VAS score for pain, higher knee joint ROM, and higher HSS knee score than the conventional group (all P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05).
CONCLUSION Multidisciplinary collaboration with ERAS can reduce blood loss, shorten hospital stay, and improve knee function in patients undergoing TKA.
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Affiliation(s)
- Jing Liu
- Operating Room, Shangrao People's Hospital, Shangrao 334000, Jiangxi Province, China
| | - Qian-Qian Zheng
- Operating Room, Shangrao People's Hospital, Shangrao 334000, Jiangxi Province, China
| | - Yang-Tao Wu
- Operating Room, Shangrao People's Hospital, Shangrao 334000, Jiangxi Province, China
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Hong M, Ghajar M, Allen W, Jasti S, Alvarez-Downing MM. Evaluating Implementation Costs of an Enhanced Recovery After Surgery (ERAS) Protocol in Colorectal Surgery: A Systematic Review. World J Surg 2023; 47:1589-1596. [PMID: 37149554 DOI: 10.1007/s00268-023-07024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been well documented in the current literature to improve healthcare outcomes by decreasing length of stay, resource utilization, and morbidity without increasing readmission rates or complications. This subsequently leads to a net decrease in hospital costs. However, the initial costs of implementing such a program have not been well described, which is crucial information for hospitals with less resources. The aim of this study was to provide a cohesive review of the current literature for the costs of implementing a colorectal surgery ERAS protocol. METHODS A comprehensive review was conducted on five databases (Google Scholar, Web of Science, PROSPERO, PubMed, and Cochrane) with the assistance of a professional librarian. All relevant English articles published between 1995 and June 2021 were screened for eligibility prior to inclusion in the review. Cost data were converted to US dollars based on the exchange rate at the end time of the study period for standardization. RESULTS Seven studies were included for review. The studies evaluated a range of 50-1295 patients through their respective ERAS programs, which were followed for 5 to 22 months. ERAS implementation costs ranged from $57 to $1536 per patient. Components for each ERAS program varied for each study, but ultimately, the greatest costs were attributed to personnel. CONCLUSIONS Despite data heterogeneity and inconsistencies between cost breakdowns, a majority of the implementation cost was found to be secondary to personnel. This review demonstrates the need for a more standardized approach for reporting ERAS implementation costs through an open database as well as a potential streamlining of the ERAS protocol to facilitate implementation in institutions with less financial resources.
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Affiliation(s)
- Minki Hong
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Mina Ghajar
- Rutgers University, George F. Smith Library of the Health Sciences, Newark, NJ, USA
| | | | | | - Melissa M Alvarez-Downing
- Department of Surgery, Division of Colorectal Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, G-514, Newark, NJ, 07103, USA.
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Ljungqvist O, de Boer HD. Enhanced Recovery After Surgery and Elderly Patients. Anesthesiol Clin 2023. [PMID: 37516500 DOI: 10.1016/j.anclin.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Enhanced recovery after surgery (ERAS) is a new way of working where evidence-based care elements are assembled to form a care pathway involving the patient's entire journey through surgery. Many elements included in ERAS have stress-reducing effects on the body or helps avoid side effects associated with alternative treatment options. This leads to less overall stress from the injury caused by the operation and helps facilitate recovery. In old, frail patients with concomitant diseases and less physical reserves, this may help explain why the ERAS care is reported to be beneficial for this specific patient group.
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Wasylak T, Benzies K, McNeil D, Zanoni P, Osiowy K, Mullie T, Chuck A. Creating Value Through Learning Health Systems: The Alberta Strategic Clinical Network Experience. Nurs Adm Q 2023; 47:20-30. [PMID: 36469371 PMCID: PMC9746610 DOI: 10.1097/naq.0000000000000552] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Design, implementation, and evaluation of effective multicomponent interventions typically take decades before value is realized even when value can be measured. Value-based health care, an approach to improving patient and health system outcomes, is a way of organizing health systems to transform outcomes and achieve the highest quality of care and the best possible outcomes with the lowest cost. We describe 2 case studies of value-based health care optimized through a learning health system framework that includes Strategic Clinical Networks. Both cases demonstrate the acceleration of evidence to practice through scientific, financial, structural administrative supports and partnerships. Clinical practice interventions in both cases, one in perioperative services and the other in neonatal intensive care, were implemented across multiple hospital sites. The practical application of using an innovation pipeline as a structural process is described and applied to these cases. A value for money improvement calculator using a benefits realization approach is presented as a mechanism/tool for attributing value to improvement initiatives that takes advantage of available system data, customizing and making the data usable for frontline managers and decision makers. Health care leaders will find value in the descriptions and practical information provided.
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Affiliation(s)
- Tracy Wasylak
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
| | - Karen Benzies
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
| | - Deborah McNeil
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
| | - Pilar Zanoni
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
| | - Kevin Osiowy
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
| | - Thomas Mullie
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
| | - Anderson Chuck
- Alberta Health Services, Edmonton, Alberta, Canada (Ms Wasylak, Dr McNeil, and Messrs Osiowy and Mullie); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Mss Wasylak and Zanoni and Drs Benzies and McNeil); and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (Dr Chuck)
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Kutnik P, Bierut M, Rypulak E, Trwoga A, Wróblewska K, Marzęda P, Kośmider K, Kamieniak M, Pająk A, Wolanin N, Gębska-Wolińska M, Borys M. The use of the ERAS protocol in malnourished and properly nourished patients undergoing elective surgery: a questionnaire study. Anaesthesiol Intensive Ther 2023; 55:330-334. [PMID: 38282499 PMCID: PMC10801458 DOI: 10.5114/ait.2023.134190] [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: 08/28/2023] [Accepted: 09/15/2023] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is a modern approach to perioperative management. This study aimed to evaluate compliance with certain aspects of the ERAS protocol in malnourished and properly nourished patients undergoing elective surgery. MATERIAL AND METHODS A questionnaire study was conducted among 197 patients undergoing elective surgery at the university hospital. We divided patients into two groups according to nutritional status. RESULTS The study's results showed that 67 patients (34%) lost weight before admission (the weight-loss group). Twenty-five participants (37%) in the weight-loss group and 15 patients (12%) in the preserved-weight group underwent surgery due to cancer ( P < 0.001). More patients in the weight loss group (45 of 67) than in the preserved-weight group (40 of 129, P < 0.001) limited their food intake a week before the surgery. The preserved-weight group participants were mobilized earlier than the weight-loss group ( P = 0.04). The median number of hours since drinking their last fluids and eating their last meals before the surgery were 12.2 hours and 25.4 hours for both groups, respectively. Only eight patients received preoperative carbohydrate loading. We found higher serum protein concentrations in the preserved-weight group (7.10 [0.5] vs. 6.92 [0.71], P = 0.023); however, white blood cell count was higher in the weight-loss group (7.85 (2.28) vs.7.10 (0.50), P = 0.04). Both groups were highly satisfied with their hospital treatments. CONCLUSIONS Our study revealed relatively high malnutrition in patients undergoing elective surgery. As a standard of perioperative care in the studied centre, the ERAS protocol implementation level is low.
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Affiliation(s)
- Paweł Kutnik
- Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Michał Bierut
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Elżbieta Rypulak
- Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Aleksandra Trwoga
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Kamila Wróblewska
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Paweł Marzęda
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Kamil Kośmider
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Maciej Kamieniak
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Agnieszka Pająk
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Natalia Wolanin
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Martyna Gębska-Wolińska
- Student Research Group, Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
| | - Michał Borys
- Second Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland
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23
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Rosyidah R, Dewanto A, Hapsari ED, Widyastuti Y. Health Professionals Perception of Enhanced Recovery After Surgery: A Scoping Review. J Perianesth Nurs 2022; 37:956-960. [PMID: 35680549 DOI: 10.1016/j.jopan.2022.02.004] [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: 11/12/2021] [Revised: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The Enhanced Recovery After Surgery (ERAS) program is currently poorly implemented by healthcare workers. Furthermore, several inhibiting and supporting factors for this implementation have been discovered to influence healthcare workers' perception of the program. This study aims to investigate the perception of healthcare workers regarding the ERAS program. DESIGN A scoping review in a systematic manner. METHODS A systematic search was performed using six databases: PubMed, ScienceDirect, SCOPUS, EBSCO, Proquest, and Sage Journals, from August 2011 to August 2021. The data was extracted using an excel worksheet, and the results obtained were presented descriptively. FINDINGS This study selected a total of 10 articles, where both qualitative and quantitative methods were used to discuss the perceptions of healthcare workers about ERAS. CONCLUSIONS Based on this study's findings, not all healthcare workers have a good perception of ERAS. The implementation of ERAS is often hindered by several factors, including resistance to change and lack of knowledge about the program. However, good teamwork and support from hospital management can support the program's implementation.
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Affiliation(s)
- Rafhani Rosyidah
- Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Department of Midwifery, Universitas Muhammadiyah Sidoarjo, East Java, Indonesia
| | - Agung Dewanto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Elsi Dwi Hapsari
- Department of Pediatric and Maternity Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Yunita Widyastuti
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
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24
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Toward Zero Prescribed Opioids for Outpatient General Surgery Procedures: A Prospective Cohort Trial. J Surg Res 2022; 278:293-302. [DOI: 10.1016/j.jss.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022]
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National Assessment of Early Discharge After Video-Assisted Thoracoscopic Surgery for Lung Resection. J Surg Res 2022; 276:242-250. [PMID: 35395564 DOI: 10.1016/j.jss.2022.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Video-assisted thoracoscopic surgery (VATS) techniques permit shorter postoperative length of stay (LOS). However, it remains unknown whether earlier discharge increases the risk of adverse postoperative events. We examined whether shorter LOS following elective VATS lung resection was associated with increased rates of readmission or postoperative complications. METHODS Patients who underwent elective thoracoscopic segmentectomy, lobectomy, or bilobectomy for lung neoplasms from 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Postoperative LOS was treated as an ordinal variable. The examined outcomes were 30-d readmission and 30-d postdischarge death or serious morbidity (DSM). Multivariable logistic regression models evaluated the association of LOS with outcomes. The most common readmission diagnoses were identified for each operation. RESULTS Among 14,418 patients, 12,410 (86.1%) underwent lobectomy, 1764 (12.2%) underwent segmentectomy, and 244 (1.7%) underwent bilobectomy. The median LOS was 3 d for patients undergoing lobectomy (IQR 2-5) and segmentectomy (IQR 2-4), and 4 d for bilobectomy (IQR 3-6). Readmission rates varied with admission time and ranged from 5.0% for patients with LOS ≤1 d to 8.5% for LOS ≥5 d. The most common readmission diagnoses were pneumothorax (19.0%) and wound complications (13.4%). Each one-day increase in LOS was associated with an increased risk of readmission (OR 1.10, 95% CI 1.04-1.17, P < 0.001). No association was seen between earlier discharge and DSM (OR 1.08, 95% CI 0.99-1.18, P = 0.070). CONCLUSIONS Early discharge following VATS lung resection is not associated with increased rates of readmission or postoperative complications among patients undergoing surgery for cancer, and may safely be considered for selected patients with uncomplicated postoperative recovery.
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Karunakaran M, Jonnada PK, Chandrashekhar SH, Vinayachandran G, Kaambwa B, Barreto SG. Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis. HPB (Oxford) 2022; 24:309-321. [PMID: 34848126 DOI: 10.1016/j.hpb.2021.11.004] [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] [Received: 08/02/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs. METHODS A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error. CONCLUSION Peri-PD CPs result in significant cost-reduction in comparison to CC.
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Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, SK Hospital, Thiruvananthapuram, India
| | - Pavan K Jonnada
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sagar H Chandrashekhar
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta- The Medicity, Gurgaon, India
| | | | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
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Delivering Value Based Care: The UK Perspective. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Soomro FH, Razzaq A, Qaisar R, Ansar M, Kazmi T. Enhanced Recovery After Surgery: Are Benefits Demonstrated in International Studies Replicable in Pakistan? Cureus 2021; 13:e19624. [PMID: 34804754 PMCID: PMC8597665 DOI: 10.7759/cureus.19624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/14/2022] Open
Abstract
Objectives To determine the efficacy of enhanced recovery after surgery (ERAS) protocols in terms of frequency of surgical site infection (SSI) and length of hospital stay in patients undergoing colorectal surgeries for colorectal carcinoma. Study design Quasi-experimental study. Setting/Duration of study Department of Surgery, Shifa International Hospital, Islamabad, from May 7, 2019 to November 6, 2019. Methodology A total of 120 patients with colorectal carcinomas who fulfilled that sample selection criteria were studied. After randomization, patients were divided into two equal groups; one group received management under ERAS while the second group received conventional management. All patients were recorded for length of hospital stay and the development of SSIs. Data were analyzed using SPSS 26.0. Results The mean age was 42.34 ± 14.45 years, with a male majority, i.e., 72 (60%). The mean duration of in-patient stay was 3.45 ± 1.73 days with ERAS and 8.25 ± 1.58 days with conventional management (p < 0.001). A total of 28 (23.3%) SSIs developed, of which nine (7.5%) SSIs occurred with ERAS, while 19 (15.8%) occurred with traditional management (p = 0.031). Conclusion ERAS protocols have been demonstrated to be effective, cheap, and safe. There is a tangible reduction in length of hospital stay and incidence of SSIs which translates into reduced utilization of resources and financial costs. However, strict adherence to the protocol may be necessary to obtain the aforementioned benefits, which may be difficult to do in the face of professional, institutional, and personal inertia. Intensive efforts are required to make these protocols more convenient and attractive to implement, so as to facilitate conversion to this management approach.
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Affiliation(s)
- Faiza H Soomro
- General Surgery, The Dudley Group NHS Foundation Trust, Dudley, GBR
| | - Aneela Razzaq
- Surgery, Shifa International Hospital Islamabad, Islamabad, PAK
| | | | - Mehwish Ansar
- General Surgery, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Tehreem Kazmi
- General Surgery, Shifa International Hospital Islamabad, Islamabad, PAK
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Dong Y, Zhang Y, Jin C. Comprehensive economic evaluation of enhanced recovery after surgery in hepatectomy. Int J Equity Health 2021; 20:245. [PMID: 34774038 PMCID: PMC8590288 DOI: 10.1186/s12939-021-01583-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/30/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is attracting extensive attention and being widely applied to reduce postoperative stress and accelerate recovery. However, the economic benefits of ERAS are less clarified at the social level. We aimed to assess the economic impact of ERAS in hepatectomy from the perspectives of patients, hospitals and society, as well as identify the approach to create the economic benefits of ERAS. METHODS By combining the literature and national statistical data, the cost-effectiveness framework was clarified, and parameter values were determined. Cost-effectiveness analysis, cost-benefit analysis and cost-minimisation analysis were used to compare ERAS and conventional treatment from the perspectives of patients, hospitals and society. The capital flow diagram was used to analyse the change between them. RESULTS ERAS significantly reduced the economic burden of disease on patients ($8935.02 vs $10,470.02). The hospital received an incremental benefit in ERAS (the incremental benefit cost ratio value is 1.09), and the total social cost was reduced ($5958.67 vs $6725.80). Capital flow diagram analysis demonstrated that the average daily cost per capita in the ERAS group increased ($669.51 vs $589.98), whereas the benefits depended on the reduction of hospital stay and productivity loss. CONCLUSION The mechanism by which ERAS works is to reduce the average length of stay, thereby reducing the economic burden and productivity loss on patients and promoting the hospital bed turnover rate. Therefore, ERAS should further focus on accelerating the rehabilitation process, and more economic support (such as subsidies) should be given to hospitals to carry out ERAS.
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Affiliation(s)
- Yihan Dong
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 Hangkong Road, Qiaokou District, Wuhan, 430030, Hubei, China.,Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 Hangkong Road, Qiaokou District, Wuhan, 430030, Hubei, China. .,Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China.
| | - Chengcheng Jin
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 Hangkong Road, Qiaokou District, Wuhan, 430030, Hubei, China.,Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Sarakatsianou C, Perivoliotis K, Tzovaras G, Samara AA, Baloyiannis I. Efficacy of Intravenous Use of Lidocaine in Postoperative Pain Management After Laparoscopic Colorectal Surgery: A Meta-analysis and Meta-regression of RCTs. In Vivo 2021; 35:3413-3421. [PMID: 34697177 PMCID: PMC8627741 DOI: 10.21873/invivo.12641] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Current literature reports regarding the effect of lidocaine in laparoscopic colectomies are still inconclusive. The purpose of this study was to review the current literature and estimate the overall effect of intravenous lidocaine administration in postoperative recovery of patients submitted to laparoscopic colectomies. MATERIALS AND METHODS This study was completed based on the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic screening using scholar databases was performed (Medline, Scopus, Web of Science, CENTRAL). RESULTS In total, 8 studies and 407 patients were included in this meta-analysis. Introduction of intravenous lidocaine in the perioperative analgesia scheme did not improve hospitalization duration (p=0.23), morphine consumption (p=0.96), perioperative bowel function (first flatus p=0.40, first bowel opened p=0.13, first diet p=0.16), or the overall complication rates (p=0.42). Overall, high heterogeneity levels were identified. CONCLUSION Current evidence indicates that lidocaine does not improve rehabilitation after laparoscopic colectomies.
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Affiliation(s)
| | | | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | - Athina A Samara
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
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Brophy L, Birkhimer D, DeVilliers A, Davis L, Meade K, Pervo V. Oncologic Surgical Care Using an Enhanced Recovery Approach. AACN Adv Crit Care 2021; 32:286-296. [PMID: 34490448 DOI: 10.4037/aacnacc2021151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Enhanced recovery programs are multimodal, evidence-based perioperative programs designed to improve a patient's functional recovery after surgery. Enhanced recovery programs promote standardized, multidisciplinary care throughout the perioperative course to improve patient outcomes, rather than focusing on surgical technique. It is important for nurses working in acute and critical care to be aware of the paradigm shift created by the trend toward the enhanced recovery approach. By learning more about facets of the approach, the nurse will be better prepared to adopt whatever aspects of enhanced recovery their institution implements for the surgical oncology population. An overview is provided of the potential components of enhanced recovery.
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Affiliation(s)
- Lynne Brophy
- Lynne Brophy is Breast Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Administration-Room 2040, 1145 Olentangy River Road, Columbus, OH 43212
| | - Danette Birkhimer
- Danette Birkhimer is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Allison DeVilliers
- Allison DeVilliers is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Loletia Davis
- Loletia Davis is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Karen Meade
- Karen Meade is Oncology Clinical Nurse Specialist, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
| | - Valerie Pervo
- Valerie Pervo is Clinical Outcomes Manager, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard M. Solve Research Institute, Columbus, Ohio
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Martin L, Gillis C, Ljungqvist O. Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity? Curr Opin Clin Nutr Metab Care 2021; 24:453-463. [PMID: 34155154 DOI: 10.1097/mco.0000000000000779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation. RECENT FINDINGS All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening. SUMMARY There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.
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Affiliation(s)
- Lisa Martin
- Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Québec, Canada
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
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33
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An overview of the evidence for enhanced recovery. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nelson G, Wang X, Nelson A, Faris P, Lagendyk L, Wasylak T, Bathe OF, Bigam D, Bruce E, Buie WD, Chong M, Fairey A, Hyndman ME, MacLean A, McCall M, Pin S, Wang H, Gramlich L. Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada. JAMA Netw Open 2021; 4:e2119769. [PMID: 34357394 PMCID: PMC8346943 DOI: 10.1001/jamanetworkopen.2021.19769] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. OBJECTIVE To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. INTERVENTIONS Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. MAIN OUTCOMES AND MEASURES Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. RESULTS A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). CONCLUSIONS AND RELEVANCE The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.
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Affiliation(s)
- Gregg Nelson
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Xiaoming Wang
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | - Alison Nelson
- Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Peter Faris
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Tracy Wasylak
- Strategic Clinical Networks, Alberta Health Services, Calgary, Alberta, Canada
| | - Oliver F. Bathe
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Bruce
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - W. Donald Buie
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael Chong
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Fairey
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - M. Eric Hyndman
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael McCall
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Haili Wang
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Pagano E, Pellegrino L, Rinaldi F, Palazzo V, Donati D, Meineri M, Palmisano S, Rolfo M, Bachini I, Bertetto O, Borghi F, Ciccone G. Implementation of the ERAS (Enhanced Recovery After Surgery) protocol for colorectal cancer surgery in the Piemonte Region with an Audit and Feedback approach: study protocol for a stepped wedge cluster randomised trial: a study of the EASY-NET project. BMJ Open 2021; 11:e047491. [PMID: 34083345 PMCID: PMC8183289 DOI: 10.1136/bmjopen-2020-047491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The ERAS protocol (Enhanced Recovery After Surgery) is a multimodal pathway aimed to reduce surgical stress and to allow a rapid postoperative recovery. Application of the ERAS protocol to colorectal cancer surgery has been limited to a minority of hospitals in Italy. To promote the systematic adoption of ERAS in the entire regional hospital network in Piemonte an Audit and Feedback approach (A&F) has been adopted together with a cluster randomised trial to estimate the true impact of the protocol on a large, unselected population. METHODS A multicentre stepped wedge cluster randomised trial is designed for comparison between standard perioperative management and the management according to the ERAS protocol. The primary outcome is the length of hospital stay (LOS). Secondary outcomes are: incidence of postoperative complications, time to patients' recovery, control of pain and patients' satisfaction. With an A&F approach the adherence to the ERAS items is monitored through a dedicated area in the study web site. The study includes 28 surgical centres, stratified by activity volume and randomly divided into four groups. Each group is randomly assigned to a different activation period of the ERAS protocol. There are four activation periods, one every 3 months. However, the planned calendar and the total duration of the study have been extended by 6 months due to the COVID-19 pandemic.The expected sample size of about 2200 patients has a high statistical power (98%) to detect a reduction of LOS of 1 day and to estimate clinically meaningful changes in the other endpoints. ETHICS AND DISSEMINATION The study protocol has been approved by the Ethical Committee of the coordinating centre and by all participating centres. Study results will be timely circulated within the hospital network and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04037787.
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Affiliation(s)
- Eva Pagano
- Clinical Epidemiology Unit and CPO Piemonte, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luca Pellegrino
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | | | | | - Danilo Donati
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Maurizio Meineri
- Department of Anesthesiology and Intensive Care, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Sarah Palmisano
- Department of Anesthesiology and Intensive Care, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Monica Rolfo
- Healthcare Services Direction, Humanitas, Torino, Italy
| | - Ilaria Bachini
- Unit of Dietetic and Clinical Nutrition, Ordine Mauriziano Hospital, Torino, Italy
| | - Oscar Bertetto
- Dipartimento Interaziendale Interregionale Rete Oncologica Piemonte-Valle d'Aosta, Torino, Italy
| | - Felice Borghi
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Giovannino Ciccone
- Clinical Epidemiology Unit and CPO Piemonte, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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de Queiroz FL, Lacerda-Filho A, Alves AC, de Oliveira FH, Neto PRF, de Almeida Paiva R. Conditions associated with worse acceptance of a simplified accelerated recovery after surgery protocol in laparoscopic colorectal surgery. BMC Surg 2021; 21:229. [PMID: 33941146 PMCID: PMC8091501 DOI: 10.1186/s12893-021-01206-2] [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: 07/21/2020] [Accepted: 04/14/2021] [Indexed: 11/15/2022] Open
Abstract
Background Enhanced Recovery Surgical Programs were initially applied to colorectal procedures and used as multimodal approach to relieve the response to surgical stress. An important factor that negatively impacts the success of these programs is the poor tolerance of these patients to certain items in the adopted protocol, especially with regard to post-operative measures. The identification of these factors may help to increase the success rate of such programs, ensuring that benefits reach a greater number of patients and that resources are better allocated. Thus, the aims of this study were to assess the results of the implementation of a Simplified Accelerated Recovery Protocol (SARP) and to identify possible factors associated with failure to implement postoperative protocol measures in patients submitted to laparoscopic colorectal surgery. Methods 161 patients were randomly divided into two groups. The SARP group (n = 84) was submitted to the accelerated recovery program and the CC group (n = 77), to conventional postoperative care. The SARP group was further divided into two subgroups: patients who tolerated the protocol (n = 51) and those who did not (n = 33), in order to analyze factors contributing to protocol nontolerance. Results The groups had similar sociodemographic and clinical characteristics. The SARP group had a shorter hospital stay, better elimination of flatus, was able to walk and to tolerate a diet sooner (p < 0.0001). Complications rates and readmissions to emergency room were similar between groups. Multivariate analysis revealed that prolonged operating time, stoma creation and rates of surgical complications were independently associated with poor adherence to SARP (p < 0.0001). Conclusions The use of our SARP resulted in improved recovery from laparoscopic colorectal surgery and proved to be safe for patients. Extensive surgeries, occurrence of complications, and the need for ostomy were variables associated with poor program adhesion. Trial registration Trial Registry: RBR2b4fyr—Date of registration: 03 October 2017.
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Affiliation(s)
- Fábio Lopes de Queiroz
- Colorectal Surgery Department, Hospital Felicio Rocho, Rua Felipe Dos Santos, 760, 501-3, Belo Horizonte, Minas Gerais, CEP 30180160, Brazil.
| | - Antonio Lacerda-Filho
- Department of Surgery at the School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Adriana Cherem Alves
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.,Semper Hospital- Belo Horizonte, Belo Horizonte, Brazil
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Hogan S, Steffens D, Vuong K, Rangan A, Solomon M, Carey S. Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients - a retrospective study. Nutr Health 2021; 28:41-48. [PMID: 33858255 DOI: 10.1177/02601060211009067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated. AIM To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery. METHODS A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations. RESULTS Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay (p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score (p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients (p = 0.022). CONCLUSIONS Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.
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Affiliation(s)
- Sophie Hogan
- 2205Royal Prince Alfred Hospital, Australia.,4334University of Sydney, Australia
| | - Daniel Steffens
- 2205Royal Prince Alfred Hospital, Australia.,4334University of Sydney, Australia
| | | | | | - Michael Solomon
- 2205Royal Prince Alfred Hospital, Australia.,4334University of Sydney, Australia
| | - Sharon Carey
- 2205Royal Prince Alfred Hospital, Australia.,4334University of Sydney, Australia
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Fawcett WJ, Mythen MG, Scott MJ. Enhanced recovery: joining the dots. Br J Anaesth 2021; 126:751-755. [PMID: 33516456 DOI: 10.1016/j.bja.2020.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/04/2020] [Accepted: 12/28/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey NHS Foundation Trust, Guildford, UK.
| | - Michael G Mythen
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - Michael J Scott
- Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Sherer EL, Erickson EC, Holland MH. Enhanced Recovery After Surgery. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Chen X, Li K, Yang K, Hu J, Yang J, Feng J, Hu Y, Zhang X. Effects of preoperative oral single-dose and double-dose carbohydrates on insulin resistance in patients undergoing gastrectomy:a prospective randomized controlled trial. Clin Nutr 2021; 40:1596-1603. [PMID: 33752148 DOI: 10.1016/j.clnu.2021.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/07/2021] [Accepted: 03/02/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS Preoperative oral carbohydrates are strongly recommended for routine use before various elective procedures. The regimen mainly includes preoperative oral single-dose carbohydrate (2-3 h before surgery) and preoperative oral double-dose carbohydrates (10 h before surgery and 2-3 h before surgery). The choice between the two options is still controversial. METHODS A total of 139 patients with gastric cancer who underwent radical gastrectomy were recruited from a hospital in Sichuan Province, China. The patients were randomly assigned to a single-dose group (n = 70) or a double-dose group (n = 69). Insulin resistance indicators, subjective comfort indicators, inflammatory mediators, immunological indicators, postoperative recovery indexes, and complications were compared between the two groups. RESULTS There were no differences in insulin resistance indicators (fasting plasma glucose, fasting insulin, and homeostasis model assessment indexes), inflammatory mediators (C-reactive protein, interleukin-6, and tumor necrosis factor-α), immunological indicators (CD3+, CD4+, CD8+, and CD4+/CD8+) between the single-dose group and double-dose group (all P > 0.05) at preoperative day 1, preoperative 3 h, and postoperative day 1. There were no differences in subjective comfort indicators (thirst, hunger, anxiety, nausea, fatigue, and weakness) between the two groups (all P > 0.05) at preoperative day 1, preoperative 3 h, preoperative 1 h, and postoperative day 1. The postoperative recovery indexes and complications (exhaust time, liquid intake time, postoperative hospital stay, complication incidence, unplanned readmission rate, and unplanned reoperation rate 30 days after operation) did not significantly differ between the two groups (all P > 0.05). The number of preoperative nighttime urinations in the double-dose group was higher than that in the single-dose group (88.3% VS 48.5%, P < 0.001), and the number of hours of preoperative sleep in the double-dose group was lower than that in the single-dose group (4.56 ± 0.68 VS 5.71 ± 0.57, P < 0.001). CONCLUSION Oral carbohydrates administered the night before surgery did not enhance the effects of oral carbohydrates administered 2-3 h before surgery on insulin resistance, subjective comfort, inflammation, and immunity and might affect the patients' night rest. In making a decision between oral carbohydrate regimes, evening carbohydrates could be omitted. TRIAL REGISTRATION ChiCTR, ChiCTR1900020608. Registered January 10, 2019, http://www.chictr.org.cn: ChiCTR1900020608.
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Affiliation(s)
- Xinrong Chen
- West China School of Nursing /West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Ka Li
- West China School of Nursing /West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
| | - Kun Yang
- Department of Gastrointestinal Surgery, West China Hospital,Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Jiankun Hu
- Department of Gastrointestinal Surgery, West China Hospital,Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital,Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Jinhua Feng
- West China School of Nursing /West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Yanjie Hu
- West China School of Nursing /West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xingxia Zhang
- West China School of Nursing /West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
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Jones CN, Morrison BL, Kelliher LJ, Dickinson M, Scott M, Cecconi Ebm C, Karanjia N, Quiney N. Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial. JMIR Perioper Med 2021; 4:e16829. [PMID: 33522982 PMCID: PMC7884210 DOI: 10.2196/16829] [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] [Received: 10/29/2019] [Revised: 12/15/2020] [Accepted: 01/10/2021] [Indexed: 12/20/2022] Open
Abstract
Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a
day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
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Affiliation(s)
- Chris N Jones
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben L Morrison
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Michael Scott
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Nial Quiney
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
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Said ET, Drueding RE, Martin EI, Furnish TJ, Meineke MN, Sztain JF, Abramson WB, Swisher MW, Jacobsen GR, Gosman AA, Gabriel RA. The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction. World J Surg 2021; 45:1102-1108. [PMID: 33454790 DOI: 10.1007/s00268-020-05915-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction. METHODS The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant. RESULTS There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01). DISCUSSION A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.
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Affiliation(s)
- Engy T Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Ross E Drueding
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Erin I Martin
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Timothy J Furnish
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Minhthy N Meineke
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Wendy B Abramson
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Garth R Jacobsen
- Department of Surgery, Division of Minimally Invasive Surgery, University of California, La Jolla, San Diego, CA, USA
| | - Amanda A Gosman
- Department of Surgery, Division of Plastic Surgery, University of California, La Jolla, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.
- Department of Medicine, Division of Biomedical Informatics, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.
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Dumitra T, Ganescu O, Hu R, Fiore JF, Kaneva P, Mayo N, Lee L, Liberman AS, Chaudhury P, Ferri L, Feldman LS. Association Between Patient Activation and Health Care Utilization After Thoracic and Abdominal Surgery. JAMA Surg 2021; 156:e205002. [PMID: 33146682 DOI: 10.1001/jamasurg.2020.5002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Increased patient activation (PA) (ie, knowledge, skills, motivation, confidence to participate in care) may result in improved outcomes, especially in surgical settings. Objective To estimate the extent to which PA is associated with 30-day postdischarge unplanned health care utilization after major thoracic or abdominal surgery. Design, Setting, and Participants This cohort study was performed at 2 centers of a tertiary care hospital network between October 2017 and January 2019. Adult patients undergoing thoracic or abdominal surgery were included. Of 880 patients assessed for eligibility, 692 were deemed eligible, of whom 34 declined to participate, 1 withdrew consent, and 4 were excluded after consent. Exposures Patient activation was measured immediately after surgery during the initial admission using the Patient Activation Measure (score range, 0-100). Patients were dichotomized into low and high PA groups using previously described thresholds (Patient Activation Measure score, ≤55.1). Main Outcomes and Measures The primary outcome was unplanned 30-day postdischarge health care utilization (composite including emergency department and outpatient clinic visits and/or hospital readmission). Secondary outcomes were length of stay, 30-day emergency department visits, 30-day readmissions, and postoperative complications. Results A total of 653 patients admitted for thoracic, general, colorectal, and gynecologic surgery were included in the study (mean [SD] age, 58 [15] years; 369 women [56%]; 366 [56%] had minimally invasive surgery; 52 [8%] had emergency surgery), of which 152 (23%) had a low level of PA. Baseline characteristics were similar between patients with low- and high-level PA. Low PA was associated with unplanned health care utilization (odds ratio [OR], 3.15; 95% CI, 2.05-4.86; P < .001), emergency department visits (OR, 1.64; 95% CI, 1.02-2.64; P = .04), complications (OR, 1.63; 95% CI, 1.11-2.41; P = .01), and length of stay (adjusted mean difference, 1.19 days; 95% CI, 0.06-2.33; P = .04). Low PA was not associated with a higher risk of readmission (adjusted OR, 1.04; 95% CI, 0.56-1.93; P = .90). Conclusions and Relevance In this study, low level of PA was associated with postdischarge unplanned health care use, hospital stay, and complications after major surgery. Identification of patients with low activation may allow the implementation of interventions to improve health care knowledge and support self-management postdischarge.
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Affiliation(s)
- Teodora Dumitra
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Hu
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nancy Mayo
- Division of Clinical Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Thanh N, Nelson A, Wang X, Faris P, Wasylak T, Gramlich L, Nelson G. Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada. Can J Surg 2020; 63:E542-E550. [PMID: 33253512 DOI: 10.1503/cjs.006720] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.
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Affiliation(s)
- Nguyen Thanh
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Alison Nelson
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Xiaoming Wang
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Peter Faris
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Tracy Wasylak
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Leah Gramlich
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
| | - Gregg Nelson
- From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson)
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Springer JE, Doumouras AG, Lethbridge S, Forbes S, Eskicioglu C. The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey. Can J Surg 2020. [PMID: 33107814 DOI: 10.1503/cjs.009419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. METHODS A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. RESULTS Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). CONCLUSION Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.
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Affiliation(s)
| | | | - Sara Lethbridge
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Shawn Forbes
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Cagla Eskicioglu
- From the Department of Surgery, McMaster University, Hamilton, Ont
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Hanney SR, Ovseiko PV, Graham KER, Chorzempa H, Miciak M. A systems approach for optimizing implementation to impact: meeting report and proceedings of the 2019 In the Trenches: Implementation to Impact International Summit. BMC Proc 2020; 14:10. [PMID: 32760445 PMCID: PMC7379765 DOI: 10.1186/s12919-020-00189-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background The In the Trenches series of cutting-edge knowledge sharing events on impact for front-line experts and practitioners provides an engagement platform for diverse stakeholders across government, research funding organizations, industry, and academia to share emerging knowledge and practical experiences. The second event of the series In the Trenches: Implementation to Impact International Summit was held in Banff, Alberta, Canada, on June 7–8, 2019. The overarching vision for the Summit was to create an engagement platform for addressing key challenges and finding practical solutions to move from implementation (i.e. putting findings into effect) to impact (i.e. creating benefits to society and the economy). Processes and proceedings The Summit used diverse approaches to facilitate active engagement and knowledge sharing between 80 delegates across sectors and jurisdictions. Summit sessions mostly consisted of short talks and moderated panels grouped into eight thematic sessions. Each presentation included a summary of Key Messages, along with a summary of the Actionable Insights which concluded each session. The presentations and discussions are analysed, synthesized and described in this proceedings paper using a systems approach. This demonstrates how the Summit focused on each of the necessary functions (and associated components) that should be undertaken, and combined, for effective research and innovation: stewardship and governance, securing finance, creating capacity, and producing and using research. The approach also identifies relevant challenges. Conclusions There is increased interest globally in the benefits that can accrue from adopting a systems approach to research and innovation. Various organizations in Canada and internationally have made considerable progress on Implementation to Impact, often as a result of well-planned initiatives. The Summit highlights the value of 1) collaboration between researchers and potential users, and 2) the adoption by funders of approaches involving an increasing range of responsibilities and activities. The Summit website (https://inthetrenchessummit.com/) will be periodically updated with new resources and information about future In the Trenches events.
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Affiliation(s)
- Stephen R Hanney
- Health Economics Research Group, Brunel University London, Uxbridge, Middlesex, UB8 3PH UK
| | - Pavel V Ovseiko
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Kathryn E R Graham
- Alberta Innovates, 1500, 10104-103 Avenue NW, Edmonton, AB T5J 0H8 Canada
| | - Heidi Chorzempa
- Alberta Innovates, 1500, 10104-103 Avenue NW, Edmonton, AB T5J 0H8 Canada
| | - Maxi Miciak
- Faculty of Rehabilitation Medicine, University of Alberta, 8205-114 St. NW, Edmonton, AB T6G 2G4 Canada
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Gianotti L, Sandini M, Romagnoli S, Carli F, Ljungqvist O. Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care. Clin Nutr 2020; 39:2014-2024. [PMID: 31699468 DOI: 10.1016/j.clnu.2019.10.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 02/06/2023]
Abstract
The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marta Sandini
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefano Romagnoli
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Franco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Clark BS, Swanson M, Widjaja W, Cameron B, Yu V, Ershova K, Wu FM, Vanstrum EB, Ulloa R, Heng A, Nurimba M, Kokot N, Kochhar A, Sinha UK, Kim MP, Dickerson S. ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization. Laryngoscope 2020; 131:E792-E799. [PMID: 32516508 DOI: 10.1002/lary.28768] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We implement a novel enhanced recovery after surgery (ERAS) protocol with pre-operative non-opioid loading, total intravenous anesthesia, multimodal peri-operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30-day readmissions. METHODS Retrospective cohort study comparing 132 ERAS vs. 66 non-ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double-blind fashion by two teams. RESULTS Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non-ERAS patients in hospital LOS, ICU LOS, complication rates, and 30-day readmissions. CONCLUSION Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E792-E799, 2021.
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Affiliation(s)
- Bhavishya S Clark
- Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Mark Swanson
- Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - William Widjaja
- Department of Anesthesiology, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Brian Cameron
- USC Keck School of Medicine, Los Angeles, California, U.S.A
| | - Valerie Yu
- Department of Anesthesiology, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Ksenia Ershova
- Department of Anesthesiology, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Franklin M Wu
- USC Keck School of Medicine, Los Angeles, California, U.S.A
| | | | - Ruben Ulloa
- USC Keck School of Medicine, Los Angeles, California, U.S.A
| | - Andrew Heng
- USC Keck School of Medicine, Los Angeles, California, U.S.A
| | | | - Niels Kokot
- Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Amit Kochhar
- Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Uttam K Sinha
- Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - M P Kim
- Department of Anesthesiology, Keck School of Medicine of USC, Los Angeles, California, U.S.A
| | - Shane Dickerson
- Department of Anesthesiology, Mount Sinai Hospital, New York, New York, U.S.A
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Value of an interactive phone application in an established enhanced recovery program. Int J Colorectal Dis 2020; 35:1045-1048. [PMID: 32166373 DOI: 10.1007/s00384-020-03563-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE An interactive mobile phone application was added to an established Enhanced Recovery After Surgery (ERAS) program to determine the impact on ERAS compliance as well as clinical outcomes. METHODS We identified patients undergoing elective colorectal surgery enrolled in our ERAS program from February 2017 to July 2018. Patients enrolled in a phone application were compared with those not enrolled in terms of age, sex, diagnosis, operative approach, bowel preparation, oral intake and solid food intake, ERAS pathway adherence, and clinical outcomes. RESULTS A total of 289 patients were included: 147 enrolled and 142 not enrolled in the phone application. The mean age of enrollees was 53.0 years, compared with 58.3 years for the non-enrollees (p = 0.003). The mean ERAS pathway medication adherence for enrollees was 82.1% versus 76.8% for those not enrolled (p = 0.005). The mean LOS and SSI rates for those enrolled versus not enrolled in the phone application was 4.4 days versus 6.4 days (p = 0.006) and 3.4% versus 11.3% (p = 0.019), respectively. There was no significant difference in readmission rates between enrollees and non-enrollees (15% versus 10.6%, p = 0.345). The mean total cost of patients enrolled was $11,560; total cost of those not enrolled was $13,946 (p = 0.024). CONCLUSIONS Use of an interactive phone application is associated with improved medication ERAS adherence along with significant reduction in length of stay and SSI rates without increasing total cost.
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