Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis

Abstract

ObjectivesTo assess the evidence on the impact of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings in the UK.DesignRapid evidence synthesis. Eight databases were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines, websites and reference lists of retrieved articles were scanned to identify additional studies. Systematic reviews, RCTs not included in the systematic reviews, economic evaluations and UK NHS cost analysis, implementation case studies and surveys of patient experience in a UK setting were eligible for inclusion.Primary and secondary outcome measuresWe assessed the impact of enhanced recovery programmes on health or cost-related outcomes, and assessed implementation case studies and patient experience in UK settings. Studies were quality assessed where appropriate using the Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effects critical appraisal process.Results17 systematic reviews and 12 additional RCTs were included. Ten relevant economic evaluations were included. No cost analysis studies were identified. Most of the evidence focused on colorectal surgery. 14 innovation case studies and 15 implementation case studies undertaken in National Health Service settings described factors critical to the success of an enhanced recovery programme.Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5–3.5 days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reductions in length of stay reflecting the limited evidence identified. Findings relating to other outcomes were hampered by a lack of robust evidence and poor reporting.ConclusionsThere is consistent, albeit limited, evidence that enhanced recovery programmes can reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes in UK settings can realise savings will depend on length of stay achieved under their existing care pathway.

Implementing enhanced recovery pathways: a literature review with realist synthesis

“…ERPs address all aspects of patient care throughout their surgery, from preoperative through to discharge and recovery. When successfully implemented, ERPs have been shown to consistently reduce length of hospital stay, and reduce patient readmission rates [2]. As well as these directly measurable benefits, ERPs have a number of secondary benefits as they empower patients and carers to become involved in the pathway of care.…”

Enhanced recovery after surgery: the future of elective arthroplasty?

“…Therefore, a standard enhanced recovery programme acts as a blueprint on which to map and adapt to local needs. (2,11) Uptake has been slow, often due to organisational inefficiency and multidisciplinary resistance to change. (3,4) The Components of ERAS Enhanced Recovery is most effective as a pre-emptive protocol, optimising the entire surgical pathway ( Figure 1).…”

“…There was concern that premature discharge could increase complication rates, resulting in a rise in readmission of up to 13% and reduced patient satisfaction. (2,10) Yet, enhanced recovery has been shown to result in no change in orthopaedic readmission rates compared to patients on traditional surgical pathways (ERAS: 4.8%; traditional pathways: 4.7%). (10) Furthermore, enhanced recovery has been shown to reduce length of stay by up to 3.5 days in colorectal patients, whilst causing no significant difference in mortality.…”

“…The approach standardises the entire surgical pathway -informed by advancing knowledge of the perioperative stress response -in order to minimise adverse events and hence, safely reduce length of hospital stay. (1,2) These reductions in average length of stay are highly cost-effective, due to a reduction in post-operative delays and the need for additional interventions. (2) ERAS was pioneered in the late 1990s by Kehlet in colorectal surgery as a response to the inadequacy of "unimodal responses to multimodal perioperative morbidity".…”

Are guidelines for 'PONV alone' sufficient!

“…But if we step forward for 'syndrome of PONV' rather than 'PONV alone', probably, incidence of PONV probably would see a reducing trend. This will be in corollary to Enhanced Recovery After Surgery where in rapid recovery is initiated with multipronged approach, starting from preoperative period and continued in postoperative management [6,7] . Similarly " Syndrome of PONV' probably requires its initiation from preoperative period by minimizing fasting status, reducing anxiety, preventive analgesia to intraoperative multimodal analgesia technique and appropriate use of pharmacotherapy for PONV to be continued in postoperative period.…”