Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System

Abstract

IMPORTANCE Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. OBJECTIVE To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. DESIGN, SETTING, AND PARTICIPANTS A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. EXPOSURES A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. MAIN OUTCOMES AND MEASURES The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. RESULTS The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46–0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45–0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03–0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06–1.44; P = .007). CONCLUSIONS AND RELEVANCE Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.

Impact of Enhanced Recovery after Surgery with Preoperative Whey Protein-Infused Carbohydrate Loading and Postoperative Early Oral Feeding among Surgical Gynecologic Cancer Patients: An Open-Labelled Randomized Controlled Trial

“…A study has demonstrated that prolonged fasting diminished the gastrointestinal peristalsis and caused irregular contraction waves instead of frequent eating peristalsis and regular contraction waves [31]. Therefore, postoperative early oral feeding not only accelerates intestinal function recovery, but also provides nutrients needed during recovery to maintain the intestinal mucosal barrier function and further accelerate organ recovery [8,32].…”

“…Thus, adding whey protein in preoperative CHO loading could reduce further the postoperative insulin resistance that otherwise leads to an increase in catabolism of skeletal muscle and results in body fat and protein loss [9]. Early oral feeding postoperatively provided early energy protein supply and subsequently reduced the risk of further catabolism due to a negative energy protein balance [32].…”

Enhanced recovery after surgery (ERAS) protocol in Oblique lumbar interbody fusion(OLIF): a case-controlled study

“…Early mobilization that likely contribute to shorter recovery without increased readmission and complications (Table 4). Other institutions have shown LOS in ERAS spine surgery was decreased by 1.5 to 2 days with no change in complication or readmission rate (15,16). So n (17) described an ERAS protocol for lumbar surgery.…”

Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery

“…Of 481 manuscripts screened, 37 individual ERPs were published in 37 studies including 41 centres as shown in Figure S1. There were 18 cohort studies, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] seven historically controlled studies, [33][34][35][36][37][38][39] five guidelines, [40][41][42][43][44] four randomized controlled trials (RCTs), [45][46][47][48] one RCT protocol, 49 one case series 50 and one narrative review. 51 Institutions in Europe were the most frequent study locations (25 of 37, 67.6%), followed by North America (10 of 37, 27%), Asia (4 of 37, 10.8%) and Oceania (2 of 37, 5.4%), respectively.…”