Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis

Grasu, Roxana; Cata, Juan P.; Dang, Anh; Tatsui, Claúdio E.; Rhines, Laurence D.; Hagan, Katherine; Bhavsar, Shreyas; Raty, Sally; Arunkumar, Radha; Potylchansky, Yury; Lipski, Ian; Arnold, Benjamin; McHugh, Thomas M.; Bird, Justin E.; Rodríguez-Restrepo, Andrea; Hernandez, Mike; Popat, Keyuri

doi:10.3171/2018.4.spine171317

Cited by 80 publications

(108 citation statements)

References 42 publications

(58 reference statements)

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“…To date, there have been few peer-reviewed publications regarding spine ERAS programs that have actually been implemented. 1,2,8,[11][12][13][14] Given that spinal fusion surgeries can be painful, morbid, and costly, the implementation of a spine ERAS program would be a major advancement in the field. In an effort to develop evidence-driven protocols for ERAS, we embarked on a quality improvement project to address the challenges spinal surgeons face in the postoperative period.…”

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confidence: 99%

Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery

Brusko¹,

Kolcun²,

Heger³

et al. 2019

Neurosurgical Focus

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OBJECTIVELumbar fusion is typically associated with high degrees of pain and immobility. The implementation of an enhanced recovery after surgery (ERAS) approach has been successful in speeding the recovery after other surgical procedures. In this paper, the authors examined the results of early implementation of ERAS for lumbar fusion.METHODSBeginning in March 2018 at the authors’ institution, all patients undergoing posterior, 1- to 3-level lumbar fusion surgery by any of 3 spine surgeons received an intraoperative injection of liposomal bupivacaine, immediate single postoperative infusion of 1-g intravenous acetaminophen, and daily postoperative visits from the authors’ multidisciplinary ERAS care team. Non–English- or non–Spanish-speaking patients and those undergoing nonelective or staged procedures were excluded. Reviews of medical records were conducted for the ERAS cohort of 57 patients and a comparison group of 40 patients who underwent the same procedures during the 6 months before implementation.RESULTSGroups did not differ significantly with regard to sex, age, or BMI (all p > 0.05). Length of stay was significantly shorter in the ERAS cohort than in the control cohort (2.9 days vs 3.8 days; p = 0.01). Patients in the ERAS group consumed significantly less oxycodone-acetaminophen than the controls on postoperative day (POD) 0 (408.0 mg vs 1094.7 mg; p = 0.0004), POD 1 (1320.0 mg vs 1708.4 mg; p = 0.04), and POD 3 (1500.1 mg vs 2105.4 mg; p = 0.03). Postoperative pain scores recorded by the physical therapy and occupational therapy teams and nursing staff each day were lower in the ERAS cohort than in controls, with POD 1 achieving significance (4.2 vs 6.0; p = 0.006). The total amount of meperidine (8.8 mg vs 44.7 mg; p = 0.003) consumed was also significantly decreased in the ERAS group, as was ondansetron (2.8 mg vs 6.0 mg; p = 0.02). Distance ambulated on each POD was farther in the ERAS cohort, with ambulation on POD 1 (109.4 ft vs 41.4 ft; p = 0.002) achieving significance.CONCLUSIONSIn this very initial implementation of the first phase of an ERAS program for short-segment lumbar fusion, the authors were able to demonstrate substantial positive effects on the early recovery process. Importantly, these effects were not surgeon-specific and could be generalized across surgeons with disparate technical predilections. The authors plan additional iterations to their ERAS protocols for continued quality improvements.

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confidence: 99%

Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery

Brusko¹,

Kolcun²,

Heger³

et al. 2019

Neurosurgical Focus

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“…Interest in the delivery of enhanced recovery pathways within the context of spinal surgery has grown substantially in the last decade. Many of the studies illustrating the institutional implementation of some components of ERSS have shown a significant reduction in the length of stay and consequent improved financial outcome [44,45]. Effective interventions not only provide for better outcomes for individual patients, but for more efficient use of resources in healthcare and avoidance of ineffective high-cost interventions [46].…”

Section: Discussionmentioning

confidence: 99%

Proposed pathway for patients undergoing enhanced recovery after spinal surgery: protocol for a systematic review

et al. 2020

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Background: The best evidence-enhanced recovery care pathway is yet to be defined for patients undergoing spinal surgery. Minimally invasive surgery, multimodal analgesia, early mobilization, and early postoperative nutrition have been considered as critical components of enhanced recovery in spinal surgery (ERSS). The objective of this study will be to synthesize the evidence underpinning individual components of a proposed multidisciplinary enhanced recovery pathway for patients undergoing spinal surgery. Methods: This is the study protocol for a systematic review of complex interventions. Our team identified 22 individual care components of a proposed pathway based on clinical practice guidelines and published reviews. We will include systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled trials, and observational studies in adults or pediatric patients evaluating any one of the pre-determined care components. Our primary outcomes will be all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). We will search the following databases (1990 onwards) MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The risk of bias for individual studies will be appraised using appropriate tools. A narrative synthesis will be provided with the information presented in the text and tables to summarize and explain the characteristics and findings of the included studies. Due to clinical and methodological heterogeneity, we do not anticipate to conduct meta-analyses. Confidence in cumulative evidence for each component of care will be classified according to the GRADE system.Discussion: This systematic review will identify, evaluate, and integrate the evidence underpinning individual components of a pathway for patients undergoing spinal surgery. The formation of an evidence-based pathway will allow for the standardization of clinical care delivery within the context of enhanced recovery in spinal surgery. Systematic review registration: PROSPERO CRD42019135289

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“…The discordance in ndings is likely due to differences in the patient population and the program goals. Grasu et al (19) noted that patients with advanced metastatic disease or terminal illness may have prolonged hospitalizations for cancer care unrelated to surgical procedures for which they were admitted. From a nancial perspective, in this study, the ERAS Program reduced direct costs per patient.…”

Section: Discussionmentioning

confidence: 99%

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

Li¹,

Shao²,

Jiang³

2020

Preprint

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Abstract Background Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it have not been widely utilized in spinal surgery. This study is to evaluate the implementation of an ERAS pathway for patients undergoing oblique lumbar interbody fusion (OLIF) surgery.Methods This was a retrospective cohort study of patient who underwent OLIF in 2018 prior to ERAS (“pre-ERAS” ,n=23) and in 2019 after ERAS was instituted (“ERAS”, n=24). Major outcomes were collected included demographics, length of hospital stay, financial cost, postoperative complications, off-bed time and perioperative factors. Visual Analogue Scale (VAS) was used to evaluate the pain. The ERAS pathway and compliance with pathway elements were also recorded.Results After ERAS implementation, we found no significant differences in the baseline characteristics between the two groups. In our study, the mean stay in the hospital was significantly lower (p= 0.033) in the ERAS group (15.3±3.9 days) compared to the standard pathway group (13.0±3.1 days). In comparison to the standard group, we also found a variation between the financial costs of surgery and hospitalization [(16446.5±4353.3)vs(14237.7±2784.9) USD, P < 0.05]. The ERAS group manifested a lower blood loss compared with the pre-ERAS group with statistical significance [(68.3±57.1)vs(119.3±104.8) ml, P < 0.05]. There was no significant difference in operative time, complications, and 30-d readmission rates ( P > 0.05 ). Pain scores between the two groups showed a significant difference during the 3th hour and 6th hour (P < 0.05).Conclusion Institution of an ERAS protocol appears to accelerate functional recovery and reduce length of stay, financial costs and decreased pain.

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Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis

Cited by 80 publications

References 42 publications

Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery

Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery

Proposed pathway for patients undergoing enhanced recovery after spinal surgery: protocol for a systematic review

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

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