Intrinsic predictors of prolonged length of stay in a colorectal enhanced recovery pathway: a prospective cohort study and multivariate analysis

Abstract

Aim This was a prospective cohort study to determine the intrinsic non-modifiable factors influencing length of stay (LOS) in unselected consecutive patients undergoing elective colorectal surgery within an enhanced recovery pathway.Methods This study interrogated a prospective database of consecutive elective procedures from October 2006 to April 2011 at a tertiary referral academic hospital in the UK to identify independent predictors of prolonged length of stay (pLOS). pLOS was defined as longer than median length of stay (mLOS). Differences in determinants were identified in three groups of increasing operative complexity.Results In all, 872 procedures were identified and ranged from a simple ileostomy reversal to complex total pelvic exenteration. Preoperative anaemia and American Society of Anesthesiologists (ASA) Grade III+ predicted pLOS in stoma reversal surgery patients (n = 191, mLOS 4 days). In colonic and small bowel surgery (n = 444, mLOS 8 days), an open procedure, new stoma formation, planned critical care admission and ASA III+ predicted pLOS. New stoma formation and planned critical care admission predicted pLOS in patients undergoing pelvic rectal surgery (n = 237, mLOS 11 days). pLOS was associated with significantly higher morbidity across Dindo-Clavien grades and a longer time to postoperative functional recovery and discharge.Conclusions Operative complexity is associated with longer LOS even with an established enhanced recovery pathway in place. Intrinsic non-modifiable predictors of pLOS differ with operative complexity, and this should be taken into account when planning benchmarking and research across units.What does this paper add to the literature? When an enhanced recovery pathway is employed in colorectal surgery 'out of trial', the intrinsic non-modifiable patient and operative factors which are a barrier to early discharge differ according to the complexity of surgery. This heterogeneity must be appreciated for future benchmarking and research.

Assessing the environmental impact of an anastomotic leak care pathway

“…Therefore, climate impacts from energy consumption for other countries could vary due to differences in national electricity grid mixes. The AL patient pathway was also developed based on European data from the ESCP audit [ 21 ] and relevant literature [ [17] , [18] , [19] , [20] , 22 ]. In practice, the estimations for environmental impact may vary based on the specific care pathways of individual hospitals, due to the use of different surgical techniques and varying amounts of consumables.…”

“…Using the study protocol of the European Society of Coloproctology (ESCP) audit [ 25 ] and information from relevant literature [ [17] , [18] , [19] , [20] , [21] , [22] ], a care pathway, describing the typical steps involved in the diagnosis and treatment of patients experiencing AL was developed, shown in Fig. 1 .…”

“…Data from the 2017 audit by the ESCP [ 21 ] were used to determine the incidence of each Grade of AL and the length of hospital stay. The proportion of patients undergoing CT scan and the split of Grade C patients undergoing Hartmann's procedure or ileostomy were based on data from relevant literature [ [17] , [18] , [19] , [20] , 22 ].

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Effect of Anterograde Lavage via Temporary Loop Ileostoma on the Recovery of Bowel Function in Patients Receiving Stoma Closure: A Retrospective Cohort Study

“…Moreover, because of the nature of the retrospective study, part of the observed differences could be attributed to confounding by other unmeasured factors that could contribute to the length of stay after surgery. [23][24][25] Therefore, future randomized controlled clinical trials are warranted to more accurately evaluate the true effect of lavage on bowel function. In future studies, we plan to evaluate the effects of lavage times and lavage drugs on the recovery of bowel function.…”