The implementation of an ERAS program in patients undergoing emergency colorectal surgery

Abstract

Objectives: The implementation of Enhanced Recovery after Surgery (ERAS) protocols has tremendously improved the patient's postoperative outcome, which also reduced the length of the hospital stay (LOS), postoperative complications, and costs. ERAS guidelines are available for various major visceral surgeries, but so far there is no ERAS protocol for hip and knee replacements. However, we have transferred the principles of Enhanced Recovery to our perioperative treatment of patients with hip and knee replacements and present the 2-year experiences. Methods: A treatment protocol for patients with hip and knee replacement, according to the principles of the ERAS Society, was implemented. The multidisciplinary team approach focused on early postoperative mobilization and motivating the patient to become active. Characterizing elements were: a preoperative patient information event, a coach system, maximum soft tissue-sparing surgical techniques with infiltrative medication to control bleeding and swelling, high security against dislocation, the avoidance of drains, pain and bladder catheters, multimodal oral pain therapy, no movement restrictions, leaving the bed on the day of surgery, activating care, activity-directed physiotherapy, motivating for self-reliant training and functional discharge criteria from hospital. Results: Between 2016 and 2017, 805 patients underwent a joint replacement (311 hip replacements (HR) and 494 knee replacements (KR)) and were treated according to this protocol. The patient satisfaction was excellent (1.4), evaluated on a 5-point Likert scale. With 111/132 points in the PPP-33 questionnaire, patients gave us a very positive feedback. Compared to patients treated before, the LOS was reduced by 7.02 days (48 %) for HR and by 5.92 days (44 %) for KR. Adverse events like fracture, infection, pneumonia, cardiovascular complication, nerve injury, pulmonary embolism, deep leg vein thrombosis and other were 5.8 % in HR and 3.2% in KR. Conclusion: The transfer of the principles of Enhanced Recovery to hip and knee replacements is possible and improves most-likely the patient's outcome. Our results encouraged us to extend the program and conduct PROMISE, a prospective multicenter project, to evaluate our improvements. PROMISE evaluates 5000 patients from 3 hospitals over 3 years and is supported financially by the Innovationsfond of the Federal Joint Committee (G-BA) with V 5.1 million.