Program for advanced recovery after surgery associated with shorter stays, better outcomes

The program for patients undergoing colorectal resection or hip fracture repair focused on optimizing nutrition, mobility, pain management, and patient engagement.

A program focused on enhanced recovery after surgery (ERAS) was associated with decreased length of stay and postoperative complication rates, according to a new study.

Researchers conducted a pre-post difference-in-differences study before and after implementation of an ERAS program at 20 medical centers in the Kaiser Permanente Northern California health care system. Target populations of patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair were compared with contemporaneous surgical comparator groups undergoing elective gastrointestinal surgery and emergency orthopedic surgery. ERAS implementation started in February and March 2014 and was completed by the end of 2014. The main outcome measure was hospital length of stay, with hospital mortality, home discharge, 30-day readmission rates, and complication rates as secondary outcome measures.

The ERAS program focused on optimizing nutrition, mobility, pain management, and patient engagement. For nutrition, prolonged postsurgical fasting was reduced by providing patients with a high-carbohydrate beverage two to four hours before surgery, solids eight to 12 hours before surgery, or both; after surgery, nutrition was provided within 12 hours. To improve mobility, patients who were ambulatory were encouraged to start walking within 12 hours of surgery completion and to walk at least 21 feet in the first three days after surgery. Opioid-sparing multimodal analgesia was used for pain management, including IV acetaminophen, NSAIDs, and perioperative IV lidocaine for colorectal surgery or peripheral nerve blocks for hip fracture repair. For patient engagement, patients received a calendar with infographics to detail what they could expect from the night before surgery through discharge; patient education was also addressed through an informational video series. Study results were published online May 10 by JAMA Surgery.

Overall, 3,768 patients having elective colorectal resection and 5,002 patients having emergency hip repair were included in the study. Mean age was 62.7 years and 79.5 years, respectively, and 48.1% and 31.7% of patients were men. The comparator surgical patients involved 5,556 patients having elective gastrointestinal surgery and 1,523 patients having emergency orthopedic surgery. Significant changes in most process metrics were seen in the ERAS target populations, and while process metrics changes were also seen in the comparator groups between the pre- and postintervention phases, these differences were more modest.

ERAS implementation was associated with increased rates of early ambulation in patients undergoing colorectal resection and hip fracture repair (rate ratios, 1.99 [95% CI, 1.80 to 2.21] and 4.44 [95% CI, 3.19 to 6.21], respectively; P<0.001 for both comparisons), as well as with decreased opioid use (rate ratios, 0.79 [95% CI, 0.71 to 0.89] and 0.73 [95% CI, 0.63 to 0.85]; P<0.001 for both comparisons). Lower hospital mortality rates (rate ratio, 0.17; 95% CI, 0.03 to 0.86; P=0.03) and lower rates of major complications (rate ratio, 0.28; 95% CI, 0.12 to 0.68; P=0.005) were associated with ERAS implementation in patients undergoing colorectal resection. In patients undergoing hip fracture repair, ERAS implementation was associated with higher rates of home discharge (rate ratio, 1.24; 95% CI, 1.06 to 1.44; P=0.007). ERAS implementation was not associated with differences in the rate of 30-day readmissions in patients receiving either type of surgery.

The study authors noted that their evaluation was not a randomized controlled trial, that the comparator groups and target populations had different surgical procedures, and that they looked only at short-term outcomes, among other limitations. However, they concluded that the ERAS program tested in their study resulted in significant changes in process-of-care metrics and was associated with significant absolute and relative improvements in both length of stay and rates of surgical complications.

The authors of an accompanying invited commentary praised the study's design and implementation and said its findings are relevant to clinical practice, research, and policy and make an important contribution to population health. “The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients,” the commentary authors wrote.