Ann Surg. 2020 Nov 18. doi: 10.1097/SLA.0000000000004642. Online ahead of print.
OBJECTIVE: To determine if implementation of a simplified enhanced recovery protocol (ERP) across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on LOS, 30-day readmission, discharge disposition, and complications.
SUMMARY BACKGROUND DATA: Enhanced Recovery After Surgery (ERAS) and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multi-modal and multi-disciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes.
METHODS: A simplified ERP with seven key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in five academic and community hospitals within a single health system. Patients who underwent non-emergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014-2017 after ERP implementation or in the 12 months preceding ERP implementation (control population).
RESULTS: 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. 3367 ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% vs Control 0.6% (p = 0.002); 1-year: ERP 3.9% vs. Control 5.1% (p < 0.0001); 2-year: ERP 6.2% vs Control 9.0% (p < 0.0001). LOS was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; Control: 4.8 ± 5.0 days, p < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; Control: 14.8%, p < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (p < 0.02).
CONCLUSIONS: A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.