Optimising recovery after surgery: Predictors of early discharge and hospital readmission

Carter J, Philip S, Wan KM. Optimising recovery after surgery: Predictors of early discharge and hospital readmission. Aust NZ J Obstet Gynaecol. 2016 Oct;56(5):489-495.

What is already known:

ERAS programmes have been consistently shown to reduce length of stay and post-operative complications. Minimally invasive surgery has largely become the gold standard, but laparotomies are still the mainstay in certain gynaecological cases. This large audit of 550 patients conducted over 7 years comprised all laparotomies for suspected or confirmed gynaecological malignancy in a single centre in Australia.

What this paper adds:

Since the introduction of their fast track surgery (FTS) programme they have shown an overall reduction in adverse events. Ultra-early discharges (on or before day 2) tended to be younger, have benign pathology, performance status 0 and a transverse incision. They report that factors associated with delayed discharge beyond day 3 were age, pathology, performance status, incision type, operating time, blood transfusion and COX-2 inhibitors. Unsurprisingly hospital readmissions were associated with longer operating times, lymph node sampling, longer length of stay, wound infections, febrile morbidity, returns to theatre, unplanned ICU admissions and presence of other complications. Their full ERAS protocol was not published.

This paper highlights that despite adherence to an ERAS protocol, the unmodifiable factors of baseline demographics and disease severity have a significant impact on length of stay and adverse events. ERAS protocols should therefore be encouraged in benign gynaecological laparotomies.

Katie Wimble, Guildford. @wimble_katie


Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs.

Schmidt HM, El Lakis MA, Markar SR, Hubka M, Low DE. Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs. The Annals of Thoracic Surgery. 2016;102(3):931-9

What is already known:

Oesophagectomy is high risk and complex surgery, and has been associated with significant impact in terms of morbidity and mortality in the past. The introduction of enhanced recovery programmes has dramatically improved outcomes in this high risk group, including post-op complications, first-day mobilisation, and length of stay in both critical care and hospital.

What this paper adds:

This prospective cohort study from Virgina Mason MC, Seattle, is based on previously published outcome data of patients in their institution that identified a subgroup of patients that exceeded their day-7 discharge goal. The study attempts to identify these patients capable of achieving ‘accelerated recovery’ (AR), as well as assessing outcomes in this group compared to those in ‘targeted recovery’ (TR) and ‘delayed recovery’ (DR) groups (defined as those with discharge days of 5 or 6 (AR), 7 or 8 (TR) and 9 or more (DR).

They found that AR patients made up 46% of their cohort, and were younger, more likely to have neoadjuvant chemotherapy, shorter operations, and less blood loss. All groups were comparable regarding comorbidities, cancer stage, and treatment approach, while DR patients were more likely to have complications. AR patients were more likely to be discharged home, with comparable 30-day readmission rates between groups. Overall costs (mean and readmission) were lower in the AR group.

It is exciting to see evidence that (already impressive) lengths of stay may be further improved in a significant subset of patients undergoing oesophagectomy, with associated decreased treatment costs. The authors conclude that ERAS programs should be designed to accommodate patients appropriate for AR. The question may be, given that a number of the variables associated with ‘accelerated recovery’ are intraoperative (though length of surgery and blood loss may be predicted to some extent), how these findings might best be translating to service provision and planned stays in hospital in this group.

Tom Barnes, East Surrey Hospital @TomBarn75870085


ERAS in Emergency Surgery

Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients.

Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients (2016) Wisely JC, Barclay KL. ANZ J Surg. 2016 Nov;86(11):883-888.

 

What is already known:
The majority of ERAS research has been focussed, quite rightly, on improving outcomes in elective surgery. However emergency surgery has high rates of morbidity and mortality and a lot more interest more recently has been directed at how ERAS elements could affect outcomes in this high-risk group.

What this paper adds:
In this retrospective review the authors compared 2 groups of patients undergoing emergency major abdominal surgery before and after an ERAS program had been introduced for their elective colorectal surgery patients. A total of 370 patients were included. The two groups were similar in age, co-morbidities and ASA scores. The post-ERAS group underwent significantly more left sided procedures. Hospital length of stay was similar in both groups [median 8 days], but the post-ERAS group received significantly less intravenous fluid, both intra-operatively and post-operatively. Significantly fewer patients in the post-ERAS group had a urinary catheter or PCA for more than 2 days. There were also fewer abdominal drains used in the post-ERAS group. This resulted in significantly reduced major post-operative complications in particular chest infections. Suggesting that ERAS elements could have a place in both elective and emergency surgery.

Chris Jones, Guildford.


ERAS in Emergency Surgery

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Quiney N, Aggarwal G, Scott M, Dickinson M (2016)Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes? World J Surg. 2016 Jun;40(6):1283-7 

 

What is already known:

Emergency general surgical operations carry a very high mortality rate, and it is estimated that they are at least ten times higher than many similar elective procedures. Roughly 55,000 emergency operations are carried out each year and it is estimated that will result in 8,000 deaths.

What this paper adds:

In this interesting paper the authors examine the evidence behind the ERAS elements and how they can be applied to emergency surgery. In particular they examine the delays can affect outcomes, in particular delays in diagnosis, resuscitation, antibiotics and definitive care. They also examine how inadequate postoperative care can affect outcomes.

Chris Jones, Guildford.


ERAS for Head and Neck Surgery

Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference?

Bater M, King W, Teare J, D’Souza J.Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference? Br J Oral Maxillofac Surg. 2017 Dec;55(10):1024-1029

What is already known:
Head and neck surgery is one of the newest specialities to embrace ERAS, but at present there are very few studies published in this area. Despite this the ERAS society have published consensus guidelines available here, based mostly on extrapolation from other surgical specialities.

What this paper adds:
This is one of the first papers to specifically describe an ERAS programme for head and neck surgery and compare it to a traditional care model. They compared 100 consecutive patients undergoing their ERAS programme and compared with 40 from a historical control group. Overall they demonstrated a 4 day reduction in length of stay (10 vs 14 days, p=0.003), with no change in morbidity or readmission rates. Suggesting that ERAS is safe and effective for this group of patients.

Chris Jones, Guildford.


ERAS for Neurosurgery

Hagan KB, Bhavsar S, Raza SM, Arnold B, Arunkumar R, Dang A, Gottumukkala V, Popat K, Pratt G, Rahlfs T, Cata JP. Enhanced recovery after surgery for oncological craniotomies. J Clin Neurosci. 2016 Feb;24:10-6.

What is already known:

The principles of ERAS have been applied to many new specialities over the recent years. One of the newest specialities is Neurosurgery. This group from the US explored how ERAS principles of ERAS could be applied to oncological craniotomies.

What this paper adds:

The authors should be congratulated for this interesting systematic review of the literature on ERAS for neurosurgery. They reviewed how each element could be applied to neurosurgery, including specific concepts such as scalp blocks and minimally invasive craniotomies. And whilst there is insufficient evidence at present for recommending a specific protocol it does support pursuing future research in this area.

Chris Jones, Guildford.