Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals
Aarts MA, Rotstein OD, Pearsall EA, Victor JC, Okrainec A, McKenzie M, McCluskey SA, Conn LG, McLeod RS; iERAS group. Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals. Ann Surg. 2018 Jun;267(6):992-997.
[And accompanying editorial: Ann Surg. 2018 Jun;267(6):998-999. ERAS Implementation-Time To Move Forward. Kehlet H.]
What is already known:
A great deal of work has already been done demonstrating how improved compliance with ERAS elements can improve both short-term and long-term outcomes. This is often in a ‘dose-dependent’ fashion with increasing compliance of all elements [e.g. Gustafsson – Arch Surg 2011, Pecorelli – Surg Endos 2016, ERAS Compliance Group – Annals of Surg 2015].
What this paper adds:
This group was made up of clinicians from 15 academic hospitals in Ontario, and setup their own version of an ERAS pathway. The original project demonstrated a small 1 day improvement in length of stay with no change in readmissions. This paper aimed to determine which components of their ERAS programme had the greatest effect on recovery in colorectal surgery. This is a large study of almost 3000 patients conducted over a two-and-a-half-year period. Their self-designed programme only used 12 elements and were divided into pre, intra and post-operative pathways, with each having 4 elements. And therefore missed out on intra-operative elements such as temperature control, antibiotics etc, but also important pre-operative ones such as pre-optimisation inc prehabilitation. Patients were deemed compliant if they achieved at least 75% compliance (3 out of 4 of the elements in each pathway).
Only 20.1% of all patients were compliant with all 3 pathways. Whilst 74.7% were compliant with the pre-operative elements only 40.3% were compliant with the post-operative elements. There were some excellent gains from baseline for example rates of preoperative counselling doubled from 41.4% to 82.2% and use of CHO went from 0% to 82%, after introduction of the programme. However, some elements were still poorly adhered to, e.g. use of goal-directed fluid therapy at only 26.7%. The authors suggest this is purely down to the fact that there was no additional funding available to the sites. But other more simple interventions were also not well adhered to, e.g. use of chewing gum post-operatively was only at 52.5%.
Two potentially modifiable factors were found to significantly impact patient outcomes: laparoscopic surgery and preoperative haemoglobin levels. (A number of RCTs are in progress looking at how preoperative intravenous iron therapy can influence outcomes.) Overall higher compliance improved outcomes in both the laparoscopic and open group but the impact was significantly higher in the open group.
The authors should be congratulated on size of the study and the multi-centred nature and the fact that it was prospective. But there were a number of limitations including only recording data from patients who consented, which could be a biased towards those patients who were naturally more motivated to follow the programme. The other issue is that as an observational study causation cannot be proved but only inferred. What are the real reasons for failure in following the post-operative elements? Are there proper medical / surgical reasons or simply organisational or logistical reasons? This is where our focus needs to be in the future and how to improve the compliance of all elements.
Chris Jones, Guildford.