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Original Investigation | Pacific Coast Surgical Association

Prospective Study of Colorectal Enhanced Recovery After Surgery in a Community Hospital

Cristina B. Geltzeiler, MD1; Alizah Rotramel, MD2; Charlyn Wilson, BSN2; Lisha Deng, PhD3; Mark H. Whiteford, MD4; Joseph Frankhouse, MD2
[+] Author Affiliations
1Oregon Health and Science University, Department of Surgery, Portland
2Legacy Good Samaritan Medical Center, Portland. Oregon
3Devers Eye Institute, Legacy Health, Portland. Oregon
4The Oregon Clinic, Portland
JAMA Surg. 2014;149(9):955-961. doi:10.1001/jamasurg.2014.675.
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Importance  Enhanced recovery after surgery (ERAS) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers; however, their efficacy in a community hospital setting remains unclear.

Objective  To determine if favorable results could be reproduced in a community hospital setting using our ERAS program, which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety.

Design, Setting, and Participants  Prospective study of ERAS program, a multidisciplinary effort involving anesthesia, preadmission staff, nursing, and surgery staff at a community hospital. The program was initiated in 2010 and was in full practice by 2011. We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 (prior to ERAS implementation), 2011, and 2012.

Main Outcomes and Measures  Laparoscopic approach, narcotic use, length of stay, 30-day readmission, ileus (defined as reinsertion of nasogastric tube), and intra-abdominal infection and association between colorectal cancer (CRC) diagnosis and these outcomes.

Results  From 2009 to 2012, the use of laparoscopy increased from 57.4% to 88.8% (P < .001). Length of stay decreased significantly (6.7 days vs 3.7 days, P < .001), without an increase in 30-day readmission rate (17.6% vs 12.5%, P = .49). Use of patient-controlled narcotic analgesia and duration of use decreased (63.2% of patients vs 15%, P < .001; 67.8 hours vs 47.1 hours, P = .02). Ileus rate decreased from 13.2% to 2.5% (P = .02). Intra-abdominal infection decreased from 7.4% to 2.5% (P = .24). When comparing laparoscopic cases alone, similar results were observed. Following regression analysis, there were no statistically significant differences between CRC diagnosis and LOS, 30-day readmission rates, ileus, and intra-abdominal infection (all P’s > .05). Length of stay reductions resulted in an estimated cost savings of $3202 per patient (2011) and $4803 per patient (2012).

Conclusions and Relevance  Implementation of this patient care–directed enhanced recovery program is feasible in a community hospital setting, and it is associated with decreased LOS without increased readmission or morbidity, as well as significant decreases in narcotic use and cost. Improved outcomes are independent of the laparoscopic approach and CRC diagnosis.

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