Enhanced Recovery after Elective Colorectal Surgery - Reasons for Non-Compliance with the Protocol

Roulin, Didier; Muradbegovic, Mirza; Addor, Valérie; Blanc, Catherine; Demartines, Nicolas; Hübner, Martin

doi:10.1159/000450685

Cited by 57 publications

(34 citation statements)

References 13 publications

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“…Roulin et al 24 studied the reason for non-compliance in colorectal surgery, with most deviations occurring during the post-operative period, and mostly decided by doctors. In their study, deviations were mainly justified by medical necessity rather than real non-compliance.…”

Section: Discussionmentioning

confidence: 99%

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

Pache

Jurt

Grass

et al. 2019

International Journal of Gynecological Cancer

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IntroductionEnhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.MethodsRetrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.ResultsA total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I–V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).ConclusionsCompliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

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Section: Discussionmentioning

confidence: 99%

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

Pache

Jurt

Grass

et al. 2019

International Journal of Gynecological Cancer

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“…Consistent with our findings, recent data suggest noncompliance with ERAS process measures is most commonly observed in the postoperative period. 1,25 The reasons for noncompliance are complex and have been mainly attributed to medical decision-making in response to changes in patient condition. 25 However, up to 25% of postoperative deviations from ERAS interventions are attributed to systems, nursing, and patient preferences for care.…”

Section: Fig 3 Leftmentioning

confidence: 99%

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Soffin

Wetmore

Beckman

et al. 2019

Neurosurgical Focus

111

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OBJECTIVEEnhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).METHODSThe authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.RESULTSThere was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).CONCLUSIONSOFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.

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“…The available literature suggests that overall compliance rates range from around 60% to over 90% . The main reasons for noncompliance cited in the literature were development of postoperative complications or logistic and communication issues with protocol implementation …”

Section: Discussionmentioning

confidence: 99%

“…[18][19][20] The main reasons for noncompliance cited in the literature were development of postoperative complications or logistic and communication issues with protocol implementation. 21,22 However, once stable compliance is achieved, it is unclear if an additional decrease in postoperative complications and length of stay is achievable. Length of stay is a complex result of not only patient readiness to be discharged but also hospital resources involved in discharge planning and the discharge process itself.…”

Section: Discussionmentioning

confidence: 99%

Postoperative complications are main reason for noncompliance with enhanced recovery after surgery program in patients undergoing hepatectomy and pancreatectomy

2019

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Background and Aim Enhanced recovery after surgery (ERAS) protocols are reported to improve postoperative outcomes in patients undergoing a routine protocol and postoperative outcomes in patients undergoing hepatic and pancreatic resections at our institution. Methods A total of 99 consecutive patients at a single institution managed with a similar ERAS protocol were divided into the “early” (50 patients) and “late” (49 patients) cohorts. Both cohorts were statistically identical in demographics and range of surgical procedures performed. Postoperative complications, readmission, reoperation rates, and length of stay were analyzed. Categorical variables were statistically compared using Fisher's exact test and continuous variables using t‐test and Mann–Whitney U‐test when appropriate. Results There were 32 hepatectomies/18 pancreatectomies in the “early” cohort and 22 hepatectomies/29 pancreatectomies in the “late” cohort. The overall complication rate was 38.8%, with a 30‐day readmission rate and reoperation rate of 16.1 and 5%, respectively. There was one mortality (1%). Group‐specific overall complication rate (40 vs 38.7%, P = 0.8), readmission rate (20 vs 12.2%, P = 0.4), reoperation rate (6 vs 4%, P = 1.0), and mortality (2 vs 0%, P = 1.0) were not statistically significant between both groups. Conclusions Despite similar rates of adherence to the established ERAS 24 protocol, there was no improvement in median length of stay (7 days) between the “early” and “late” groups. The only reason for noncompliance with the ERAS protocol was development of surgery‐related complications.

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Enhanced Recovery after Elective Colorectal Surgery - Reasons for Non-Compliance with the Protocol

Cited by 57 publications

References 13 publications

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Postoperative complications are main reason for noncompliance with enhanced recovery after surgery program in patients undergoing hepatectomy and pancreatectomy

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