Length of Stay: An Inappropriate Readout of the Success of Enhanced Recovery Programs

Abstract

Background Enhanced recovery after surgery (ERAS) programs are designed to reduce hospital length of stay by shortening the postoperative recovery period. The intended effect of an accelerated recovery on the length of stay may be frustrated by a delayed discharge. This study was designed to assess the influence of an ERAS program on the proportion, appropriateness, and extent of delay in discharge. Results Ninety percent of the pre-ERAS patients and 87% of the ERAS patients were not discharged on the day that discharge criteria were fulfilled. The additional stay of 59% of the pre-ERAS patients and 69% of the ERAS patients was inappropriate. Wound care (15% in the pre-ERAS and 3% of the ERAS group) and observation of any symptoms pointing to an anastomotic leakage (10% in both groups) were the most important reasons for a medical appropriate delay of discharge. The extent of delay in discharge decreased significantly from a median of two days in the pre-ERAS group to a median of 1 day in the ERAS group (p = 0.004).Conclusions Reductions in length of stay up to a median of 2 days after start of an enhanced recovery program may relate to changes in organization of care and not to a shorter recovery period. Recovery statistics should replace or at least be added to the length of stay as outcome of enhanced recovery programs.

Prospective Evaluation of Discharge Trends after Colorectal Surgery within an Enhanced Recovery after Surgery Pathway

“…This is a strong aspect of our prospective study, in which for every patient and for every day, all 5 discharge criteria were documented. Discharge criteria were also documented in the study by Maessen et al [13] about discharge trends in patients in a colorectal enhanced recovery pathway. In their cohort, 87% of patients were not discharged on the day that all discharge criteria were fulfilled.…”

“…On the one hand, doctor's being reason for the delay in discharge should not occur in the framework of safe discharge criteria; on the other hand, restricted resources (beds, costs), especially within an ERAS pathway, should not be the reason for delayed discharge. Better surgeon education and prospective audit institutional outcomes are probably the most effective and enduring ways of convincing the surgical staff to follow the perioperative care pathway including standardized discharge criteria [13] . The 'early birds' merit particular attention; patients fulfilling all discharge criteria within 24-48 h of the operation were not encouraged to go home during the study period.…”

“…Furthermore, social and cultural country-based particularities make extrapolation of the present findings to other health care systems difficult. Despite the limitations, this study provides a prospective documentation of all discharge criteria and reasons for delayed discharge within a fully implemented ERAS pathway; this information is an important complement to the increased length of stay, which is seen as a problematic outcome measure [13,21] . It remains speculative whether readmission rates would increase if a higher percentage of patients would leave hospital on the day of their medical recovery, as it was observed in the initial works by Andersen et al [14] .…”

Benchmarking of aggregated length of stay after open and laparoscopic surgery for cancers of the digestive system

“…LOS is a widely reported outcome measure in the era of laparoscopy, but subject to the criticism that it reflects not only functional recovery but also organizational structure and logistics3. In addition, short LOS has been associated with increased rates of readmission14.…”

“…Functional recovery after surgery is important for patients and carers1 2, although it may be difficult to assess objectively. Postoperative length of hospital stay (LOS) is a readily available surrogate endpoint, often assumed to be a measure of recovery, although open to criticism3. The focus on financial savings with the emergence of laparoscopic approaches to gastrointestinal surgery has nevertheless consolidated a focus on LOS as a meaningful outcome, especially when it is shorter than anticipated4 5.…”