The Impact of Anesthesia-Influenced Process Measure Compliance on Length of Stay: Results from an Enhanced Recovery after Surgery for Colorectal Surgery Cohort
Hypothesis: “Increased compliance to the anesthesia process measures of an institution’s ERAS protocol will lead to a decrease in hospital LOS for patients undergoing colorectal surgery.”
Methods: 1140 adults who underwent colorectal surgery from 2013-2015 at Johns Hopkins University were included. Exclusion criteria – emergent surgery, outpatient procedures, preoperative hospital admission. Prior to ERAS, patients were followed by the acute pain team only if they had a history of chronic pain or received a continuous regional anesthesia technique. The patients in the ERAS cohort had a dedicated anesthesia team for ERAS colorectal cases, were followed by an acute pain service postoperatively independent of regional technique usage and subject to ~30 interventions related to the Johns Hopkins ERAS protocol. The process measures of interest included carbohydrate intake ~4 hours preoperatively, preoperative pain medications, use of regional anesthesia techniques, TIVA, PONV prophylaxis, and fluid and analgesic medication limitations postoperatively. The primary outcome was postoperative LOS.
Results: There was an increased process-measure adherence rate in the ERAS cohort. Patients who received a greater number of process-measures had a shorter index LOS (Median 5 days vs 8 days in patients who received >8 process measures vs. 0 process measures). ERAS-era patients had a shorter LOS compared to pre-ERAS patients when they received the same number of process measures. PONV prophylaxis, 48-hour postoperative NSAID use, and adherence to an opioid protocol were process measures that were independently associated with shorter LOS.
Strengths: Study evaluated how actual compliance with process measures affected results
Weaknesses: Limited external validity (lack of pain service at smaller hospitals); LOS may not be the most important outcome for patients and is only associated with recovery; anesthesiologists provide a limited portion of care and many other factors may positively or negatively impact recovery
Key Point: Increasing compliance with ERAS process measures was associated with reduced length of stay in patients undergoing colorectal surgery.