It’s difficult to herd cats. It’s also difficult to get physicians in general, and anesthesiologists in particular, to manage a group of patients in the same fashion. However, a program for managing patients based on evidence can improve quality and also decrease cost.
Dr. Tong J Gan, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, and colleagues used just such a program for managing patients undergoing colorectal surgery. The results of their study are published in this month’s edition of Anesthesia & Analgesia in the article “Reduced Length of Hospital Stay in Colorectal Surgery after Implementation of an Enhanced Recovery Protocol.”
Patients undergoing open or laparoscopic colorectal surgery within the Enhanced Recovery After Surgery (ERAS) protocol (142 patients) were compared with a previous group of patients before introduction of the ERAS protocol (99 patients). Standardized care within the ERAS protocol consists of three parts: preoperative, intraoperative, and postoperative care.
The preoperative component began when patients visited the surgical clinic. Elective surgery patients who could benefit from participation in the study were identified and given an oral description of the pathway and expectations of the study. This oral instructions were reinforced with a written copy of the study plan and expectations. They were also screened for risk factors such as malnutrition, nicotine abuse, and diabetes. During the preoperative assessment patients were given a routine screening with specific attention paid to known risk factors. They received smoking cessation information, nutritional supplements if serum albumin was <3.5, chlorhexidine sponges for 2 preoperative showers, and a carbohydrate drink for the morning of surgery, which they were told to drink 3 hours preoperatively. They also received written instructions.
Intraoperative care consisted of epidural anesthesia. Intravenous opioids were avoided during surgery. Patients received thromboprophylaxis with heparin after the epidural catheter was placed and antibiotic prophylaxis before surgical incision. Sequential compression devices were applied before anesthesia induction, and patients received intraoperative goal-directed intravenous fluid therapy. The orogastric tube and Foley catheter were removed before leaving the OR, with the exception of pelvic operations, in which case the Foley catheter stayed in place after surgery.
The postoperative care included starting oral intake and walking the night of surgery. The head of the bed remained at 30°at all times. The epidural was continued for up to 72 hours after surgery.
Use of the ERAS protocol decreased the length of hospital stay (7 vs. 5 days). It also decreased the incidence of urinary tract infections (24% vs. 13%) and readmission rates (20.2% vs. 9.8%).
The results are impressive. Dr. Gan and his group should be congratulated for working together as a team. Could these results be questioned because the study was not a blinded randomized controlled trial? Perhaps, but a blinded study of ERAS would be nearly impossible to design.
It will be interesting to see if this idea can catch on: care will be improved and costs will be reduced. Indeed, as Drs. Maxime Cannesson and Zeev Kain, Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, California, note in their accompanying editorial titled “Enhanced Recovery After Surgery Versus Perioperative Surgical Home: Is It All In The Name?,”“the future of anesthesiology and perioperative medicine must not only rely on the development of new pharmacological and diagnostic modalities and treatments but also in better and more consistent implementation of evidence-based best practices.”