Authors: Chunyuan Qiu, M.D., M.Sc. et al
Introduction: Enhanced recovery after surgery (ERAS) has enjoyed tremendous success in changing surgical outcomes .1 However, the value for same day surgery has not been well studied, partially due to the difficulty in actuating additional safety, quality, and cost in the ambulatory setting. By using the ERAS principles, we designed and implemented the ambulatory ERAS program for open inguinal hernia repair (OIHR) surgeries in the Southern California Kaiser Permanente (KPSoCal) system, which consisted of 15 hospitals and 16 surgical centers. The primary goal was to reduce the emergency room/urgent care returns after the ambulatory surgery and the secondary goals were to decrease postoperative pain and PONV.
Methods: 5753 OIHR patients were divided into two groups: 2929 OIHR patients from before the ERAS implementation and 2823 OIHR patients after the ERAS implementation. 8 Elements of ERAS protocol was designed and implemented crossing 21 facilities in our system. The implementation was a top-down approach, which was conducted by following the principle of Consolidated Framework for Implementation Research (CFIR).2 This was a retrospective cohort study which was conducted as a quality improvement project and herein reported the following Standards for Quality Improvement Reporting Excellence (SQUIRE Guidelines).
Results: Basic demographic characteristics was shown in Figure 2. The propensity score was generated using logistic regression based on age, gender, and anesthesia type. The matching was done on a 1:1 basis based on the logit of the propensity score with a caliper of 0.2 standard deviations of the logit of the propensity score without replacement. 2574 patients were matched and used for the outcome analysis. After matching Wilcoxon signed rank test for continuous covariates and McNemar’s test for binary covariates were used to compare the characteristics.
Conclusion: The design and implementation of 8 elements of ERAS protocol for open inguinal hernia repair over a 14-month period did not reduce 30 days ER/UC returns and did not reduce length of hospital stay. It was possible that ERAS program was less effective for minimal invasive surgery such as OIHR, in which surgical stress response, inflammatory changes and homeostasis disturbance are minimum or can be easily and adequately compensated by majority patient’s own defense mechanism. Our results suggested that ERAS principle, which has been studied extensively over the last 20 years for complicated inpatient surgeries, need to be validated for other ambulatory surgeries and in other settings.
References: 1. Aging Clinical and Experimental Research 2018; 30:249-252 2. Implementation Science 2016; 11:72 3. Anesthesia & Analgesia 2019; 128:5-7