Author: Monica J. Smith
Expanding enhanced recovery after surgery (ERAS) protocols to surgical service lines beyond colorectal surgery can have a positive impact on patient outcomes, hospital length of stay and the hospital’s bottom line, according to an evaluation of one center’s rapid expansion to multiple surgical service lines.
“We wanted to know if broad implementation of ERAS is feasible. Have we improved patient care? What about length of stay [LOS] and hospital costs? That is what we wanted to get into,” said Michelle Fillion, MD, a surgical oncologist at New Hanover Regional Medical Center, in Wilmington, N.C. The center adopted an ERAS protocol for colorectal surgery in 2016, and expanded the protocol to seven additional service lines within the next year and a half.
To assess the result of this expansion, Dr. Fillion and her colleagues analyzed prospectively gathered data from 1,680 patients who underwent ERAS-specific operations in 2018, using pre-ERAS data from the previous year as a baseline. They compared six service lines—colorectal, gynecology, hepatopancreatobiliary (HPB), urology, cardiac and spinal fusion—in terms of complications, readmissions, LOS, mortality and cost, excluding urgent procedures.
The 30-day readmission rate either fell (for colorectal, gynecology, urology and HPB) or remained about the same compared with pre-ERAS procedures. Complications, too, were either fewer (for colorectal, gynecology, urology and spinal fusion) or about the same as they had been for the pre-ERAS procedures.
“There was a significant improvement in LOS for the colorectal surgery service line, from 5.5 days to 3.6,” Dr. Fillion said. LOS was also significantly shorter in gynecology (from 3.9 to 1.4 days) and spinal fusion (from 2.38 to 1.6 days). A decreased LOS in cardiac surgery (from 4.67 to 3.05 days) was not statistically significant, “but may show some clinical significance because of the volume of patients that are involved in this service line.”
Overall, the shorter LOS resulted in 1,846 hospital days saved in 2018. The cost savings per patient was substantial in the cardiac ($6,575), spine fusion ($2,865), colorectal ($1,558) and HPB ($1,342) patients. The cost savings was likely a reflection of the decreased LOS and less time spent in ICU and step-down care units, Dr. Fillion said. “This came to a very significant hospital cost savings of more than $4.7 million in 2018 alone.”
William Cobb, MD, a general surgeon at Prisma Health in Greenville, S.C., remarked that this study is one of the first to evaluate cost savings related to LOS, but questioned whether it offset any additional costs associated with ERAS protocols. “Did you consider the added costs of elements of the protocol, like the preoperative carbohydrate drink, the multimodal pain medication, in your cost analysis?”
Dr. Fillion said although some medications are expensive, such as bupivacaine liposome injectable (Exparel, Pacira Pharmaceuticals) and alvimopan (Entereg, Merck), the costs of the carbohydrate drink and multimodal pain control were insignificant. “Overall, the additional costs associated with ERAS elements are mitigated by reductions in LOS and complications.”
Dr. Cobb also asked whether the broad implementation of ERAS protocols had any effect on opioid use. “The emphasis on ERAS protocols is rightly growing in the literature, especially in light of the opioid crisis. Did you assess the reduction in opioids or morphine equivalents?”
In 2016, the same year that her center began ERAS in colorectal surgery, the city of Wilmington established an opioid task force. “I will say that we reduced our opioid prescriptions by more than 20%, but it’s a bit hard to determine whether that is directly related to ERAS or just the fact that we now have standardized protocols for opioid prescriptions. It’s a little confounding,” Dr. Fillion said.
Lastly, Dr. Cobb asked whether the investigators had any thoughts on what particular aspect of ERAS protocols makes the difference. “One criticism of ERAS protocols is that a lot of interventions are just thrown at the patient, but we never truly determine what provides benefit. What really matters? Is it one element or a combination of different factors?”
The ERAS protocols used by surgeons at New Hanover generally follow the same tenets that other centers use: patient education and optimization; multimodal preoperative, intraoperative and postoperative pain management; and early mobilization and rapid return to a solid diet. As a result, it can be difficult to pinpoint one specific item, Dr. Fillion said.
“But I think from the beginning it’s expectation management, making patients active participants in their own care,” she said. “They know exactly what’s going to happen before they set foot in the hospital, what we expect on day 1, day 2 and so forth. In addition to that, limiting their fluids and multimodal pain control are the key winners to help move patients through recovery as much as possible.”