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New Approach for Surgery Patients Cuts Hospital Stays, Costs

‘Enhanced recovery’ reduces readmission rate by half

Changes in managing patients before, during, and after colorectal surgery cut hospital stays by 2 days and reduced readmission rates, according to researchers at Duke University Hospital.

The practice, called enhanced recovery, is easier on patients before surgery, eliminating the fasting period and bowel evacuation that are typically prescribed. After surgery, patients are encouraged to eat and move about as soon as possible, leading to faster recoveries.

In the May 2014 issue of Anesthesia & Analgesia, the researchers reported that the enhanced recovery approach used for colorectal surgery cut hospital admissions from an average 7 days to 5, and reduced the rate of readmissions by half.

Senior author Tong J. Gan, MD and his colleagues collected data from 241 consecutive patients at Duke University Hospital undergoing open or laparoscopic colorectal surgery during two time periods: before the enhanced recovery approach was implemented, and after. Ninety-nine patients were studied in the traditional approach, and 142 were studied using enhanced recovery.

With traditional perioperative care — defined as the care provided through a patient's hospitalization for surgery — few procedures are standardized, but patients are typically told to fast the night before and undergo laxative treatments, and then are not given food or drink after surgery until bowel sounds are restored, sometimes several days later. In addition, traditional perioperative care includes a variety of different anesthesia regimens, fluid management, and pain control, depending on the surgical team’s preferences.

Under traditional perioperative care, patients who experience pain, stress, immobilization, and postoperative constipation can remain in the hospital for 10 days or more, with complication rates of up to 48%. Such complications can be expensive, estimated at an average of $10,000.

Enhanced recovery after surgery (ERAS), which has gained favor in Europe but has not been widely accepted in the U.S., aims to standardize perioperative care using procedures backed by scientific evidence that demonstrate their benefits.

In the Duke study, patients in the ERAS group were educated about what they should expect. Routine bowel preparation was not performed, and patients were allowed to drink clear fluids, notably a sports drink, until 3 hours before their surgeries.

All of the ERAS patients received an epidural as well as non-opioid painkillers to reduce opioid side effects, such as nausea, vomiting, constipation, urinary retention, and drowsiness. They then underwent general anesthesia. After surgery, the patients transitioned to oral acetaminophen or other nonsteroidal anti-inflammatory drugs, plus oral opioids, if necessary, after about 72 hours. Patients were also encouraged to drink liquids and to get out of bed on the day of surgery, and for at least 6 hours every subsequent day.

Gan said the researchers saved costs for about 85% of the ERAS patients, at about $2,000 per patient. He said the ERAS approach could be used for numerous surgeries; it has been expanded at Duke University Hospital to include bladder, pancreas, and liver surgeries.

Sources: Medical Xpress; April 24, 2014; and Anesthesia & Analgesia; May 2014.

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