Critical Elements To Enhanced Recovery After Surgery (eras): Optimal Compliance For Optimal Success
*Toni S Carter, *Michael E Egger, *Prejesh Phlips, Robert CG Martin
University of Louisville, Louisville, KY
Objectives:The implementation and initiation of Enhanced Recovery after Surgery(ERAS) has been widely accepted when implemented across all phases or care: pre-operative, intra-operative, and post-operation. The aim of this study was to evaluate and validate the critical elements in ERAS success defined as reduction in length of stay, reduction in re-admission, and reduction in hospital opioid use.Methods:Fifteen critical pre-operative(N=7), intra-operative(N=3) and post-operative(N=5) ERAS elements were extracted from the published literature and from our previous publication. These elements were then tested in an IRB approved initial training set for all patients undergoing ERAS at the medical center. These critical ERAS elements were then validated in a system wide(4 hospitals) ERAS implementation from 5/19-12/19. Data collection was obtained prospectively and then compliance and outcomes were evaluated.Results:Thirty-six(36) patients were enrolled in the training set in which compliance was achieved in <50%(n=10); 50-70%(n=16); and >70% compliance(N=10). The most common non-compliance factors identified were intra- and post-operative opioid sparing(6; 50%), early mobilization(6; 50%), and goal directed fluid therapy(5; 42%). The validation set(770 patients) was them implemented after 2 months of education following the training set: In the first 3 months, 355 patients ERAS was scheduled with only 61(17%) patients meeting compliance in all 15 categories; however over the next 3 months 415 patients had ERAS scheduled with 158(38%) meeting compliance(Table 1). Multivariate analysis demonstrated that failure of smoking cessation(OR 1.4;CI 1.1-2.3), lack of any form of pre-habilitation(OR 2.1;CI 1.3-4.3), failure of goal directed fluid management(OR 1.2;CI 1.1-3.9), failure of early nutrition(2.3;CI 1.3-3.5), and failure of early mobilization(OR 2.1;CI 1.4-4.1) were all factors of prolonged length of stay in this validation set. Conclusion:ERAS remains an effective and optimal strategy in all types of surgical procedures. Compliance to the 15 critical elements remains a multi-disciplinary challenge across all three phases of surgery. Constant and continuous education of all team and ancillary staff members are essential, since failure in one phase can negate any and all ERAS benefits to a patient.
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