Impact of ERAS® protocols and early nutrition provision on length of stay and compliance among surgery patients: An evaluation of a multidisciplinary ERAS® institution
Allyson Cochran MSPH1, Bridget A. Cassady PhD RDN LD2, Kirk W. Kerr PhD2, Meshka K. Anderson MD3, David A. Iannitti MD3, Dionisios Vrochides PhD MD3
1Carolinas Center for Surgical Outcomes Science, Atrium Health, Charlotte, NC; 2Scientific and Medical Affairs, Abbott Nutrition; 3Division of HPB Surgery, Atrium Health, Charlotte, NC
Enhanced Recovery After Surgery (ERAS®) protocols emphasize the importance of nutrition provision, including preoperative oral carbohydrate loading and early immunonutrition, for optimal recovery of surgical patients. This study evaluates the impact of ERAS® protocols including post-operative nutrition implementation on hospital length of stay (LOS) and compliance, for pancreaticoduodenectomy (implemented September 2015), distal pancreatectomy (August 2016), hepatectomy (January 2017), cystectomy (January 2018), and head and neck cancer (July 2018) surgical procedures at a high-volume medical center in United States.
Retrospective data for patients undergoing head and neck cancer (n=122), hepatectomy (n=104), distal pancreatectomy (n=102), cystectomy (n=170), and pancreaticoduodenectomy (n=96) procedures at the institution were collected from the ERAS Interactive Audit System (EIAS). Patients from 1 year pre- and 1 year post-ERAS® were case-matched on age, body mass index, diabetes status, sex, and surgery type. Hospital LOS and compliance to pre-operative oral carbohydrate loading and post-operative nutrition, were compared across the pre- and post-ERAS® surgery groups. Hospital LOS was regressed on ‘early nutrition' (day of surgery (DoS) or postoperative day (POD) 1), ‘late nutrition' (POD 2 or 3), and ‘no nutrition' indicators.
Post-ERAS®, average hospital LOS was significantly shorter across all surgeries (10.0 vs. 8.3 days, p=.001), and specifically for distal pancreatectomy (6.3 vs 9.1 days, p=0.014), head and neck cancer (11.7 vs 13.1 days, p=0.024), and pancreaticoduodenectomy (10.0 vs 15.1 days, p=0.003). No significant difference was observed between post- and pre-ERAS LOS for hepatectomy (5.0 vs 5.2 days, p=0.72) and cystectomy (8.0 vs 8.4 days, p=0.159). Early post-operative nutrition was associated with a 3.75 day shorter LOS (p<0.01), while ‘no nutrition' was associated with a 3.29 day longer LOS (p<0.01). Compliance with pre-operative carbohydrate loading was significantly higher across all surgeries post-ERAS® (63% vs 1%, p< 0.01).
Implementation of ERAS® protocols was associated with reduction in hospital LOS in three of the five of the studied surgery areas. Additionally, delivery of nutrition on DoS or POD1 significantly decreases overall LOS, while ‘no nutrition' significantly increases LOS. These findings support the use of ERAS® protocols including pre-operative carbohydrate loading and early immunonutrition to improve recovery of surgery patients in a variety of surgeries, within the limitations of retrospective studies. Future research should continue to control for confounding factors and patient differences not accounted for in our analysis and work toward assessment of causal relationships.
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