B. Sharif-Askary1, R. Zhao1, S. Hollenbeck1 1Duke University Medical Center,Division Of Plastic And Reconstructive Surgery,Durham, NC, USA
Introduction: Hospitals are evaluated for quality based on a number of metrics including the occurrence of complications. Recently, our hospital instituted the Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing free flap breast reconstruction. Urinary tract infections are among the most common healthcare-associated infections, with the majority seen after prolonged urinary catheterization. The ERAS protocol calls for early removal of urinary catheters. In this study, we compare the rate of UTI in patients who have undergone traditional recovery after surgery (pre-ERAS) to those who were enrolled in the ERAS protocol. We hypothesized that early catheter removal would decrease the rate of UTI in patients undergoing breast reconstruction with free flaps.
Methods: We retrospectively reviewed the charts of 238 patients who underwent free flap breast reconstruction. We initiated the ERAS protocol in May of 2015. This study includes patients seen between March 2012 and June 2017 to capture both pre- and post-ERAS cohorts. UTI was defined using the American College of Surgeons NSQIP definition. Statistical analyses were conducted using SPSS software (Version 24.0, IBM Corp). We compared the incidence of UTI before and after ERAS initiation using a logistic regression while controlling for age, BMI, rate of diabetes and length of surgery.
Results: There were 160 patients evaluated prior to ERAS implementation and 78 patients evaluated in the post-ERAS group. The overall incidence of UTI for all patients who underwent free flap reconstruction was 4.6%. Next, we compared patients from the pre-ERAS group to the post-ERAS group. There were no significant differences with regards to mean age, BMI, or length of surgery. However, the rate of diabetes was higher in the pre-ERAS group compared to the post-ERAS group (11% vs. 4%, p=0.04, t-test). Post-ERAS patients had a significantly higher rate of UTI than pre-ERAS patients when controlling for age, BMI, rate of diabetes and length of surgery (1.9% vs. 10.3% p=0.008, OR=6.72). Of post-ERAS patients who were found to have post-op UTI, 25% were found to have bacteria on a pre-operative urinalysis.
Conclusion: In contrast to our hypothesis, we found that the rate of UTI was significantly higher in the post-ERAS patients. Further analysis is needed to determine the cause of this finding but may include the need for re-catheterization after early catheter removal. Based on these findings, we suggest individualized decision-making within the ERAS protocol in regards to timing of urinary catheter removal.