L. Theiss1, F. Gleason1, S. Baker1, A. Ali2, T. Wahl1, L. Wood1, L. Goss1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, D. I. Chu1 1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA
Introduction: The implementation of enhanced recovery after surgery (ERAS) pathways has lead to multifactorial improvements in patient care, including reduction of hospital length-of-stay. Despite many successes, some patients do not benefit from this approach. We sought to identify risk factors associated with ERAS failure. We hypothesized that preoperative health status and surgical acuity would predispose patients to ERAS failure.
Methods: Patients undergoing elective colorectal surgery under ERAS from 2015 to 2017 were stratified into ERAS failure or non-failure. ERAS failure was defined as an observed postoperative length of stay (pLOS) that was at least 1-day greater than the expected pLOS calculated by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator. Chi-square and Wilcoxon Rank Sums were used to compare group characteristics. An adjusted analysis was performed via a generalized regression model.
Results: Of 683 ERAS patients, 508 patients (74%) succeeded with ERAS and 175 patients (24%) failed ERAS. Demographics such as age, gender, and race did not significantly vary between groups. On unadjusted comparison, patients who failed ERAS were more likely to be admitted urgently (p<0.01), have a dependent functional status (p=0.02), and have lost >10% of their body weight in the 6 months prior to surgery (p<0.01). Patients who failed ERAS were also more likely to have a diagnosis of IBD (p<0.01), undergo surgery for a benign indication (p<0.01), and undergo operations involving the small bowel and stoma creation (p<0.01). Complications of significance during hospitalization associated with ERAS failure included clostridium difficile infection, myocardial infarction, respiratory failure requiring intubation and mechanical ventilation, organ space surgical site infection, pneumonia, intraoperative anemia requiring transfusion, and urinary tract infection (p value for all ≤0.04). On adjustment for covariate differences, independent factors associated with ERAS failure included elective vs. urgent admission type (OR 0.07, CI 0.01-0.3, p<0.01) and significant postoperative complication occurrences (OR 2.53, CI 1.33-4.82, p<0.01).
Conclusion: In an analysis of 683 ERAS patients, preoperative risk factors affected patient outcomes, but largely postoperative complications drove ERAS failure. Independent risk factors for ERAS failure were urgent admission type and significant postoperative complications. Opportunities may exist for further targeted interventions within these higher-risk groups to improve patient outcomes.