S. M. Stapleton1,2, R. M. Sisodia1,2, D. C. Chang1,2, N. P. Perez1,2, B. V. Udelsman1,2, M. G. Del Carmen1,2, K. D. Lillemoe1,2 1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA
Introduction: Multi-modal approaches for enhanced recovery after surgery (ERAS) represent evidence-based protocols designed which standardize peri-operative care, to improve patient outcomes and reduce cost to the health system. ERAS protocols were first developed for use in the field of colorectal surgery. More recent efforts seek to expand implementation throughout surgical and nonsurgical specialties. We aim to evaluate implementation of an ERAS protocol within the department of obstetrics and gynecology. We hypothesize that care standardization will reduce length of stay in a field that does not routinely perform bowel surgery.
Methods: An observational study at a tertiary academic medical center was performed for the 12-months pre- and 6-months post-ERAS implementation. Female patients with ICD10 codes for elective hysterectomy were included. In-hospital deaths were excluded. Endpoints assessed included length of stay (LOS), and likelihood of same-day discharge or readmission. Multivariable analysis adjusted for ERAS, minimally invasive vs. open hysterectomy, procedure performed for malignancy, and case start time. Difference-in-difference analyses were performed by race.
Results: We analyzed 1004 hysterectomies, 88.9% (n=812) lap and 98.3% (n=987) for benign disease. Hospital duration was significantly reduced post-ERAS (24.2 [IQR11.4-28.5] hrs. vs. 13.1 [IQR10.6-27.7] hrs., p=<0.01). Additionally, hospital duration was significantly reduced post-ERAS for patients staying <24 hrs. (13.0 hrs. pre vs. 11.9 hrs. post, p=0.01), but interestingly the opposite trend was observed for patients staying >24 hrs. (47.8 hrs. pre vs. 65.2 hrs. post, p=0.02). Furthermore, rates of same-day discharge increased significantly post-ERAS (49.1% for pre vs. 63.2% for post, p=<0.01). There was no significant difference in readmission rates (15.7% pre vs. 18.1% post, p=0.34). When stratifying into pre-ERAS vs. post-ERAS, same-day discharge rates were 50.4% vs. 45.5% pre-ERAS, and 63.3% vs. 62.9 post-ERAS for whites vs. non-whites respectively (figure). Lastly, cases started before 1pm were significantly more likely to be discharged on the same day as the surgery (OR 1.26, p=0.07).
Conclusion: As an example of value-based care, ERAS is effective in reducing hospital duration by increasing rates of same day discharge through identifying borderline patients who would otherwise stay an additional day. Additionally, ERAS is effective in reducing racial disparity in care, suggesting that standardization of care pathways may reduce bias in decision making. Lastly, future ERAS protocols may consider supplementing current practices with systems level interventions, such as starting complex cases that are eligible for same-day discharge before 1 pm.
