Enhanced Recovery Protocol for Colorectal Surgery

Alex Macario, MD, MBA


May 12, 2014

Reduced Length of Hospital Stay in Colorectal Surgery After Implementation of an Enhanced Recovery Protocol

Miller TE, Thacker JK, White WD, et al; Enhanced Recovery Study Group
Anesth Analg. 2014;118:1052-1061

Study Summary

This study investigated the feasibility, clinical effectiveness, and cost savings of a multimodal approach to enhanced recovery after surgery, designed to enable early mobilization and feeding after open or laparoscopic colorectal surgery.

Baseline data were collected on 99 consecutive patients undergoing colorectal surgery and receiving traditional care that included little standardization and was at the discretion of the surgical and anesthesia providers. For example, baseline patients fasted from midnight on the day of surgery, received bowel preparation, and rarely received thoracic epidurals because of a surgical preference for enoxaparin to be given 2 hours preoperatively. Early mobilization and day-of-surgery feeding were not part of the traditional care regimens.

The investigators then implemented a multimodal regimen to enable early mobilization and feeding after surgery. Staff members received training before a 3-month implementation period during which 142 patients were prospectively enrolled, allowing providers to become familiar with the enhanced recovery protocol. A before-and-after comparison of key outcomes was made.

Study Findings

The median length of stay was reduced from 7 to 5 days with the enhanced recovery protocol compared with the traditional group (P < .001). The reduction in length of stay was significant for both open procedures (median, 6 vs 7 days; P = .01) and laparoscopic procedures (4 vs 6 days; P < .001). Patients who received the enhanced recovery protocol also had fewer urinary tract infections (13% vs 24%; P = .03) and fewer readmissions (9.8% vs 20.2%; P = .02).

Of interest, even with a shorter length of stay and lower patient ward costs, there was no statistically significant difference in unadjusted total hospital costs for patients who received the enhanced protocol compared with traditional care ($18,377 vs $20,537).


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