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The impact of ERAS on length of hospital stay and complications

Discuss about the Protocol Compliance on Morbidity System.

The review of nine research articles gave insight into the effectiveness of enhanced recovery after surgery (ERAS) protocol in the elderly patients going for colorectal surgery. Length of hospital stay (LoS), complications, readmissions, mortality and adherence or compliance to treatment were taken as the main theme for research because these five variables are the important predictor that can determine success of ERAS for elderly patients with colorectal surgery. LoS and complications rate were evaluated in all the nine research articles, readmission rate and mortality was examined in seven studies and adherence rate was covered in only four studies. The significance and differences between research outcome in each studies and issue found in each theme is discussed in the next section.

The critical review of nine research articles on the theme of LoS revealed that LoS is significantly reduces in colorectal cancer patient after the implementation of ERAS protocol and total hospitalization days ranged between 5-7 days across all studies. There was one study which categorized research participant into 65 years below and 65 years above group Kisialeusk et al. (2015), however other articles took diverse range of age group such as patients above and below 70 years (Slieker et al. 2017), patients above 80 and below 55 and other diverse age categories (P?dziwiatr et al. 2015). However, no difference in outcome was found because of age of participants indicating that chronological age is not a predictor of positive ERAS protocol performance (Alvarez-Nebreda et al. 2018). This theme gave an important clinical implication that instead of focusing on age factor to reduce LoS for elderly patients undergoing colorectal cancer, there is a need to focus on important elements of ERAS protocol such as early mobilization process to prevent complication and reduce LoS. The use of early mobilization to reduce complicating rate in elderly patient was given by two studies (Braga et al. 2017; Slieker et al. 2017). Overall, more the number of ERAS protocol element is fulfilled, the more is the likelihood of getting positive outcome in patients. Hence, the importance of the first theme was that it gave convincing evidence to prove that age is not a risk factor of post-operative complications in elderly patients with colorectal surgery. A study comparing the frequency of complication in patients under and over 7 years going for elective colorectal cancer surgery also proved that age did not influenced the occurrence of peri-operative complication in patient (Wydra et al. 2013).

Effectiveness of ERAS protocol in reducing complication rate

Complication rate after the implementation of ERAS protocol was analyzed in all the nine studies and Clavien-Dindo classifications was a used as a tool to evaluate complication rate in most of the studies (Forsmo et al. 2017; Kisialeuski et al. 2015; Gonzalez-Ayora et al., 2016; Zeng et a. 2017; Slieker et al. 2017; Braga et al. 2017) except two (P?dziwiatr et al. 2015; Baek et al. 2013). The primary issues found for the theme of complication rate was research outcome differed significantly for all the research studies. For some studies, the overall complication rate was 33% (Kisialeusk et al. 2015) and some with complication rate of 26.6% (Zeng 2017). The characteristics and nature of complication was different for different studies. However, the effectiveness of ERAS in reducing complication rate can be justified after by the fact that minor complication rate was higher compared to major complication in elderly patient. For instance, Gonzalez-Ayora et al. (2016) showed that 60% has no complication, 24% has minor complication and only 13% experienced major complication. Link between length of hospital stay and complication rate was also found as the selected studies indicated that shorter hospital stay minimizes the likelihood of post-operative complication in patient. The finding is consistent with other studies as well as there are lot of studies which states that elderly patient undergoing laparascopic colorectal surgery have shorter LoS, reduces complication rate and less intensive care after implementation of ERAS protocol (Grailey et al. 2013; Damania and Cocieru 2017).

For the theme of readmission rate, age wise difference in readmission rate was found after the implementation of ERAS protocol for elderly patient with colorectal surgery. The review of the nine articles revealed that admission rate increased for patient above 65 year compared to those below 65 years. In addition, the effectiveness of ERAS on reducing the readmission rate was also observed as majority of studies had readmission rate of less than 10%. P?dziwiatr et al. (2015) is the best research study that as it achieved higher readmission rate for patients above 80 year compared to those above 55 years. The credibility of the work was also enhanced by the explanation of factors that helped to achieve such outcome for very elderly patient. However, this finding also rebutted the fact age lead to high risk of admission. Other studies could not achieve the same outcome because of poor sampling strategy and poor consideration for improving outcome in very elderly patient. Tan et al. (2012) gave an indication that assessment of frailty can predict the planning of ERAS protocol specific to the needs of elderly population.

Age-wise difference in readmission rate after the implementation of ERAS protocol

For the theme of mortality, the review of nine research articles indicated that mortality related outcome was almost similar in all the studies. Even if death cases were reported, it did not occur because of the inefficiency of ERAS protocol. Other factors like intra-peritoneal drain influence mortality rate in elderly patient. Secondly, the theme of adherence also proved that adherence rate does not differ because of age difference (Forsmo et al. 2017). This fact was proved by the research study of (Forsmo et al. 2017) which reported highest adherence rate for very elderly patient. However, there were some studies which showed negative results related to adherence rate. Based on the identification of above issues in the theme, it can be said that different elements included in the ERAS protocol can predict adherence rate. Poor adherence in study by Braga et al. (2017) was obtained because of low preoperative physical status. Communication process between clinician and patient may also determine the success of the program. Gillis et al. (2017) argued that patient who have better understanding about the ERAS programme are likely to adhere to the expected protocol. Overall conclusion from the analysis of nine articles is that ERAS protocol is effective in reducing LoS, complication rate, admission rate, adherence and mortality in elderly patient. It also showed that age does not affects the quality of the protocol and the outcome is dependent on different elements of the ERAS protocol and ease with which it can be implemented by patient.

The critical review of research literature convincingly proved that ERAS protocol improve outcome in elderly patient going for colorectal surgery. It also showed that age is not a predictor of the success of the program and optimal outcome for patient is dependent on the type of ERAS element included for patients. This is consistent with other research too (Messenger,. The nine articles also gave many important clinical implications for improving the efficacy of the ERAS protocol. Some of the finding could not be applied because they were done in single setting and results may not be applicable for other health care setting ((P?dziwiatr et al. 2015). Hence, studies using multi-center approach and those done by means of randomized controlled trial can be applied as it addressed selection biases. Gillis et al. (2017) showed that safety of ERAS program is dependent on elderly patient adaptability to the ERAS criteria. Hence, utilizing this evidence, it is recommended that health care providers should modify existing ERAS protocol and make it more flexible so that all patients irrespective of age or ailment can easily adhere to the protocol (Shida et al. 2017).

Mortality-related outcome and its relationship with ERAS protocol adherence

Another important clinical implication of the study is for nurses and health care providers This is said because rapport with health care providers and level of communication skill of nurse can determine how focused are medical staffs on following ERAS protocol irrespective of patient’s clinical condition (Govaert et al. 2016). This is likely to enhance the adherence rate to ERAS protocol which the strongest predictor for efficacy of the program in elderly patient. In response to the evaluation of research studies on the basis of complication rate and LoS, it was found that age difference did not influence outcome of patients. Instead, positive outcome was dependent on elements of the ERAS protocol. For improvement in existing ERAS protocol, it is recommended that process should be developed to identify important ERAS element that accelerate post-operative recovery in patient. The benefit of early mobilization as the important element of ERAS protocol should be evaluated in future research studies (Rogers et al. 2018). As the review of nine studies indicated that reducing the length of hospital stay minimizes the rate of complication in elderly patient, it is recommended to critically consider the process that can shorten the total duration of hospitalization in patient (Roulin, Najjar and Demartines 2017). Health care managers can consider the possibility of reallocation of resources to ensure that discharge planning is efficient and readmission post-discharge does not occur (Khan and Pandey 2016). There were some studies which reported safety of ERP for older patients above 75 years, however as the study was done by observation method, future studies should confirm the result by conducting randomized controlled trial in the future.

References:

Alvarez-Nebreda, M.L., Bentov, N., Urman, R.D., Setia, S., Huang, J.C.S., Pfeifer, K., Bennett, K., Ong, T.D., Richman, D., Gollapudi, D. and Rooke, G.A., 2018. Recommendations for preoperative management of frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI). Journal of clinical anesthesia, 47, pp.33-42.

Baek, S.J., Kim, S.H., Kim, S.Y., Shin, J.W., Kwak, J.M. and Kim, J., 2013. The safety of a “fast-track” program after laparoscopic colorectal surgery is comparable in older patients as in younger patients. Surgical endoscopy, 27(4), pp.1225-1232.

Braga, M., Pecorelli, N., Scatizzi, M., Borghi, F., Missana, G. and Radrizzani, D. (2017) Enhanced recovery program in high-risk patients undergoing colorectal surgery: results from the perioperative Italian Society Registry. World Journal of Surgery. 41(3), pp. 860-867.

Damania, R. and Cocieru, A., 2017. Impact of enhanced recovery after surgery protocols on postoperative morbidity and mortality in patients undergoing routine hepatectomy: review of the current evidence. Annals of translational medicine, 5(17).

Clinical implications for improving efficacy of ERAS protocol

Forsmo, H.M., Erichsen, C., Rasdal, A., Körner, H. and Pfeffer, F., 2017. Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients. Gerontology and geriatric medicine, 3, p.2333721417706299.

Gillis, C., Gill, M., Marlett, N., MacKean, G., GermAnn, K., Gilmour, L., Nelson, G., Wasylak, T., Nguyen, S., Araujo, E. and Zelinsky, S., 2017. Patients as partners in Enhanced Recovery After Surgery: A qualitative patient-led study. BMJ open, 7(6), p.e017002.

Gonzalez-Ayora, S., Pastor, C., Guadalajara, H., Ramirez, J.M., Royo, P., Redondo, E., Arroyo, A., Moya, P. and Garcia-Olmo, D., 2016. Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS. International journal of colorectal disease, 31(9), pp.1625-1631.

Govaert, J.A., van Dijk, W.A., Fiocco, M., Scheffer, A.C., Gietelink, L., Wouters, M.W. and Tollenaar, R.A., 2016. Nationwide outcomes measurement in colorectal cancer surgery: improving quality and reducing costs. Journal of the American College of Surgeons, 222(1), pp.19-29.

Grailey, K., Markar, S.R., Karthikesalingam, A., Aboud, R., Ziprin, P. and Faiz, O., 2013. Laparoscopic versus open colorectal resection in the elderly population. Surgical endoscopy, 27(1), pp.19-30.

Khan, M.A. and Pandey, S. (2016) Clinical outcomes of the very elderly undergoing enhanced recovery programmes in elective colorectal surgery. Annals of The Royal College of Surgeons of England. 98(1), pp. 29-33.

Kisialeuski, M., P?dziwiatr, M., Mat?ok, M., Major, P., Migaczewski, M., Ko?odziej, D., Zub-Pokrowiecka, A., Pisarska, M., Budzy?ski, P. and Budzy?ski, A., 2015. Enhanced recovery after colorectal surgery in elderly patients. Videosurgery and Other Miniinvasive Techniques, 10(1), p.30.

Messenger, D.E., Curtis, N.J., Jones, A., Jones, E.L., Smart, N.J. and Francis, N.K., 2017. Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surgical endoscopy, 31(5), pp.2050-2071.

P?dziwiatr, M., Pisarska, M., Wierdak, M., Major, P., Rubinkiewicz, M., Kisielewski, M., Matyja, M., Lasek, A. and  Budzy?ski, A.  (2015) The use of the enhanced recovery after surgery (ERAS) protocol in patients undergoing laparoscopic surgery for colorectal cancer – a comparative analysis of patients aged above 80 and below 55. Polish Journal of Surgery. 87(11), 565- 572.

Rogers, L.J., Bleetman, D., Messenger, D.E., Joshi, N.A., Wood, L., Rasburn, N.J. and Batchelor, T.J., 2018. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. The Journal of thoracic and cardiovascular surgery, 155(4), pp.1843-1852.

Roulin, D., Najjar, P. and Demartines, N., 2017. Enhanced Recovery After Surgery Implementation: From Planning to Success. Journal of Laparoendoscopic & Advanced Surgical Techniques, 27(9), pp.876-879.

Shida, D., Tagawa, K., Inada, K., Nasu, K., Seyama, Y., Maeshiro, T., Miyamoto, S., Inoue, S. and Umekita, N., 2017. Modified enhanced recovery after surgery (ERAS) protocols for patients with obstructive colorectal cancer. BMC surgery, 17(1), p.18.

Slieker, J., Frauche, P., Jurt, J., Addor, V., Blanc, C., Demartines, N. and Hübner, M., 2017. Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery. International journal of colorectal disease, 32(2), pp.215-221.

Tan, K.Y., Kawamura, Y.J., Tokomitsu, A. and Tang, T., 2012. Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. The American journal of surgery, 204(2), pp.139-143.

Wydra, J., Kruszewski, W., Jasi?ski, W., Szajewski, M., Ciesielski, M., Szefel, J. and Walczak, J., 2013. Is age a risk factor of postoperative complications in colorectal cancer?. Polish Journal of Surgery, 85(9), pp.491-495.

Zeng, W.G., Liu, M.J., Zhou, Z.X. and Wang, Z.J., 2017. Enhanced recovery programme following laparoscopic colorectal resection for elderly patients. ANZ journal of surgery.

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