Predicting delayed discharge in a multimodal Enhanced Recovery Pathway

Abstract

Background

Despite advances with Enhanced Recovery Pathways(ERP), some patients have unexpected prolonged lengths of stay(LOS). Our goal was to identify the patient and procedural variables associated with delayed discharge despite an established ERP.

Methods

A divisional database was reviewed for minimally invasive colorectal resections with a multimodal ERP(8/1/13–7/31/15). Patients were stratified into ERP success or failure based on length of stay ≥5 days. Logistic regression modeling identified variables predictive of ERP failure.

Results

274 patients were included- 229 successes and 45 failures. Groups were similar in demographics. Failures had higher rates of preoperative anxiety(p = 0.0352), chronic pain(p = 0.0040), prior abdominal surgery(p = 0.0313), and chemoradiation(p = 0.0301). Intraoperatively, failures had higher conversion rates(13.3% vs. 1.7%, p = 0.0002), transfusions(p = 0.0032), and longer operative times(219.8 vs. 183.5min,p = 0.0099). Total costs for failures were higher than successes($22,127 vs. $13,030,p = 0.0182). Variables independently associated with failure were anxiety(OR 2.28, p = 0.0389), chronic pain(OR 10.03, p = 0.0045), and intraoperative conversion(OR 8.02, p = 0.0043).

Conclusions

Identifiable factors are associated with delayed discharge in colorectal surgery. By prospectively preparing for patient factors and changing practice to address procedural factors and ERP adherence, postoperative outcomes could be improved.

Introduction

Since their introduction, Enhanced Recovery Pathways (ERP) or fast-track protocols have improved patient outcomes in colorectal surgery.3, 4, 5 These multimodal pathways improve outcomes by standardizing care, which reduces complications and hospital length of stay (LOS).3, 4, 5, 6, 7, 8, 9, 10 In addition to improving clinical outcomes, standardization of health care processes with ERP have been found to decrease cost and healthcare utilization.11, 12, 13, 14 Reducing LOS is a consistent outcome in all ERP, and thus a measure of ERP success in uncomplicated patients. The specific elements in ERPs continue to develop, with multimodal pain management further enhancing recovery.¹⁵ Despite these advances, some patients continue to have unexpected prolonged LOS. This issue warrants attention, as LOS is an increasingly important measure of surgical quality and efficiency.16, 17 Prolonged LOS is associated with increased overall costs and resource consumption, mainly from higher rates of postoperative complications and readmissions.18, 19, 20

Identifying which factors are associated with prolonged LOS in elective laparoscopic colorectal surgery could help resource allocation, postoperative support, and the informed consent process, as well as reducing costs.²¹ A few studies have evaluated characteristics associated with prolonged LOS in surgery, finding impaired functional status, advanced age, major comorbidities, and lower socioeconomic status made patients more susceptible.19, 22, 23 These studies are based on large administrative databases, and lack patient-level details or specifics on enhanced recovery protocol use. Studies have also shown deviation and lack of compliance with an ERP can delay discharge following laparoscopic colorectal surgery.24, 25 However, the demographic, procedural, and perioperative variables associated with ERP failure and prolonged LOS have not been clearly defined or used to enact process change in minimally invasive colorectal surgery.

The goal of this project was to identify the patient and procedural variables associated with delayed discharge despite following an established ERP. The hypothesis was that preoperative demographic and intraoperative factors associated with longer LOS could be prospectively recognized and addressed to prepare for patients at risk of delayed discharge.