Five Strategies That Reduce Total Length of Stay for Colorectal Surgery At Academic Teaching Hospitals

Mary-Anne Aarts, MD, Allan Okrainec, MD, Amy Glicksman, MD, Emily Pearsall, Robin S McLeod, MD. DEPARTMENT OF SURGERY, University of Toronto

The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery and lead to a shortened length of hospital stay for patients. Which ERAS strategies contribute most to this shortened length of stay is not clear.
Objective: To determine which ERAS strategies contribute significantly to overall shortened length of hospital stay in patients undergoing elective colorectal surgery.
Methods: A retrospective cohort study of 336 consecutive patients undergoing elective colorectal resection at 7 hospitals was performed. Demographic, length of stay, complications and data on 18 ERAS components identified from a systematic review of the literature were collected. A multi-regression analysis was performed to assess for factors independently associated with a length of stay of 5 days or less.
Outcomes: Fifty-five per cent were males, (mean age 63), 55.6% had an ASA III or IV, 76.5% had cancer and 28.0% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On univariate analysis the strategies associated with total length of stay of 5 days or less were use of a laparoscopic approach, use of a Pfannenstiel or other transverse incision, preoperative counseling, avoidance of an oral bowel prep, introduction of clear fluids on day of surgery and discontinuation of Foley catheter <24 hours from the time of surgery (all p<0.01). On multivariate analysis the factors that remained significantly associated with length of stay of 5 days or less included use of a laparoscopic approach (OR=1.38, 95% confidence interval, CI 1.33-1.44), pre-operative counseling regarding expected length of stay (OR= 1.23, 95%CI 1.16-1.30), avoidance of oral bowel prep (OR=1.03, 95%CI 1.02-1.05), clear fluids on day of surgery (OR=1.12, 95%CI 1.04-1.21), and Foley catheter discontinued within 24 hrs of colon surgery and 72 hours or rectal surgery (OR=1.08, 95%CI 1.00-1.16).
Conclusions: In hospitals with variable uptake of ERAS strategies, preoperative counseling regarding early discharge, omission of an oral bowel preparation, use of a laparoscopic approach, initiation of clear fluids on day of surgery, and early discontinuation of the Foley catheter all independently contribute to shortened length of stay.