Walker Ueland, BS, Margaret A Plymale, DNP, RN, Daniel L Davenport, PhD, Mary C Plymale, BS, John S Roth, MD, FACS. University of Kentucky
Introduction: Ventral hernia repair (VHR) is a commonly-performed procedure that may be associated with prolonged hospitalization. Enhanced Recovery after Surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS). This study aims to evaluate the impact of compliance with individual VHR ERAS protocol elements on LOS.
Methods: With IRB approval, medical record review including compliance with ERAS elements was conducted of consecutive cases of open VHR performed between August 2013 and July 2017 with ERAS protocol implemented in August 2015. ERAS elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. Then the effects of specific ERAS elements on LOS were assessed after adjusting for clinical predictors.
Results: 234 patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the geometric mean LOS was 4.8 days (95% CI 4.5 – 5.1). Independent predictors (p’s < .05) of increased LOS were CDC Wound Class III or IV, COPD, prior infected mesh, concomitant procedure, mesh size, and age. Formal ERAS implementation was associated with a 15% or 0.7 day (95% CI 6% – 24%) reduction in mean LOS after adjustment. ERAS element compliance associated with reduced LOS are shown in the Table. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (-37%).
Conclusions: Implementation of a VHR ERAS protocol results in decreased LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.
| Protocol Element | Non-compliant | Partial Compliance | Compliant | Risk-Adjusted Change in log-LOS(95% CI) |
| Preop Fasting | 80.8% | 0% | 19.2% | 0.88****(0.77-1.01) |
| Preop Fluid Management | 41.9% | 2.1% | 56.0% | 0.87**(0.78-0.96) |
| Hypothermia Prevention | 40.2% | 0% | 59.8% | 0.89**(0.80-0.99) |
| Multimodal Pain Management | 2.6% | 36.3% | 61.1% | 0.87***(0.78-0.97) |
| Acceleration of Intestinal Recovery | 13.2% | 61.1% | 25.6% | 0.63*(0.52-0.75) |
| Early Mobilization | 47.9% | 0% | 52.1% | 0.85**(0.77-0.95) |
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94529
Program Number: S098
Presentation Session: Inquinal and Ventral Hernia
Presentation Type: Podium