Importance Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes and cost savings. Observations Enhanced Recovery After Surgery is a multimodal, multidisciplinary approach to the care of the surgical patient. Enhanced Recovery After Surgery process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, such as evidence-based modern care changes from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. Enhanced Recovery After Surgery protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured implementation programs that are currently in use in more than 20 countries. Local ERAS teams from hospitals are trained to implement ERAS processes. Audit of process compliance and patient outcomes are important features. Enhanced Recovery After Surgery started mainly with colorectal surgery but has been shown to improve outcomes in almost all major surgical specialties. Conclusions and Relevance Enhanced Recovery After Surgery is an evidence-based care improvement process for surgical patients. Implementation of ERAS programs results in major improvements in clinical outcomes and cost, making ERAS an important example of value-based care applied to surgery.

Enhanced Recovery After Surgery: A Review

Background Preoperative risk assessment is important yet inexact in older patients because physiologic reserves are difficult to measure. Frailty is thought to estimate physiologic reserves, although its use has not been evaluated in surgical patients. We designed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models. Study Design We prospectively measured frailty in 594 patients (age 65 years or older) presenting to a university hospital for elective surgery between July 2005 and July 2006. Frailty was classified using a validated scale (0 to 5) that included weakness, weight loss, exhaustion, low physical activity, and slowed walking speed. Patients scoring 4 to 5 were classified as frail, 2 to 3 were intermediately frail, and 0 to 1 were nonfrail. Main outcomes measures were 30-day surgical complications, length of stay, and discharge disposition. Multiple logistic regression (complications and discharge) and negative binomial regression (length of stay) were done to analyze frailty and postoperative outcomes associations. Results Preoperative frailty was associated with an increased risk for postoperative complications (intermediately frail: odds ratio [OR] 2.06; 95% CI 1.18–3.60; frail: OR 2.54; 95% CI 1.12–5.77), length of stay (intermediately frail: incidence rate ratio 1.49; 95% CI 1.24–1.80; frail: incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted-living facility after previously living at home (intermediately frail: OR 3.16; 95% CI 1.0–9.99; frail: OR 20.48; 95% CI 5.54–75.68). Frailty improved predictive power (p Conclusions Frailty independently predicts postoperative complications, length of stay, and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models. Assessing frailty using a standardized definition can help patients and physicians make more informed decisions.

Frailty as a Predictor of Surgical Outcomes in Older Patients

Background Data used for evaluating quality of medical care need to be of high reliability to ensure valid quality assessment and benchmarking. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) has continually emphasized the collection of highly reliable clinical data through its program infrastructure. Study Design We provide a detailed description of the various mechanisms used in ACS NSQIP to assure collection of high quality data, including training of data collectors (surgical clinical reviewers) and ongoing audits of data reliability. For the 2005 through 2008 calendar years, inter-rater reliability was calculated overall and for individual variables using percentages of agreement between the data collector and the auditor. Variables with > 5% disagreement are flagged for educational efforts to improve accurate collection. Cohen's kappa was estimated for selected variables from the 2007 audit year. Results Inter-rater reliability audits show that overall disagreement rates on variables have fallen from 3.15% in 2005 (the first year of public enrollment in ACS NSQIP) to 1.56% in 2008. In addition, disagreement levels for individual variables have continually improved, with 26 individual variables demonstrating > 5% disagreement in 2005, to only 2 such variables in 2008. Estimated kappa values suggest substantial or almost perfect agreement for most variables. Conclusions The ACS NSQIP has implemented training and audit procedures for its hospital participants that are highly effective in collecting robust data. Audit results show that data have been reliable since the program's inception and that reliability has improved every year.

Toward Robust Information: Data Quality and Inter-Rater Reliability in the American College of Surgeons National Surgical Quality Improvement Program

The two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval [CI], 0.24 to 0.68; P = 0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% CI, 0.14 to 0.61; P = 0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, −2.45 days; 95% CI, −4.17 to −0.72; P = 0.006). CONCLUSIONS As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical out comes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.)

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1301082

A trial of intraoperative low-tidal-volume ventilation in abdominal surgery.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2812%2961148-9.pdf

Mortality after surgery in Europe: a 7 day cohort study

Objective: The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations. Background Data: The National Surgical Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy. Methods: NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively. Results: The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses. Conclusions: The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.

Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications

Background:The Veterans Affairs ’ (VA) National Surgical Quality Improvement Program (NSQIP) has been associated with significant reductions in postoperative morbidity and mortality. We sought to determine if NSQIP methods and risk models were applicable to private sector (PS) hospitals and if imple

Successful Implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the Private Sector: The Patient Safety in Surgery Study

Background We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men. Study Design This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems. Results The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p=0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p Conclusions In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.

https://www.journalacs.org/article/S1072-7515(07)00323-7/pdf

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Men

Cecilia Mosca

Papers

Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications

Successful Implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the Private Sector: The Patient Safety in Surgery Study

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Men