Does Enhanced Recovery Stop on the Weekend? · Department of Visceral Surgery University Hospital...

For peer review only

Does Enhanced Recovery Stop on the Weekend?

Journal: BMJ Open

Manuscript ID bmjopen-2016-011067

Article Type: Research

Date Submitted by the Author: 06-Jan-2016

Complete List of Authors: ROMAIN, Benoit; CHUV Lausanne, Visceral Surgery

GRASS, Fabian; CHUV Lausanne, Visceral Surgery ADDOR, Valerie; CHUV Lausanne, Visceral Surgery DEMARTINES, Nicolas; CHUV Lausanne HUBNER, Martin; CHUV LAusanne

<b>Primary Subject Heading</b>:

Surgery

Secondary Subject Heading: Global health

Keywords: ERAS, enhanced recovery, weekdays, Colorectal surgery < SURGERY, complications

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Does Enhanced Recovery Stop on the Weekend?

Benoît ROMAIN, Fabian GRASS, Valérie ADDOR, Nicolas DEMARTINES, Martin

HÜBNER

Department of Visceral Surgery, University Hospital CHUV, 1011-Lausanne,

Switzerland

Corresponding address:

Nicolas DEMARTINES, MD

Department of Visceral Surgery

University Hospital (CHUV)

Rue du Bugnon 46

CH-1011 Lausanne, Switzerland

Telephone: +41 21 314 24 06

Fax: +41 21 314 23 70

Email: [email protected]

Key words: ERAS, enhanced recovery, weekdays, colorectal surgery, complications

Word count: 1582 words

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Abstract

Objective: To compare enhanced recovery after surgery (ERAS) protocol compliance

and clinical outcomes depending on the weekday of surgery.

Settings: Cohort of consecutive non-selected patients undergoing elective colorectal

from January 2012 to March 2015. This retrospective analysis of our prospective

database compared patients operated early in the week (Monday and Tuesday) with

patients operated in the second half (late: Thursday, Friday).

Primary outcome measures: Compliance to ERAS protocol, functional recovery,

complications and length of stay.

Results: Demographic and surgical details were similar between the early (n=352) and

late groups (n=204). Overall compliance to the ERAS protocol was 78% vs. 76% for

early and late group, respectively (p=0.009). Significant differences were notably

prolonged urinary drainage and intravenous fluid infusion in the late group. Complication

rates and length of stay however were not different between surgery on Monday or

Tuesday and surgery on Thursday or Friday.

Conclusions: Application of ERAS protocol showed only minor differences for patients

operated early or late during the week, and clinical outcomes were similar. A fully

implemented ERAS program appears to work also over the weekend.

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Strengths and limitations of this study

- All consecutive patients undergoing elective colorectal were included in the

present study and data were retrieved from a dedicated prospectively maintained

database.

- Staffing may be considered as generous on weekdays and during the weekend

in Swiss hospitals compared to some other countries. This makes the application

of complex and work-intensive care pathways easier than in health care systems

with restricted resources.

- It is therefore possible that our findings could not be reproduced in hospitals

where ERAS implementation has not been firmly established.

Authorship and contributions: Conception and design: BR, MH; Data acquisition:

BR, FG, VA; Drafting or revising: BR, MH, FG, ND; Final approval: BR, FG, VA, ND,

MH

Funding: No funding source

No competing interests: The authors declare that we have no competing interests

Data sharing statement: Data from this project can be made available by a request to

the corresponding author

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Introduction

Evidences from various areas of clinical medicine suggest that the day of the

week on which medical care is provided may have a significant impact on health

outcomes, 1,2. Some studies have shown increased mortality associated with elective

surgery performed before the weekend, compared to earlier in the week. 2,3,5,6

Enhanced recovery after surgery (ERAS) pathways have shown to reduce

complications, hospital length of stay and costs in colorectal surgery. 7,8,9,10 The ERAS

guidelines have been updated recently and include more than 20 items. 10,11

Compliance with those items is very important, as it is significantly correlated with better

clinical outcome. 12,13 Implementation of enhanced recovery protocols should therefore

aim for possibly complete fulfilment of the individual items. Early postoperative care

items are of utmost importance but appear to be most challenging to apply. 14

Successful ERAS programmes need active collaboration between multidisciplinary team

collaborators giving nurses a key role. Our hypothesis is that due to medical and

nursing staff reduction during weekends, successful application of the ERAS pathway,

and thus improved clinical outcomes, could be jeopardized for patients operated during

the second half of the week.

The aim of the present study was to assess the effect of the day of the week of

surgery (Monday to Tuesday versus Thursday to Friday) on compliance to the ERAS

protocol, recovery and clinical outcomes.

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Material and Methods

The ERAS program was systematically introduced for colorectal surgery in our

academic center in May 2011. 9 Prospective documentation of compliance with the

ERAS pathway and systematic audit of clinical outcome are a key component and were

performed systematically for all patients on routine basis. The present retrospective

study analyzed complications, length of stay and compliance to ERAS protocol

according to the day of the surgery (early: Monday to Tuesday versus late: Thursday to

Friday). Of note, no colorectal interventions were performed on Wednesday, as this day

is reserved for outpatient consultation. The Institutional Review Board approved the

study and all patients provided written consent before surgery. The study was

conducted in accordance with the STROBE criteria and registered under www.

researchregistry.com (No. 627).

Patients

The patient population included a consecutive cohort of non-selected elective

colorectal patients operated from January 2012 to March 2015. Of note, all patients

were treated according to the protocol and no patient was excluded from analysis.

ERAS protocol and compliance

Our institutional enhanced recovery pathway is applied in accordance with the

recently updated ERAS guidelines. 10,11 (Figure 1) Compliance with the ERAS protocol

was prospectively assessed for the different phases of peri-operative care (pre-, intra-

and post-operative; total) as previously published. 15 Briefly, enhanced recovery items

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were handled as dichotomous variables. Compliance with individual items was

calculated as percentage of compliant patients/total patients. The number of fulfilled

items divided by the total number of the 21 enhanced recovery measures (%) was

presented as overall compliance with the pathway.

Data collection

A dedicated and specially trained enhanced recovery nurse (VA) was in charge

of completing the prospective database (database and ERAS Interactive Audit System).

Demographic and surgical details of all patients in the enhanced recovery pathway were

captured along with detailed information on compliance with the protocol and audit of

clinical outcomes until a minimum of 30 days after surgery. Return of bowel function

(flatus/stool) was recorded, and postoperative complications were graded according to

the Clavien classification system. 16 Length of stay was counted from day of surgery

until discharge. Total hospital stay included preoperative days and early readmissions

within 30 days after surgery.

Statistical analysis

Descriptive statistics for categorical variables were reported as frequency (%),

while continuous variables were reported as means (standard deviation) or median

(interquartile range: IQR) as appropriate. Chi-square was used for comparison of

categorical variables. All statistical tests were two-sided and a level of 0.05 was used to

indicate statistical significance. Data analyses were performed using SPSS 10 (SPSS

Inc., Chicago, IL).

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Results

Cohort demographics

A total of 556 patients underwent surgery within the enhanced recovery

programme from January 2012 to March 2015. Data were analysed according to the

day of the surgery (early: Monday to Tuesday: n=352 versus late: Thursday to Friday:

n=204) (Table 1). There was no significant difference between the two groups in terms

of demographics and surgical details.

Compliance to ERAS protocol

Total compliance to ERAS protocol was 78% for the early group and 76% for the

late group (p=0.009). When analyzing compliance by the different perioperative periods

(pre-, intra- and post-operative), no significant difference was noted (Supplementary

Fig. 1). In fact, only three individual items showed small but significant differences in

disfavour of patients operated later in the week: these were prolonged urinary drainage,

intravenous fluid infusion and higher postoperative weight gain (Figure 1).

Postoperative complications according to week days

Overall complication rates were 42% and 43% for the early and late group,

respectively (p=0.88). No significant difference was observed for major complications

(12 vs. 11%, p=0.39). Median hospital stay was 6 days [4; 10] for patients operated on

Monday/Tuesday as compared to 5 days [4; 9] for patients operated on Thursday/Friday

(p=0.24). Readmission rates were 5.4% and 6.3% for the early and late group,

respectively (p= 0.52).

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Discussion

Application of the established ERAS protocol was equally high in our cohort on

weekdays and during the weekend with minor differences for three individual items only.

Despite significant lower compliance to ERAS pathway for the group operated at

the end of the week, ERAS protocol was applied equally in the 3 pre-per and

postoperative. The difference should be considered as clinically irrelevant because all

patients had the same functional and clinical outcomes.

Evidences from several clinical medicine areas suggest that the day of the week

on which medical care is provided may have a significant impact on health outcomes.

Some articles have even described a “weekend effect” which represents worse outcome

for patients admitted at weekends compared to weekdays in terms of mortality and

length of hospital stay. 4 Zare et al have found a higher 30 days mortality (deaths in

hospital and after discharge) after non emergency surgery on Fridays, compared to

early weekdays in patients admitted to regular wards. 3 One possible explanation could

be the poorer quality of care on weekends due to reduced staffing in terms of number

and experience, with less senior staff. Furthermore, in the study of Aylin et al, the

overall risk of death within 30 days for patients undergoing elective surgery increased

with the day of the week on which the procedure was performed. 2 Compared with

Monday, the adjusted odds of death for all elective surgical procedures was respectively

44% and 82% higher if the procedures were carried out on Friday or at the weekend.

The reasons for this difference remain unknown, but it appears that serious

complications are more likely to occur within the first 48 hours after an operation, and a

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failure to rescue the patient could be related to reduced and/or locum staffing

(expressed as number and level of experience) and poorer availability of services over a

weekend. Improved clinical outcomes require a possibly complete application of the

ERAS protocol. In clinical practice, a threshold of at least 70% of overall compliance

was found to be significant, 12 (own unpublished data). In the present study, similarly

high level of health care was maintained independently of the day of the week as

reflected by overall compliance of 78% and 76%, respectively. Some differences were

documented for nurse-related measures like delayed urinary drainage and prolonged

intravenous fluid administration that could be explained by reduced staffing on the

weekend. However, absolute differences were marginal and had no effect on recovery

and clinical outcomes.

The application of enhanced recovery protocols in colorectal surgery allows

some significant reduction in post-operative complication rates, length of stay, and

costs. A successful collaboration between multidisciplinary team members on the ward

is needed to achieve high compliance to ERAS items and thus support patient recovery

after surgery.

Ihedioha et al have examined the impact of the day of surgery on short-term

recovery after colorectal surgery. 6 They observed a significantly longer length of stay in

patients operated later in the week. The results of their study differ from our present

results, since we did not observed any difference in length of stay and complication

rates between patients operated on Monday and Tuesday versus Thursday and Friday.

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This is a retrospective study with inherent limitations and sources of bias.

However, selection bias appears unlikely because OR scheduling was based on logistic

and administrative reasons only with no clinical considerations behind. Furthermore, all

consecutive patients were included in the present study and data were retrieved from a

dedicated prospectively maintained database. Staffing may be considered as generous

on weekdays and during the weekend in Swiss hospitals compared to some other

countries. This makes the application of complex and work-intensive care pathways

easier than in health care systems with restricted resources. Furthermore, ERAS was

implemented early in 2011 in our institution, and thus study patients were treated after

the initial implementation process. It is therefore possible that our findings could not be

reproduced in hospitals where ERAS implementation has not been firmly established.

In conclusion, compliance to ERAS pathway was high for both, patients operated

early or late during the week. Minor differences in terms of urinary drainage and IV

fluids had no impact on functional and clinical outcomes. While this is plausible with a

long-standing program and trained staff, it might be more challenging for teams in the

beginning of ERAS implementation process.

References

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IA. Exploratory study of the 'weekend effect' for acute medical admissions to

public hospitals in Queensland, Australia. Intern Med J. 2010; 40: 777-83.

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2. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure

and 30 day mortality for elective surgery: retrospective analysis of hospital

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3. Zare MM, Itani KM, Schifftner TL, Henderson WG, Khuri SF. Mortality after

nonemergent major surgery performed on Friday versus Monday through

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4. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on

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Surg. 2015;102: 1272-7.

6. Ihedioha U, Esmail F, Lloyd G, Miller A, Singh B, Chaudhri S. Enhanced recovery

programmes in colorectal surgery are less enhanced later in the week: An

observational study. JRSM Open. 2015; 6:2 1-5

7. Greco M, Capretti G, Beretta L, et al. Enhanced Recovery Program in Colorectal

Surgery: A Meta-analysis of Randomized Controlled Trials. World J Surg. 2014;

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8. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N; Zurich Fast Track

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9. Roulin D, Donadini A, Gander S, Griesser AC, Blanc C, Hübner M, Schäfer M,

Demartines N. Cost-effectiveness of the implementation of an enhanced

recovery protocol for colorectal surgery. Br J Surg. 2013; 100: 1108-14.

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10. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in

elective colonic surgery: Enhanced Recovery After Surgery (ERAS((R))) Society

recommendations. World J Surg. 2013; 37: 259-84.

11. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective

rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS((R))) Society


12. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery

after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg.

2011; 146:571-7.

13. Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA;

Collaborative LAFA Study Group. Which fast track elements predict early

recovery after colon cancer surgery? Colorectal Dis. 2012; 14: 1001-8.

14. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG,

Revhaug A, Kehlet H, Ljungqvist O, Fearon KC, von Meyenfeldt MF. A protocol is

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9.

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Table1: Surgical and demographics details of the cohort

Monday + Tuesday

n=352

Thursday + Friday

n=204 p-value

Sex Ratio M/F 197/155 (1.27) 123/81 (1.52) 0.18

Mean BMI ± SD 25.51 ± 5.01 25.48 ± 5.11 0.94

Mean Age ± SD 61.34 ± 15.6 60.33 ± 15.7 0.46

ASA group

1 -2

3 -4

274 (77.84%)

78 (22.15%)

52 (74.5%)

52 (25.5%)

0.23

Surgical procedure

Laparoscopy

Open surgery

Stoma procedure

Conversion

178 (50.5%)

83 (23.6%)

63 (17.9%)

27 (7.7%)

87 (42.6%)

66 (32.4%)

36 (17.6%)

15 (7.4%)

0.32

Operative time (minutes) 179.5 193.5 0.41

Mean blood loss (mL) ± SEM 149.3 ± 13.04 199.2 ± 26.02 0.058

SEM: Standard Error of he Mean; SD: Standard Deviation; p<0.05 indicates statistical significance

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Figure 1: Components of pre-, intra- and post-operative compliance

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Supplementary Figure 1: Details of compliance to ERAS protocol: pre-, intra- and

post-operative compliance

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cohort studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 4

Objectives 3 State specific objectives, including any prespecified hypotheses 4

Methods

Study design 4 Present key elements of study design early in the paper 5

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

5

Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up 5

(b) For matched studies, give matching criteria and number of exposed and unexposed NA

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

5,6

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

5,6

Bias 9 Describe any efforts to address potential sources of bias 5,6

Study size 10 Explain how the study size was arrived at 5

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

6

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 6

(b) Describe any methods used to examine subgroups and interactions NA

(c) Explain how missing data were addressed 6

(d) If applicable, explain how loss to follow-up was addressed NA

(e) Describe any sensitivity analyses NA

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, confirmed

eligible, included in the study, completing follow-up, and analysed

7

(b) Give reasons for non-participation at each stage NA

(c) Consider use of a flow diagram NA

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

7

(b) Indicate number of participants with missing data for each variable of interest 7

(c) Summarise follow-up time (eg, average and total amount) 7

Outcome data 15* Report numbers of outcome events or summary measures over time 7

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

7

(b) Report category boundaries when continuous variables were categorized 7

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period 7

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses NA

Discussion

Key results 18 Summarise key results with reference to study objectives 8

Limitations

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

10

Generalisability 21 Discuss the generalisability (external validity) of the study results 10

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

3

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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Impact of weekday of surgery on application of enhanced recovery pathway – a retrospective cohort study

Journal: BMJ Open

Manuscript ID bmjopen-2016-011067.R1


Date Submitted by the Author: 13-May-2016

Complete List of Authors: ROMAIN, Benoit; CHUV Lausanne, Visceral Surgery GRASS, Fabian; CHUV Lausanne, Visceral Surgery ADDOR, Valerie; CHUV Lausanne, Visceral Surgery DEMARTINES, Nicolas; CHUV Lausanne HUBNER, Martin; CHUV LAusanne


Surgery




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Impact of weekday of surgery on application of enhanced recovery pathway – a

retrospective cohort study


HÜBNER


Switzerland





Rue du Bugnon 46


Telephone: +41 21 314 24 06

Fax: +41 21 314 23 70




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Abstract


















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database.









MH





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Introduction




















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is reserved for outpatient consultation. Staff situation in our institution is as follows: 5

nurses take care of 22 patients during the week, and 4 nurses are in charge during the

weekend. On average, 2 surgical residents take care of about 15 patients during the

week, while only 2 residents are responsible for all hospitalized surgical patients (about

60) on the weekend. They are back-upped by one fellow and one consultant on call.

The Institutional Review Board approved the study and all patients provided written

consent before surgery. The study was conducted in accordance with the STROBE

criteria and registered under www. researchregistry.com (No. 627).

Patients





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were handled as dichotomous variables. Of note, recommended omissions were

accounted as compliant, if the measure was not performed; e.g. no bowel preparation or

no nasogastric tube were documented as being compliant with the pathway.

Compliance with individual items was calculated as percentage of compliant

patients/total patients. The number of fulfilled items divided by the total number of the

21 enhanced recovery measures (%) was presented as overall compliance with the

pathway.

Data collection











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Inc., Chicago, IL).

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Results

Cohort demographics




















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Discussion











length of hospital stay. 4,17,18 Zare et al have found a higher 30 days mortality (deaths in











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weekend. Improved clinical outcomes require a possibly complete application of the

ERAS protocol. In clinical practice, a threshold of at least 70% of overall compliance

was found to be significant, 12 (own unpublished data). In the present study, similarly

high level of health care was maintained independently of the day of the week as

reflected by an overall compliance of 78% and 76%, respectively. Although this

difference was statistically significant, it appears unlikely that a 2% gap would be of

clinical relevance. Furthermore, no difference was detected when analyzing ERAS

compliance by perioperative phase. This finding is important when the postoperative

phase coincides with the weekend for patients operated on Thursday or Friday,

respectively. The smallest meaningful difference for ERAS compliance has not been

identified yet. However, studies focusing on the correlation of compliance with clinical

outcomes found clinically significant effects for differences in compliance of 10% or

more. 12, 19 This is in accordance with our findings of similar clinical outcomes for the two

comparative groups. A well standardized pathway (like ERAS) might help to cope with

limited resources on weekends or in general. Not every individual item of the complex

protocol might have the same importance 14. Subtle differences existed between the two

comparative groups. These were nurse-related measures like delayed urinary catheter

removal and prolonged intravenous fluid administration that could be explained by

reduced staffing on the weekend. But again, absolute differences were marginal and

had no effect on recovery and clinical outcomes.

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after surgery.




results, since we did not observe any difference in length of stay and complication rates

between patients operated on Monday and Tuesday versus Thursday and Friday.





dedicated prospectively maintained database. The study might be underpowered to

detect small differences of certain endpoints (e.g. complications) between the

comparative groups (risk of type II error). However, 556 prospectively documented

patients were available and no significant difference in outcomes was detected.

Staffing may be considered as generous on weekdays and during the weekend

in Swiss hospitals compared to some other countries. This makes the application of

complex and work-intensive care pathways easier than in health care systems with

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12

restricted resources. Furthermore, ERAS was implemented early in 2011 in our

institution, and thus study patients were treated after the initial implementation process.

It is therefore possible that our findings could not be reproduced in hospitals where

ERAS implementation has not been firmly established.




long-standing program with standardized measures and trained staff, it might be more

challenging for teams in the beginning of ERAS implementation process.

References

1. Clarke MS, Wills RA, Bowman RV, Zimmerman PV, Fong KM, Coory MD, Yang

IA. Exploratory study of the 'weekend effect' for acute medical admissions to

public hospitals in Queensland, Australia. Intern Med J. 2010; 40: 777-83.

2. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure

and 30 day mortality for elective surgery: retrospective analysis of hospital

episode statistics. BMJ. 2013; 346: f2424.


nonemergent major surgery performed on Friday versus Monday through

Wednesday. Ann Surg 2007; 246:866-874

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13

4. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on

weekends as compared with weekdays. N Engl J Med 2001; 345: 663-68.

5. Vohra RS, Pinkney T, Evison F, Begaj I, Ray D, Alderson D, Morton DG. Br J

Surg. 2015;102: 1272-7.


programmes in colorectal surgery are less enhanced later in the week: An

observational study. JRSM Open. 2015; 6:2 1-5


Surgery: A Meta-analysis of Randomized Controlled Trials. World J Surg. 2014;

38: 1531-41.

8. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N; Zurich Fast Track

Study Group. A fast-track program reduces complications and length of hospital

stay after open colonic surgery. Gastroenterology. 2009; 136: 842-7.


Demartines N. Cost-effectiveness of the implementation of an enhanced

recovery protocol for colorectal surgery. Br J Surg. 2013; 100: 1108-14.

10. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in

elective colonic surgery: Enhanced Recovery After Surgery (ERAS((R))) Society





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12. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery

after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg.

2011; 146:571-7.


Collaborative LAFA Study Group. Which fast track elements predict early

recovery after colon cancer surgery? Colorectal Dis. 2012; 14: 1001-8.

14. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG,

Revhaug A, Kehlet H, Ljungqvist O, Fearon KC, von Meyenfeldt MF. A protocol is

not enough to implement an enhanced recovery programme for colorectal

resection. Br J Surg. 2007; 94: 224-31.

15. Roulin D, Blanc C, Muradbegovic M, Hahnloser D, Demartines N, Hübner M.

Enhanced recovery pathway for urgent colectomy. World J Surg. 2014; 38: 2153-

9.

16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a

new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Ann Surg. 2004; 240: 205-13.

17. Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient

satisfaction after hip and knee replacement surgery: fast-track experience in 712

patients. Acta Orthop 2008; 79:168-73.

18. Rathi P, Coleman S, Durbin-Johnson B, Giordani M, Pereira G, Di Cesare PE.

Effect of day of the week of primary total hip arthroplasty on length of stay at a

university-based teaching medical center. Am J Orthop 2014; 43:E299-E303

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19. ERAS Compliance Group. The Impact of Enhanced Recovery Protocol

Compliance on Elective Colorectal Cancer Resection: Results from an

International Registry. Ann Surg. 2015 Jun; 261: 1153-9

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Monday + Tuesday

n=352

Thursday + Friday

n=204 p-value

Sex Ratio M/F 197/155 (1.27) 123/81 (1.52) 0.18

Mean BMI ± SD 25.51 ± 5.01 25.48 ± 5.11 0.94

Mean Age ± SD 61.34 ± 15.6 60.33 ± 15.7 0.46

ASA group

1 -2

3 -4

274 (77.84%)

78 (22.15%)

52 (74.5%)

52 (25.5%)

0.23

Surgical procedure

Laparoscopy

Open surgery

Stoma procedure

Conversion

178 (50.5%)

83 (23.6%)

63 (17.9%)

27 (7.7%)

87 (42.6%)

66 (32.4%)

36 (17.6%)

15 (7.4%)

0.32

Etiology

Primary adenocarcinoma 183 (52%) 103 (50.5%)

Other primary malignancy 3 (0.9%) 4 (1.9%)

Surgery for metastasis or recurrence of any malignancy 11 (3.1%) 13 (6.4%)

Benign tumor including polyp (s) 17 (4.8%) 9 (4.4%) 0.56

Crohn disease 20 (5.6%) 4 (2%)

Infammatory bowel disease 27 (7.6%) 11 (5.4%)

Diverticular disease 44 (12.5%) 27 (13.2%)

Functional disorder 18 (5.1%) 12 (5.9%

Other benign disorder 29 (8.2%) 21 (10.3%)

Rectal resections

75 (21.6%)

32 (15.7%)

0.09




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Figure 1: Components of pre-, intra- and post-operative compliance: Enhanced recovery items were handled as dichotomous variables. Recommended omissions were accounted

as compliant, if the measure was not performed; e.g. no bowel preparation or no nasogastric tube were

documented as being compliant with the pathway. Compliance with individual items was calculated as percentage of compliant patients/total patients.

Figure 1

160x119mm (300 x 300 DPI)

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Supplementary Figure 1: Details of compliance to ERAS protocol: pre-, intra- and post-operative compliance Supplementary Figure 1

160x119mm (300 x 300 DPI)

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Section/Topic Item




Introduction



Methods



collection

5




applicable

5,6

Data sources/

measurement



5,6




why

6






Results

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7




confounders

7






7




Discussion


Limitations



10


Other information



3





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Impact of weekday of surgery on application of enhanced recovery pathway – a retrospective cohort study

Journal: BMJ Open

Manuscript ID bmjopen-2016-011067.R2


Date Submitted by the Author: 18-Aug-2016

Complete List of Authors: ROMAIN, Benoit; CHUV Lausanne, Visceral Surgery GRASS, Fabian; CHUV Lausanne, Visceral Surgery ADDOR, Valerie; CHUV Lausanne, Visceral Surgery DEMARTINES, Nicolas; CHUV Lausanne HUBNER, Martin; CHUV LAusanne


Surgery




BMJ Open on M


http://bmjopen.bm

j.com/

BM



ownloaded from



1

Impact of weekday of surgery on application of enhanced recovery pathway – a

retrospective cohort study


HÜBNER


Switzerland





Rue du Bugnon 46


Telephone: +41 21 314 24 06

Fax: +41 21 314 23 70




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Abstract


















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database.









MH





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Introduction




















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5









is reserved for outpatient consultation. Staff situation in our institution is as follows: 5

nurses take care of 22 patients during the week, and 4 nurses are in charge during the

weekend. On average, 2 surgical residents take care of about 15 patients during the

week, while only 2 residents are responsible for all hospitalized surgical patients (about

60) on the weekend. They are back-upped by one fellow and one consultant on call.

The Institutional Review Board approved the study and all patients provided written

consent before surgery. The study was conducted in accordance with the STROBE

criteria and registered under www. researchregistry.com (No. 627).

Patients





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were handled as dichotomous variables. Of note, recommended omissions were

accounted as compliant, if the measure was not performed; e.g. no bowel preparation or

no nasogastric tube were documented as being compliant with the pathway.

Compliance with individual items was calculated as percentage of compliant

patients/total patients. The number of fulfilled items divided by the total number of the

21 enhanced recovery measures (%) was presented as overall compliance with the

pathway.

EDAs were systematically used for open major resections except for patients with

contraindications including patients’ refusal. Recently, new pain management strategies

such as intravenous lidocaine infusion or ultrasound guided transversus abdominis

plane blocks have been exerted for some of the open procedures of the present cohort.

Data collection







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Inc., Chicago, IL).

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Results

Cohort demographics




















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Discussion











length of hospital stay. 4,17,18 Zare et al have found a higher 30 days mortality (deaths in











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weekend. In our experience, no clinically relevant difference was found. We attribute

this to the fact, that most of our nursing staff is dedicated staff, with several of our

caregivers remaining in the Department for several years, and thus through the ERAS

implementation and consolidation process. In order to ensure a continuity of care

through the weekend, senior and junior staff members are paired whenever possible,

likewise for medical and nursing staff. Furthermore, new collaborators receive formal

teaching on ERAS on arrival and periodically, the junior medical and nursing staff is

instructed by senior surgeons and the dedicated clinical ERAS nurse to update all

caregivers on ERAS care during Institutional staff meetings. Improved clinical outcomes

require a possibly complete application of the ERAS protocol. In clinical practice, a

threshold of at least 70% of overall compliance was found to be significant, 12 (own

unpublished data). In the present study, similarly high level of health care was

maintained independently of the day of the week as reflected by an overall compliance

of 78% and 76%, respectively. Although this difference was statistically significant, it

appears unlikely that a 2% gap would be of clinical relevance. Furthermore, no

difference was detected when analyzing ERAS compliance by perioperative phase. This

finding is important when the postoperative phase coincides with the weekend for

patients operated on Thursday or Friday, respectively. The smallest meaningful

difference for ERAS compliance has not been identified yet. However, studies focusing

on the correlation of compliance with clinical outcomes found clinically significant effects

for differences in compliance of 10% or more. 12, 19 This is in accordance with our

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11

findings of similar clinical outcomes for the two comparative groups. A well standardized

pathway (like ERAS) might help to cope with limited resources on weekends or in

general. Not every individual item of the complex protocol might have the same

importance 14. Subtle differences existed between the two comparative groups. These

were nurse-related measures like delayed urinary catheter removal and prolonged

intravenous fluid administration that could be explained by reduced staffing on the

weekend. But again, absolute differences were marginal and had no effect on recovery

and clinical outcomes.





after surgery.




results, since we did not observe any difference in length of stay and complication rates

between patients operated on Monday and Tuesday versus Thursday and Friday.




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dedicated prospectively maintained database. The cohort is heterogenous (colon and

rectal resections) and the study might be underpowered to detect small differences of

certain endpoints (e.g. complications) between the comparative groups (risk of type II

error). However, 556 prospectively documented patients were available and no

significant difference in outcomes was detected. Length of stay was longer in our cohort

as compared to previous reports, but still within the reported range of the international

ERAS benchmarking included in the international ERAS database 20, 21, 22. Lastly,

overall compliance was not yet optimal despite full implementation process, similar to

other reports 12, 14, 23. We would expect improved outcomes for both comparative groups

with higher compliance levels but no difference between patients operated on early or

later during the week.

Staffing may be considered as generous on weekdays and during the weekend

in Swiss hospitals compared to some other countries. This makes the application of

complex and work-intensive care pathways easier than in health care systems with

restricted resources. Furthermore, ERAS was implemented early in 2011 in our

institution, and thus study patients were treated after the initial implementation process.

It is therefore possible that our findings could not be reproduced in hospitals where

ERAS implementation has not been firmly established.




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long-standing program with standardized measures and trained staff, it might be more

challenging for teams in the beginning of ERAS implementation process.

References

1. Clarke MS, Wills RA, Bowman RV, Zimmerman PV, Fong KM, Coory MD, Yang IA.

Exploratory study of the 'weekend effect' for acute medical admissions to public hospitals

in Queensland, Australia. Intern Med J. 2010; 40: 777-83.

2. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and

30 day mortality for elective surgery: retrospective analysis of hospital episode statistics.

BMJ. 2013; 346: f2424.


nonemergent major surgery performed on Friday versus Monday through Wednesday.

Ann Surg 2007; 246:866-874

4. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as

compared with weekdays. N Engl J Med 2001; 345: 663-68.

5. Vohra RS, Pinkney T, Evison F, Begaj I, Ray D, Alderson D, Morton DG. Br J Surg.

2015;102: 1272-7.


programmes in colorectal surgery are less enhanced later in the week: An observational

study. JRSM Open. 2015; 6:2 1-5

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Surgery: A Meta-analysis of Randomized Controlled Trials. World J Surg. 2014; 38:

1531-41.

8. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N; Zurich Fast Track Study

Group. A fast-track program reduces complications and length of hospital stay after open

colonic surgery. Gastroenterology. 2009; 136: 842-7.


Demartines N. Cost-effectiveness of the implementation of an enhanced recovery

protocol for colorectal surgery. Br J Surg. 2013; 100: 1108-14.

10. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective

colonic surgery: Enhanced Recovery After Surgery (ERAS((R))) Society





12. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery after

surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011; 146:571-

7.


Collaborative LAFA Study Group. Which fast track elements predict early recovery after

colon cancer surgery? Colorectal Dis. 2012; 14: 1001-8.

14. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug

A, Kehlet H, Ljungqvist O, Fearon KC, von Meyenfeldt MF. A protocol is not enough to

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15

implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;

94: 224-31.

15. Roulin D, Blanc C, Muradbegovic M, Hahnloser D, Demartines N, Hübner M. Enhanced

recovery pathway for urgent colectomy. World J Surg. 2014; 38: 2153-9.

16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new

proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg.

2004; 240: 205-13.

17. Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after

hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop

2008; 79:168-73.

18. Rathi P, Coleman S, Durbin-Johnson B, Giordani M, Pereira G, Di Cesare PE. Effect of

day of the week of primary total hip arthroplasty on length of stay at a university-based

teaching medical center. Am J Orthop 2014; 43:E299-E303

19. ERAS Compliance Group. The Impact of Enhanced Recovery Protocol Compliance on

Elective Colorectal Cancer Resection: Results from an International Registry. Ann Surg.

2015 Jun; 261: 1153-9

20. Levy BF, Scott MJ, Fawcett WJ, Rockall TA. 23-hour-stay laparoscopic colectomy.

Diseases of the colon and rectum 2009; 52: 1239-43.

21. Keller DS, Stulberg JJ, Lawrence JK, Delaney CP. Process control to measure process

improvement in colorectal surgery: modifications to an established enhanced recovery

pathway. Diseases of the colon and rectum 2014; 57: 194-200.

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22. Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H. Readmission rates after a

planned hospital stay of 2 versus 3 days in fast-track colonic surgery. The British journal

of surgery 2007; 94: 890-3.

23. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J; Enhanced

Recovery After Surgery Study Group. Adherence to the enhanced recovery after surgery

protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011; 146: 571-7.

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Monday + Tuesday

n=352

Thursday + Friday

n=204 p-value

Sex Ratio M/F 197/155 (1.27) 123/81 (1.52) 0.18

Mean BMI ± SD 25.51 ± 5.01 25.48 ± 5.11 0.94

Mean Age ± SD 61.34 ± 15.6 60.33 ± 15.7 0.46

ASA group

1 -2

3 -4

274 (77.84%)

78 (22.15%)

52 (74.5%)

52 (25.5%)

0.23

Surgical procedure

Laparoscopy

Open surgery

Stoma procedure

Conversion

179 (50.8%)

83 (23.6%)

63 (17.9%)

27 (7.7%)

87 (42.6%)

66 (32.4%)

36 (17.6%)

15 (7.4%)

0.32

Etiology

Primary adenocarcinoma 183 (52%) 103 (50.5%)

Other primary malignancy 3 (0.9%) 4 (1.9%)

Surgery for metastasis or recurrence of any malignancy 11 (3.1%) 13 (6.4%)

Benign tumor including polyp (s) 17 (4.8%) 9 (4.4%) 0.56

Crohn disease 20 (5.6%) 4 (2%)

Infammatory bowel disease 27 (7.6%) 11 (5.4%)

Diverticular disease 44 (12.5%) 27 (13.2%)

Functional disorder 18 (5.1%) 12 (5.9%

Other benign disorder 29 (8.2%) 21 (10.3%)

Rectal resections

75 (21.6%)

32 (15.7%)

0.09




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Figure 1: Components of pre-, intra- and post-operative compliance: Enhanced recovery items were handled as dichotomous variables. Recommended omissions were accounted

as compliant, if the measure was not performed; e.g. no bowel preparation or no nasogastric tube were

documented as being compliant with the pathway. Compliance with individual items was calculated as percentage of compliant patients/total patients.

Figure 1 254x190mm (300 x 300 DPI)

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Supplementary Figure 1: Details of compliance to ERAS protocol: pre-, intra- and post-operative compliance Supplementary Figure 1:

254x190mm (300 x 300 DPI)

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Section/Topic Item




Introduction



Methods



collection

5




applicable

5,6

Data sources/

measurement



5,6




why

6






Results

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7




confounders

7






7




Discussion


Limitations



10


Other information



3





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Does Enhanced Recovery Stop on the Weekend? · Department of Visceral Surgery University Hospital...

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