NIHR Signal Following programmes to improve recovery after surgery linked to shorter hospital stays

Published on 24 January 2017

Reduced compliance with enhanced recovery protocols was associated with more days in hospital after keyhole bowel surgery, an increased likelihood of readmission and complications. Enhanced recovery, also known as fast track access, is considered standard practice but there is considerable variation in what this means and how this is implemented locally.

This systematic review included 34 studies where protocols were used to enhance recovery after laparoscopic colorectal resection surgery. The review aimed to identify which elements of local protocols such as early walking or epidural anaesthesia, are associated with a successful outcome. However, because local protocols vary considerably and the individual elements were not always clearly defined, it proved difficult to pool results and to quantify which elements of enhanced recovery might be most critical. The study did find that those hospitals sticking closely to the full recovery programme got the best results.

The review highlights compliance could be a key factor in poorer outcomes which suggests clinical teams may benefit from reviewing and auditing local protocols.

Share your views on the research.

Why was this study needed?

Since the early 1990s, enhanced recovery programmes, also known as fast track programmes, have been increasingly implemented globally. In 2011 UK researchers estimated that about 33% of colorectal surgery was undertaken laparoscopically and 50% used an enhanced recovery protocol. This will have increased in the last five years as these quality improvement initiatives have been rolled out.

Protocols work across all aspects of colorectal cancer care and enhanced recovery has been shown to benefit both patients and health providers. An earlier review, funded by NIHR, found enhanced recovery in colorectal surgery reduced length of stay by 0.5 to 3.5 days. Programmes which reduced length of stay were found to be cost effective with no negative impact on complications, readmissions or quality of life.

However, there are instances when patients don’t seem to benefit from enhanced recovery. Clinical teams need to understand which aspects of an enhanced recovery package are most critical for a successful outcome. This would help identify patients who might be at risk from a poorer outcome so that clinicians can take appropriate actions.

What did this study do?

The review identified 34 studies, including randomised controlled trials, comparative cohort studies and case series. In total, the studies reported on 10,861 laparoscopic resections. The different approaches taken by the studies meant a meta-analysis was not possible and only 26 described the protocol fully.

The most common outcome measures used in studies were: length of stay, morbidity and readmissions. Studies reported on 159 different outcome measures and some of these were poorly defined, making it difficult to compare the different components of enhanced recovery. The authors therefore could not meet their original aim of assessing the most effective components in detail as interventions and outcomes varied across studies. Whilst length of stay is of interest, it can be an unreliable indicator as patients may be medically fit to discharge but discharge is delayed until social care support is available.

In addition, poor compliance, particularly with post-operative enhanced recovery protocols may be misleading as it could be an indication of complications rather than deviation from the package. Many of the trials had some bias due to a lack of blinding of the outcome assessors and the lack of any statistical assessment of the strength of any association also limits the interpretation of the results.

What did it find?

  • There were 34 studies included in the review and these reported on 10,861 patients. Eight were randomised controlled trials and eight were non-randomised controlled studies and the rest were case series. The exact composition of enhanced recovery packages varied considerably, including, on average, 14 different elements. This mean that the strength of any links between protocol and outcome could not be quantified and only broad conclusion were possible.
  • Compliance to the protocol was highest for pre-operative patient education; intra-operative warming; avoidance of naso-gastric tubes and abdominal drains; early removal of urinary catheters; resuming solid food within 24 hours; and use of non-steroidal anti-inflammatories.
  • Reduced overall compliance was associated with longer length of stay, increased morbidity and increased readmissions.
  • Older age was associated with reduced compliance with protocols, suggesting possibly more complex needs.

What does current guidance say on this issue?

Enhanced recovery has been promoted widely within the NHS. The Enhanced Recovery Partnership Programme worked with a range of innovator sites and agreed a national consensus statement to advocate enhanced recovery as standard practice. Guidance from the Association of Surgeons of Great Britain and Ireland recommends full compliance with protocols to ensure the best possible outcomes.

What are the implications?

There is a broad literature on enhanced recovery programmes and differences can reflect local preferences. This review confirms that compliance with enhanced recovery protocols can minimise complications and reduce length of stay. Clinical teams may find it useful to review local protocols to ensure components and outcome measures are clearly defined. It may also be worthwhile to invest in an audit to test compliance and to understand local barriers and enablers to compliance.

Citation and Funding

Messenger DE, Curtis NJ, Jones A, et al. Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc. 2016. [Epub ahead of print].

No funding information was provided for this study.

Bibliography

Currie AC, Malietzis G and Jenkins JT. Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer. Br J Surg. 2016;103(13):1783-94.

Enhanced Recovery Partnership Programme. Delivering enhanced recovery: helping patients to get better sooner after surgery. London: Department of Health; 2010.

NHS Improving Quality. A better journey for patients seven days a week and better deal for the NHS. Enhanced recovery care pathway. Progress review (2012/13) and level of ambition (2014/15). London: NHS Improving Quality; 2013.

Paton F, Chambers D, Wilson P, et al. Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis. BMJ Open. 2014;4(7): e005015.

Paton F, Chambers D, Wilson P, et al. Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes. 2014. Health Services and Delivery Research. 2014;2(21).

Kehlet H and Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-98.

Khan S, Gatt M, Horgan A, et al. Guidelines for implementation of enhanced recovery protocols. London: Association of Surgeons of Great Britain and Ireland; 2009.

Why was this study needed?

Since the early 1990s, enhanced recovery programmes, also known as fast track programmes, have been increasingly implemented globally. In 2011 UK researchers estimated that about 33% of colorectal surgery was undertaken laparoscopically and 50% used an enhanced recovery protocol. This will have increased in the last five years as these quality improvement initiatives have been rolled out.

Protocols work across all aspects of colorectal cancer care and enhanced recovery has been shown to benefit both patients and health providers. An earlier review, funded by NIHR, found enhanced recovery in colorectal surgery reduced length of stay by 0.5 to 3.5 days. Programmes which reduced length of stay were found to be cost effective with no negative impact on complications, readmissions or quality of life.

However, there are instances when patients don’t seem to benefit from enhanced recovery. Clinical teams need to understand which aspects of an enhanced recovery package are most critical for a successful outcome. This would help identify patients who might be at risk from a poorer outcome so that clinicians can take appropriate actions.

What did this study do?

The review identified 34 studies, including randomised controlled trials, comparative cohort studies and case series. In total, the studies reported on 10,861 laparoscopic resections. The different approaches taken by the studies meant a meta-analysis was not possible and only 26 described the protocol fully.

The most common outcome measures used in studies were: length of stay, morbidity and readmissions. Studies reported on 159 different outcome measures and some of these were poorly defined, making it difficult to compare the different components of enhanced recovery. The authors therefore could not meet their original aim of assessing the most effective components in detail as interventions and outcomes varied across studies. Whilst length of stay is of interest, it can be an unreliable indicator as patients may be medically fit to discharge but discharge is delayed until social care support is available.

In addition, poor compliance, particularly with post-operative enhanced recovery protocols may be misleading as it could be an indication of complications rather than deviation from the package. Many of the trials had some bias due to a lack of blinding of the outcome assessors and the lack of any statistical assessment of the strength of any association also limits the interpretation of the results.

What did it find?

  • There were 34 studies included in the review and these reported on 10,861 patients. Eight were randomised controlled trials and eight were non-randomised controlled studies and the rest were case series. The exact composition of enhanced recovery packages varied considerably, including, on average, 14 different elements. This mean that the strength of any links between protocol and outcome could not be quantified and only broad conclusion were possible.
  • Compliance to the protocol was highest for pre-operative patient education; intra-operative warming; avoidance of naso-gastric tubes and abdominal drains; early removal of urinary catheters; resuming solid food within 24 hours; and use of non-steroidal anti-inflammatories.
  • Reduced overall compliance was associated with longer length of stay, increased morbidity and increased readmissions.
  • Older age was associated with reduced compliance with protocols, suggesting possibly more complex needs.

What does current guidance say on this issue?

Enhanced recovery has been promoted widely within the NHS. The Enhanced Recovery Partnership Programme worked with a range of innovator sites and agreed a national consensus statement to advocate enhanced recovery as standard practice. Guidance from the Association of Surgeons of Great Britain and Ireland recommends full compliance with protocols to ensure the best possible outcomes.

What are the implications?

There is a broad literature on enhanced recovery programmes and differences can reflect local preferences. This review confirms that compliance with enhanced recovery protocols can minimise complications and reduce length of stay. Clinical teams may find it useful to review local protocols to ensure components and outcome measures are clearly defined. It may also be worthwhile to invest in an audit to test compliance and to understand local barriers and enablers to compliance.

Citation and Funding

Messenger DE, Curtis NJ, Jones A, et al. Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc. 2016. [Epub ahead of print].

No funding information was provided for this study.

Bibliography

Currie AC, Malietzis G and Jenkins JT. Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer. Br J Surg. 2016;103(13):1783-94.

Enhanced Recovery Partnership Programme. Delivering enhanced recovery: helping patients to get better sooner after surgery. London: Department of Health; 2010.

NHS Improving Quality. A better journey for patients seven days a week and better deal for the NHS. Enhanced recovery care pathway. Progress review (2012/13) and level of ambition (2014/15). London: NHS Improving Quality; 2013.

Paton F, Chambers D, Wilson P, et al. Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis. BMJ Open. 2014;4(7): e005015.

Paton F, Chambers D, Wilson P, et al. Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes. 2014. Health Services and Delivery Research. 2014;2(21).

Kehlet H and Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-98.

Khan S, Gatt M, Horgan A, et al. Guidelines for implementation of enhanced recovery protocols. London: Association of Surgeons of Great Britain and Ireland; 2009.

Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review

Published on 16 September 2016

Messenger, D. E.,Curtis, N. J.,Jones, A.,Jones, E. L.,Smart, N. J.,Francis, N. K.

Surg Endosc , 2016

OBJECTIVE: To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery. BACKGROUND: ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood. METHODS: A systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures. RESULTS: Thirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission. CONCLUSION: Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection.

Enhanced recovery: The concept of enhanced recovery, developed by Kehlet and Wilmore, originates from colorectal surgery. The protocol originally comprised 21 different components covering pre-operative (e.g. carbohydrate loading), intra-operative (e.g. goal directed fluid therapy) and post-operative (e.g. no nasogastric tube) care. Since its introduction, clinicians and organisations have refined the model, developing local versions.  These local protocols vary considerably and typically feature between four and fourteen different elements.

Expert commentary

Enhanced recovery pathways have improved outcomes and experience of care for patients using evidence based replicable steps from referral to recovery. This systematic review demonstrates the importance of pathway compliance in achieving the optimal outcomes. These pathways should become the standard for care, and pathway compliance the measure of a quality service.

Dr Nigel Acheson (Patient safety and clinical risk management), Regional Medical Director (South), NHS England