Thiele Robert H, Rea Kathleen M, Turrentine Florence E, Friel Charles M, Hassinger Taryn E, McMurry Timothy L, Goudreau Bernadette J, Umapathi Bindu A, Kron Irving L, Sawyer Robert G, Hedrick Traci L
Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA.
University of Virginia Health System, Charlottesville, VA.
J Am Coll Surg. 2015 Apr;220(4):430-43. doi: 10.1016/j.jamcollsurg.2014.12.042. Epub 2015 Jan 9.
Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution.
A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables.
One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period.
Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.
结直肠手术伴有相当高的发病率和较长的住院时间（LOS）。认识到改进的必要性，我们在一所学术机构为所有接受择期结直肠手术的患者实施了强化康复（ER）方案。
一个多学科团队实施了一项基于以下内容的ER方案：术前咨询并让患者积极参与、碳水化合物负荷、多模式镇痛并避免静脉使用阿片类药物、术中目标导向性液体复苏、术后立即进食和活动。出院要求始终保持不变。采用前后对照研究设计，比较实施ER方案之前（2012年8月至2013年2月）和之后（2013年8月至2014年2月）的患者。使用NSQIP风险计算器进行风险分层，根据23个变量计算每位患者的预测住院时间。
109例连续患者按照ER方案接受了手术，与之相比有98例连续的历史对照患者（传统治疗）。两组的风险调整预测住院时间相似，分别为5.1天和5.2天。ER组在住院时间、吗啡当量、静脉输液量、肠功能恢复和总体并发症方面均有大幅降低。ER组每位患者的直接成本降低了7129美元，相应地节省了777,061美元的成本。在研究期间，通过Press Ganey测量的患者满意度有显著提高。
实施ER方案可提高患者满意度，并显著降低接受开放和腹腔镜结直肠手术患者的住院时间、并发症发生率和成本。这些数据表明，在围手术期环境上的小投资可带来巨大回报。
