The Enhanced Recovery After Surgery (ERAS) Elements that Most Greatly Impact Length of Stay and Readmission

Background Enhanced recovery after surgery (ERAS) protocols have been shown to decrease length of stay (LOS) and improve patient outcomes in a wide variety of surgical fields; however, barriers exist preventing the implementation of all elements. We hypothesize that a subset of ERAS elements are most influential on LOS and readmission following colorectal surgery. Study Design A retrospective review of 840 patients was performed and their compliance with 24 ERAS components evaluated. Two independent machine-learning statistical algorithms were employed to determine which subset of ERAS elements was most impactful on LOS <3 days and hospital readmission. Results Increasing compliance with ERAS elements had an inverse linear relationship with LOS. Open (vs minimally invasive) surgery was associated with increased LOS. Early mobilization and multimodal pain management are the elements most protective against increased LOS. Readmissions increase with the number of morphine milligram equivalents (MME)/day. The subset of patients who underwent minimally invasive procedures, had multimodal pain control, and less than 16 MME per day were least likely (23%) to have >3-day LOS. Those patients who underwent an open procedure with less than 15 ERAS elements completed were most likely (84%) to have >3-day LOS. Conclusion While increasing compliance with ERAS protocols and minimally invasive procedures decrease LOS and readmission overall, a subset of components—multimodal pain control, limited opioid use, and early mobilization—was most associated with decreased LOS and readmission. This study provides guidance on which ERAS elements should be emphasized.

Can We Eliminate Opioid Medications for Postoperative Pain Control? A Prospective, Surgeon-Blinded, Randomized Controlled Trial in Knee Arthroscopic Surgery

Background: Orthopaedic surgeons have a responsibility to develop responsible opioid practices. Growing evidence has helped define an optimal number of opioids to prescribe after surgical procedures, but little evidence-based guidance exists to support specific practice patterns to decrease opioid utilization. Hypothesis: After knee arthroscopic surgery with partial meniscectomy, patients who were provided a prescription for opioids and instructed to only fill the prescription if absolutely necessary for pain control would take fewer opioids than patients with opioids automatically included as part of a multimodal approach to pain control prescribed at discharge. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients undergoing arthroscopic partial meniscectomy were provided multimodal pain control with aspirin, acetaminophen, and naproxen and randomized to receive oxycodone as either included with their multimodal pain medications (group 1) or given an optional prescription to fill (group 2). Patients were contacted at time points up to 1 month after surgery to assess opioid utilization and medication side effects. The mean number of tablets utilized was the primary outcome measure, with a 50% reduction defined as a successful outcome. Results: A total of 105 patients were initially enrolled, and 95 (91%; 48 in group 1 and 47 in group 2) successfully completed the study. There was no significant reduction in the number of tablets utilized between groups 1 and 2 (3.5 vs 4.5, respectively; P = .45), days that opioids were required (2.2 vs 3.2, respectively; P = .20), or postoperative pain at any time point. The group with the option to fill their prescription had significantly fewer unused tablets remaining than the group with opioids included as part of the multimodal pain control regimen (75% of potentially prescribed tablets vs 82% of prescribed tablets; P < .001). Overall, 37% of patients did not require any opioids after surgery, and 86% used ≤8 tablets. Conclusion: Patients required a minimal number of opioids after knee arthroscopic surgery with partial meniscectomy. There was no difference in the number of tablets utilized whether the opioid prescription was included in a multimodal pain control regimen or patients were given an option to fill the prescription. Offering optional opioid prescriptions in the setting of a multimodal approach to pain control can significantly reduce the number of unused opioids circulating in the community. Registration: NCT03876743 (ClinicalTrials.gov identifier)