title: Newly implemented enhanced recovery pathway positively impacts hospital length of stay.
abstract: Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes.
  
  
  
  This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway.
  
  
  
  The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04).
  
  
  
  A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Martin
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Talya
authors.initials: T
authors.lastname: Lorenz
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Jane
authors.initials: J
authors.lastname: Ferraro
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Chagin
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Lampman
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Emery
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Joan E
authors.initials: JE
authors.lastname: Zurkan
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Jami L
authors.initials: JL
authors.lastname: Boyd
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Karin
authors.initials: K
authors.lastname: Montgomery
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Lang
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Vandewarker
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA. Robert.Cleary@stjoeshealth.org.
authors.forename: Robert K
authors.initials: RK
authors.lastname: Cleary
mesh_terms: D003106:Colon / Q000601:surgery*; D057186:Comparative Effectiveness Research; D013505:Digestive System Surgical Procedures; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008824:Michigan; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D019990:Perioperative Care / Q000379:methods*; D012007:Rectum / Q000601:surgery*
keywords: Enhanced recovery after surgery; Enhanced recovery pathway; Fast-track surgery; Minimally invasive colorectal surgery; Quality improvement