Evidence
Alert

People leave hospital after surgery sooner if hospitals follow ‘enhanced recovery protocols’

Strategies to improve or enhance recovery after planned surgery can reduce the amount of time people over 60 spend in hospital, compared with standard care. These strategies include minimising fasting before operations, targeted anaesthesia, getting people up and about quickly after surgery and an early return to eating.

In this review, hospital stay could be reduced by up to five days with the use of enhanced recovery protocols. Exercises and nutritional programmes to prepare for surgery (‘prehabilitation’) were also helpful.

There was some variation in the way hospital stay was recorded but the effectiveness of programmes after colorectal surgery or lower limb joint replacement is clear. Shorter hospitalisation is expected to translate to lower treatment costs, suggesting that these strategies are useful and cost-effective approaches in improving recovery.

 

Why was this study needed?

The number of people over 60 in the UK is expected to rise to 21.9 million in two decades, and many will require hospital treatment. Between 2006 and 2016, the number of people aged 60 to 65 admitted to hospital rose by 57%. Older patients may have longer recovery periods from elective surgery than younger patients, because of multiple healthcare conditions, increased frailty and care needs.

Managing patients over 60 to enhance their chances of a quick recovery could benefit both the patients and the NHS, by making the best use of bed occupancy. This was the first systematic review of multiple intervention protocols aimed at reducing hospital stay. Researchers wanted to find out whether such protocols were effective and cost-effective in adults over 60.

 

What did this study do?

This was a systematic review of 218 comparative studies, with 73 studies (26,365 participants) selected for synthesis. Researchers then prioritised 34 randomised controlled trials (RCTs) from outside the UK and 39 studies within the UK, 12 of which were RCTs.

The majority of studies included colorectal surgery or hip or knee replacement in people over 60 years. The main types of intervention were:

  • enhanced recovery protocols, which included reduced fasting time before surgery, targeted anaesthesia, early mobilisation after surgery and a quicker return to eating food
  • prehabilitation, which included strengthening or mobilisation exercises and nutritional interventions to get people into good shape before surgery.

The review found many trials did not report length of hospital stay in a consistent way that allowed them to be included in meta-analyses. This means the figures reported are less precise than if all trials could be included.

 

What did it find?

  • Enhanced recovery protocols for people having colorectal surgery reduced hospital stay by approximately 1.5 days (10 RCTs, one from the UK of 25 people; 2,001 participants overall). Markers of physical recovery, such as pain control and being able to get around, were reached sooner among patients having enhanced recovery protocols. Other outcomes were either better or no worse than usual care.
  • Prehabilitation before hip or knee replacement reduced average hospital stay by 2.5 days (2 RCTs from Canada and Taiwan, 376 participants).
  • Enhanced recovery protocols after hip or knee replacement reduced hospital stays by on average 3.3 days (2 RCTs from Denmark and Iceland, 140 participants). Other outcomes, where reported, were either better or no worse than usual care.
  • UK studies found enhanced recovery protocols for hip or knee replacement shortened hospital stays by less than a day to 4.5 days (7 studies) and on average 2.4 days after colorectal surgery (3 studies).
  • Only 15 of the studies analysed included cost-effectiveness calculations. As costs reflected length of stay, those studies which showed strategies could reduce length of stay tended to find that the strategies were cost-effective. However, there was too much variation between studies to give a reliable figure for this.

 

What does current guidance say on this issue?

There are no guidelines on the use of specific multi-component interventions to reduce hospital stay published by NICE, the Royal College of Surgeons of England, or the Royal College of Anaesthetists.

Most specialist society guidelines address the specific surgical techniques or issues such as training and staffing for safety. Many NHS trusts have now implemented enhanced recovery programmes.

 

What are the implications?

Despite the moderate to low quality of some of the evidence, this review suggests that strategies designed to improve recovery from some planned surgeries are effective in reducing hospital stay and thus are likely to be cost-effective.

These strategies should, therefore, be given careful consideration by hospital managers wishing to manage the rising demand of people over 60 having planned surgical treatment.

 

Citation and Funding

Nunns M, Shaw L, Briscoe S et al. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. Health Serv Deliv Res. 2019;7(40).

The study was funded by the NIHR Health Services and Delivery Research Programme (project number 16/47/22).

 

Bibliography

Oxford University Hospitals NHS Foundation Trust. Enhanced recovery after surgery (ERAS). Oxford University Hospitals NHS Foundation Trust. Oxford; 2012.

University Hospital Southampton NHS Foundation Trust. Patient information and advice: enhanced recovery programme. Total hip replacement. University Hospital Southampton NHS Foundation Trust. Southampton; 2019.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

Template content only

Commentaries

Expert commentary

Prehabilitation and enhanced recovery pathways are relatively recent innovations for older people undergoing elective surgery. At risk of oversimplifying a 178-page article, the results are ‘sooner, healthier and cheaper’.

This is welcome in the bed-pressured NHS. The findings are likely to generalise to all types of non-day case elective surgery undertaken in older people.

The studies examined in the review were remarkably unselective, indicating that these interventions can be routine for all older people undergoing elective surgery rather than surgeons having to pick and choose.

This will surely help them to be embedded as part of normal practice.   

John Gladman, Professor of Medicine of Older People, University of Nottingham; Honorary Consultant in Health Care of Older People, Nottingham University Hospitals NHS Trust

The commentator declares no conflicting interests