Predicting delayed discharge in a multimodal Enhanced Recovery Pathway

Background: Despite advances with Enhanced Recovery Pathways(ERP), some patients have unexpected prolonged lengths of stay(LOS). Our goal was to identify the patient and procedural variables associated with delayed discharge despite an established ERP.

Methods: A divisional database was reviewed for minimally invasive colorectal resections with a multimodal ERP(8/1/13-7/31/15). Patients were stratified into ERP success or failure based on length of stay ≥5 days. Logistic regression modeling identified variables predictive of ERP failure.

Results: 274 patients were included- 229 successes and 45 failures. Groups were similar in demographics. Failures had higher rates of preoperative anxiety(p = 0.0352), chronic pain(p = 0.0040), prior abdominal surgery(p = 0.0313), and chemoradiation(p = 0.0301). Intraoperatively, failures had higher conversion rates(13.3% vs. 1.7%, p = 0.0002), transfusions(p = 0.0032), and longer operative times(219.8 vs. 183.5min,p = 0.0099). Total costs for failures were higher than successes($22,127 vs. $13,030,p = 0.0182). Variables independently associated with failure were anxiety(OR 2.28, p = 0.0389), chronic pain(OR 10.03, p = 0.0045), and intraoperative conversion(OR 8.02, p = 0.0043).

Conclusions: Identifiable factors are associated with delayed discharge in colorectal surgery. By prospectively preparing for patient factors and changing practice to address procedural factors and ERP adherence, postoperative outcomes could be improved.