Implementation of an early recoveryafter surgery (ERAS) protocol in patients undergoing female pelvic reconstructive Surgery: Impact on complications, hospital stayand cost

Objective: Minimizing hospital admission and maximizing utilization of outpatient surgery facilities are critical for patients undergoing elective surgery during the COVID-19 pandemic in order to prevent viral spread within healthcare facilities and maximize inpatient hospital bed availability. Methods: We implemented an early recovery after surgery (ERAS) protocol for all patients undergoing female pelvic reconstructive surgery starting on June 1st, 2020 by a single surgeon. The protocol included pre-op hydration, a urinary anesthetic, pre- and post-op acetaminophen and ibuprofen, postop perineal ice and bowel regimen, identification and enrollment of family members to assist with care, and communication regarding planned sameday discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients pre (PRE) and post (POST) ERAS implementation. Results: In all, 173 patients (82 PRE Nov 2019 - Feb 2020, 91 POST June - Sept 2020) were included. There were no differences in age, body mass index, ASA score, smoking history, surgery type, operative time, intra-op complications, and post-op complications between the PRE and POST groups (P > 0.05). POST patients had a higher mean Charlson Comorbidity Index (2.6 vs 1.9, P = 0.0132). Significantly more surgeries were done in an outpatient setting in the POST group (73.6% vs 48.8%, P = 0.0008), and significantly more patients were discharged on the day of surgery in the POST group (80.2% vs 50.0%, P = 0.0003). There were no differences in the rates of unexpected emergency room or clinic visits (P > 0.05). Both peri-op and discharge opiate requirements did not significantly differ but trended towards being reduced in POST patients (P = 0.0782 and 0.0926, respectively). Post-op opiate requirement was significantly reduced in the POST group (P 0.05);however, there was a trend towards an increased operating margin in the POST group ($4,554 vs $2,151, p = 0.1163). Bed unit cost was significantly lower in the POST group ($210 vs $533, P < 0.0001). Conclusions: In patients undergoing female pelvic reconstructive surgery, an early recovery after surgery protocol facilitated transfer of procedures to an outpatient surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It may also reduce cost and improve operating margins to hospital systems.