Pre-operative Predictors of Prolonged Length-of-Stay with Enhanced Recovery After Surgery (ERAS)

Objective: ERAS decreases post-operative length-of-stay (pLOS) and cost following colorectal surgery. It remains unclear, however, which patients will fail ERAS based on pre-operative assessments. We hypothesized that... [ view full abstract ]

Objective: ERAS decreases post-operative length-of-stay (pLOS) and cost following colorectal surgery. It remains unclear, however, which patients will fail ERAS based on pre-operative assessments. We hypothesized that patient-level factors, such as social determinants of health (SDOH), would predict prolonged post-operative length-of-stay.

Methods: All adult patients undergoing colorectal surgery with ERAS from 2015 at a single-institution were identified. ERAS failure was defined as an observed pLOS greater-than-the-expected pLOS calculated using the ACS-NSQIP Risk Calculator. Patients were stratified by ERAS success or failure. Pre-operative patient-level characteristics including SDOH were compared. Backwards step-wise logistic regression identified independent predictors of ERAS failure.

Results: Of 210 patients, 39 (18.6%) patients were ERAS failures. No differences in SDOH or ERAS compliance rates were observed between groups. Compared to non-ERAS failures, ERAS failure patients experienced a median pLOS 12 days (IQR 8-14) compared to 3 days (IQR 3-4) (p<0.001). ERAS failure was associated with active smoking, white race, and emergency surgery. On adjusted analysis, pre-operative smoking status (OR 2.4 95%CI 1.1-5.6, p=0.03) and emergency surgery (OR 5.0 95%CI 1.9-13.5, p<0.01) were independently associated with ERAS failure. On adjusted analysis of elective surgery patients, the presence of pre-operative opioid prescriptions was independently associated with ERAS failure (OR 4.8 95%CI 1.7-13.7, p=0.03).

Conclusions: Pre-operative patient characteristics associated with ERAS failure are smoking status, emergency surgery, and having outpatient opioid prescriptions. These factors represent potential targets for future interventions to prevent ERAS failure.