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Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery

Keil, Dayley S. BA*; Schiff, Lauren D. MD; Carey, Erin T. MD; Moulder, Janelle K. MD; Goetzinger, Amy M. PhD§; Patidar, Seema M. PhD§; Hance, Lyla M. MPH§; Kolarczyk, Lavinia M. MD§; Isaak, Robert S. DO§; Strassle, Paula D. MSPH; Schoenherr, Jay W. MD§

doi: 10.1213/ANE.0000000000003339
Obstetric Anesthesiology: Original Clinical Research Report
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BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway.

METHODS: This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway.

RESULTS: There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36–7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02–5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02–1.50; P = .04).

CONCLUSIONS: We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.

From the *University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina

Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina

Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee

§Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina

Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Published ahead of print 16 February 2018.

Accepted for publication February 16, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Jay W. Schoenherr, MD, Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599. Address e-mail to jschoenherr@aims.unc.edu.

Copyright © 2018 International Anesthesia Research Society
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