Effect of the first wave of COVID-19 on the implementation of Enhanced Recovery After Surgery (ERAS) protocols based on perceptions of healthcare professionals

Lorente, J.V.; Ripollés-Melchor, J.; Aldecoa, C.; Abad-Motos, A.
doi:10.1016/j.redare.2021.09.003
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Enhanced recovery after surgery &#40;ERAS&#41; programmes have been shown to reduce postoperative complications&#44; use of critical care units&#44; and length of hospital stay without increasing readmission rates&#44; and are also cost-effective<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The number of declared ERAS centres in Spain has grown exponentially in recent years&#44; but much work remains to be done&#46; However&#44; the spread of the Coronavirus disease &#40;COVID-19&#41; in the spring of 2020 created major challenges for healthcare systems&#46; Non-urgent and non-cancer-related procedures&#44; and even cancer-related procedures in some heavily affected hospitals&#44; were cancelled worldwide to make way for COVID-19 patients&#44; many of which were admitted to intensive care units&#44; generating the so-called Post COVID-19 Surgical Backlog<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Some ERAS preoperative interventions&#44; such as anaemia correction or prehabilitation&#44; might also have been curtailed due to lockdown travel rules and the restrictions imposed on hospital admissions for therapy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Hospitals where ERAS is routine practice have had difficulties maintaining these programmes due to the high number of COVID-19 patients&#44; and those that did not routinely apply ERAS before the pandemic have found it difficult to start introducing the protocols&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this study was to evaluate current ERAS practice in major surgery by means of a questionnaire sent to anaesthesiologists and surgeons after the first wave of the COVID19 pandemic in Spain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Spanish Perioperative Audit and Research Network &#40;REDGERM&#41;&#44; the Spanish Society of Anaesthesiology and Critical Care &#40;SEDAR&#41; and the Spanish Association of Surgeons &#40;AEC&#41; endorsed the survey after it had been approved by their respective scientific and research committees&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The target population of this study were members of REDGERM&#46; The estimated size of the target population for our survey was about 1000 researchers&#46; Using a study sample size calculator &#40;total population 1000&#44; 95&#37; confidence interval&#41;&#44; we calculated that a total sample size of 278 participants would be needed to obtain useful information&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We contacted REDGERM researchers from more than 125 Spanish centres inviting them to voluntarily complete an open questionnaire on the Internet&#46; The invitation included a link to the survey&#46; The survey was not made public&#44; so access to the questionnaire by uninvited people was unlikely&#46; Participant responses were collected using Google forms&#46; The survey was active for 1 month&#46; Respondents implicitly gave their informed consent by opening&#44; completing&#44; and returning the online questionnaire&#46; The questionnaire was a structured&#44; web-based form with single and multiple response questions&#46; All questions were mandatory&#46; To prevent investigators completing multiple questionnaires&#44; they were asked to provide their name and email&#44; and duplicate entries in the database were eliminated before performing the analysis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A 44-item questionnaire was developed to determine the changes in the perioperative management of patients caused by the COVID pandemic&#46; Participants were asked to answer the questions based on their personal clinical practice at the time the survey was launched &#8212; 15 June 2020 &#8212; and not on the changes introduced mid-way during the first wave of the pandemic&#46; The questions were structured in blocks&#58; in the first&#44; the respondent&#39;s demographic characteristics were obtained&#59; in the second&#44; the change in each of the perioperative items was characterized based on the recommendations of the ERAS Society&#59; and in the third&#44; participants were asked to rate their adherence &#40;from 0 &#91;minimum&#93; to 10 &#91;maximum&#93;&#41; to a series of ERAS items&#46; The face validity and content of the questionnaire were established and tested during the development phase by a panel of experts from REDGERM &#40;JVL&#44; JRM&#44; AAM&#41;&#44; SEDAR &#40;CA&#41; and AEC&#46; Data were expressed as frequency &#40;proportion&#41; and median &#40;IQR&#41; and analysed according to the number of responses obtained for each item&#46; Median adherence to each perioperative item was compared using Friedman&#8217;s test&#46; To avoid incongruent answers&#44; we eliminated comparisons made by respondents who had previously stated that a particular ERAS item was not implemented&#46; We also eliminated answers where respondents had already stated that the pandemic did not change a particular item&#44; but in the next question &#40;which assessed the extent of adherence to that item&#41;&#44; the respondent answered that the change in adherence before and after the pandemic was greater than half&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The questionnaire was completed by 30&#46;3&#37; of physicians contacted&#46; We received a total of 320 completed questionnaires&#46; Two hundred and fifteen questionnaire were completed by anaesthesiologists &#40;67&#46;2&#37;&#41;&#44; 99 by surgeons &#40;30&#46;9&#37;&#41; and 6 by other specialists &#40;1&#46;87&#37;&#41;&#59; 212 physicians &#40;66&#46;3&#37;&#41; worked in hospitals with up to 600 beds&#46; More than half of the participants &#40;58&#46;8&#37;&#41; had been routinely tested for Coronavirus&#46; Almost all respondents reported that in their centres&#44; patients were screened for SARS-CoV-2 infection preoperatively &#40;98&#46;4&#37;&#41;&#44; with RT-PCR of nasopharyngeal swabs being the most common test &#40;94&#46;4&#37;&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of the total number of respondents&#44; 37&#37; stated that surgery for non-malignant diseases had been postponed in their centres&#44; 18&#37; stated that only oncologic surgeries were performed&#44; and 2&#46;82&#37; that only emergency surgeries were performed in their hospital&#46; Multidisciplinary meetings to decide on the surgical oncology programme were held frequently &#40;38&#46;4&#37;&#41; or had been reduced &#40;23&#46;8&#37;&#41;&#46; Respondents believed that in many cases the decisions have been influenced by the pandemic&#44; prioritising neoadjuvant therapy over surgery &#40;36&#46;9&#37;&#41;&#46; Our survey has shown that post-operative care has been adapted to the pandemic&#44; with shorter than usual stays in the Critical Care Unit &#40;44&#46;8&#37;&#41;&#46; In many cases&#44; critical care beds were not available in the post-operative period&#44; and patients were transferred directly to the ward &#40;7&#46;19&#37;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Respondents also stated that standard clinical pathways have been altered&#44; with some patients being discharged home earlier than usual due to the workload and to avoid Coronavirus infection &#40;31&#46;6&#37;&#41;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nearly all &#40;83&#46;4&#37;&#41; respondents stated that ERAS pathways were implemented in their centres&#46; Despite this&#44; before the pandemic&#44; only 60&#37; of respondents stated that ERAS patients attended a specific pre-operative visit in their hospitals&#44; and in 44&#46;1&#37; of cases no regular specific multidisciplinary meetings were held to audit improvements and monitoring&#46; A large number of respondents indicated that prehabilitation programmes had never been implemented in their centres &#40;35&#46;9&#37;&#41;&#46; In centres where prehabilitation was implemented &#40;64&#46;1&#37;&#41;&#44; there was a statistically significant decrease in the subjective perception of patients who underwent prehabilitation before versus after COVID &#40;Friedman X<span class="elsevierStyleSup">2</span> &#61; 96&#46;593&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#41;&#46; Two-hundred and fifty-seven respondents &#40;80&#46;3&#37;&#41; performed preoperative nutritional assessment before the pandemic&#46; There were significant differences among participants who believed that patient screening had changed before and after the COVID pandemic &#40;Friedman X<span class="elsevierStyleSup">2</span> &#61; 61&#46;357&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Treatment of anaemia had not changed in the hospitals of 65&#46;3&#37; of respondents&#44; but respondents observed differences in the number of patients who underwent preoperative assessment and treatment of anaemia&#46; The administration of carbohydrate drinks 2 h before surgery had been slightly reduced due to the pandemic&#46; Adherence to this measure remains very low &#40;55&#46;6&#37;&#41;&#46; Most surgical approaches were laparoscopic &#40;88&#46;4&#37;&#41;&#44; and epidural analgesia was usually used in open surgery &#40;88&#46;1&#37;&#41;&#46; Respondents observed that the use of multimodal analgesia &#40;95&#46;6&#37;&#41;&#44; thromboprophylaxis according to guidelines &#40;97&#46;2&#37;&#41;&#44; management of postoperative fluids&#44; early oral intake &#40;92&#46;2&#37;&#41;&#44; treatment of postoperative malnutrition &#40;85&#46;3&#37;&#41;&#44; and early mobilization &#40;89&#46;7&#37;&#41; have varied less than 5&#37; following the outbreak of SARS CoV-2&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Hospital adherence to ERAS protocols&#44; according to respondents&#44; was lower than before the pandemic &#40;Friedman X2 &#61; 56&#44;828&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#41; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">These results&#44; which reflect the personal opinion of respondents&#44; show a decline in adherence to ERAS items&#44; particularly those involving preoperative optimization&#44; including preoperative management of anaemia&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The latest estimates suggest that more than 28 million surgeries were cancelled or postponed during the first wave of the pandemic<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; In addition&#44; many specialists involved in ERAS pathways have had to be relocated within their hospital to care for COVID-19 patients&#46; Changes in these multidisciplinary teams may result in decreased adherence to ERAS items&#44; and this has been associated with changes in postoperative outcomes<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; Moreover&#44; as our survey shows&#44; adherence to ERAS protocols was already poor before the pandemic&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study has limitations&#58; first&#44; the questionnaire collected the respondent&#8217;s opinion&#44; not objective data&#59; second&#44; being members of the REDGERM group&#44; the respondents were already interested in ERAS programmes&#59; third&#44; we do not know whether some responders worked in the same centre as others&#46; Furthermore&#44; the dynamic of the questionnaire itself may result in responses that are not sufficiently rigorous&#44; especially the ordinal assessment questions&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">This survey shows that the quality of perioperative management in patients who underwent surgery just after the first wave of the COVID pandemic declined significantly&#44; particularly in terms of adherence to ERAS items&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Given the high number of cancelled and postponed surgeries&#44; hospital staff should give priority to optimising healthcare resources&#46; The application of ERAS protocols can be an important tool in the management of the Post COVID-19 Surgical Backlog<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial or not-for-profit sectors&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Declaration of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare</p></span></span>"
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