Delivery of drinking, eating and mobilising (DrEaMing) and its association with length of hospital stay after major noncardiac surgery: observational cohort study

Charles M Oliver; Samantha Warnakulasuriya; Dermot McGuckin; Georgina Singleton; Peter Martin; Cristel Santos; James Bedford; Duncan Wagstaff; Arun Sahni; David Gilhooly; Jonathan Wilson; Kylie Edwards; Rachel Baumber; Cecilia Vindrola-Padros; Jenny Dorey; Irene Leeman; Hannah Boyd-Carson; Ravi Vohra; Pritam Singh; Matthew Bedford; Abigail Vallance; Giuseppe Aresu; Olga Tucker; Michael Swart; Monty G Mythen; PQIP project delivery team; Suneetha R Moonesinghe; PQIP collaborative

doi:10.1016/j.bja.2022.03.021

Delivery of drinking, eating and mobilising (DrEaMing) and its association with length of hospital stay after major noncardiac surgery: observational cohort study

Br J Anaesth. 2022 Jul;129(1):114-126. doi: 10.1016/j.bja.2022.03.021. Epub 2022 May 12.

Authors

Charles M Oliver¹, Samantha Warnakulasuriya², Dermot McGuckin², Georgina Singleton², Peter Martin³, Cristel Santos⁴, James Bedford⁴, Duncan Wagstaff⁵, Arun Sahni⁴, David Gilhooly², Jonathan Wilson⁶, Kylie Edwards⁵, Rachel Baumber⁷, Cecilia Vindrola-Padros⁵, Jenny Dorey⁸, Irene Leeman⁸, Hannah Boyd-Carson⁹, Ravi Vohra¹⁰, Pritam Singh¹¹, Matthew Bedford¹², Abigail Vallance¹³, Giuseppe Aresu¹⁴, Olga Tucker¹², Michael Swart¹⁵, Monty G Mythen¹⁶; PQIP project delivery team; Suneetha R Moonesinghe¹⁷; PQIP collaborative

Affiliations

¹ Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK.
² Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK.
³ Department for Applied Health Research, University College London, London, UK.
⁴ Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK.
⁵ Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK.
⁶ York University Hospitals, York, UK.
⁷ Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Royal National Orthopaedic Hospital, Stanmore, UK.
⁸ Royal College of Anaesthetists, London, UK.
⁹ East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK; Department of General Surgery, Derby Teaching Hospitals NHS Foundation Trust, Royal Derby Hospital, Derby, UK.
¹⁰ East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK; Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK.
¹¹ Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, Surrey, UK.
¹² Division of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
¹³ Bristol Medical School, University of Bristol, Bristol, UK.
¹⁴ Department of Thoracic Surgery, Royal Papworth NHS Foundation Trust, Cambridge, UK.
¹⁵ Department of Anaesthesia and Perioperative Medicine, Torbay Hospital, Torquay, UK.
¹⁶ University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK.
¹⁷ Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK. Electronic address: ramani.moonesinghe@nhs.net.

Abstract

Background: Enhanced recovery pathways are associated with improved postoperative outcomes. However, as enhanced recovery pathways have become more complex and varied, compliance has reduced. The 'DrEaMing' bundle re-prioritises early postoperative delivery of drinking, eating, and mobilising. We investigated relationships between DrEaMing compliance, postoperative hospital length of stay (LOS), and complications in a prospective multicentre major surgical cohort.

Methods: We interrogated the UK Perioperative Quality Improvement Programme dataset. Analyses were conducted in four stages. In an exploratory cohort, we identified independent predictors of DrEaMing. We quantified the association between delivery of DrEaMing (and its component variables) and prolonged LOS in a homogenous colorectal subgroup and assessed generalisability in multispecialty patients. Finally, LOS and complications were compared across hospitals, stratified by DrEaMing compliance.

Results: The exploratory cohort comprised 22 218 records, the colorectal subgroup 7230, and the multispecialty subgroup 5713. DrEaMing compliance was 59% (13 112 patients), 60% (4341 patients), and 60% (3421), respectively, but varied substantially between hospitals. Delivery of DrEaMing predicted reduced odds of prolonged LOS in colorectal (odds ratio 0.51 [0.43-0.59], P<0.001) and multispecialty cohorts (odds ratio 0.47 [0.41-0.53], P<0.001). At the hospital level, complications were not the primary determinant of LOS after colorectal surgery, but consistent delivery of DrEaMing was associated with significantly shorter LOS.

Conclusions: Delivery of bundled and unbundled DrEaMing was associated with substantial reductions in postoperative LOS, independent of the effects of confounder variables. Consistency of process delivery, and not complications, predicted shorter hospital-level length of stay. DrEaMing may be adopted by perioperative health systems as a quality metric to support improved patient outcomes and reduced hospital length of stay.

Keywords: enhanced recovery; patient-centred outcomes; perioperative; quality improvement; quality metric; shared decision-making; surgical outcomes.

Publication types

Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Cohort Studies
Colorectal Neoplasms* / surgery
Humans
Length of Stay
Postoperative Complications* / epidemiology
Prospective Studies