Colorectal surgery is associated with a high rate of postoperative complications
compared to other surgical specialities, and reported morbidity rates reaching up to 35% (1)(2).
Patients with complications after surgery are at increased risk of poor outcome and increased
length of stay. Oncological patients are at particular risk as complications can delay the start
of adjuvant therapy and thereafter influence negatively the rate of recurrence (1)(3).
The most frequent complications related to colorectal surgery are surgical site infections,
urinary tract infections and other surgical complications such as anastomotic leakage, ileus,
bleeding and organ space infection (1)(4). The economic impact of complications after
colorectal surgery is not trivial. A recent multicentre study showed that they can increase the
costs per case from 26% for minor and up to 126% for major complications, respectively (5).
An anastomotic insufficiency at its own can triple the costs (5).The risk factors for complications
after colorectal surgery can be related either to the patients (older age, gender, specific
comorbidities, ASA score) and/or to the surgical intervention such as prolonged operating time
(>3 hours), surgical technique (laparotomy), intraoperative blood loss and lack of prophylactic
antibiotics (5)(4).
Numerous strategies were developed to decrease the incidence of complications.
Among them the Enhanced Recovery After Surgery (ERAS) protocols (in CHUV since 2011)
have been implemented to optimize the peri-operative management. The rationale was to
reduce the peri-operative stress response and organ dysfunction induced by surgical
interventions (6). One of the major contributions of the ERAS program was to standardize the
patient pathway before, during and after surgery. Important issues include standardized
anaesthetic protocol, the use of minimal invasive surgery, postoperative management of pain,
nutritional status, and early mobilization (7)(8). To provide the desired effect, this
multidisciplinary approach requires a high compliance of the different health care
professionals. It has been shown that an increase of 27% of the adherence to the ERAS
protocol is associated to the same reduction of postoperative morbidity, postoperative
symptoms and with a shorter length of stay (9)(10). More specifically in colorectal surgery, it
decreases the postoperative complications by almost 50%. Our published data of the CHV
series showed that ERAS has beneficial effects on the length of stay with a diminution of >2
days and on the direct cost per patient with a decrease of almost 2000 CHF (11).
Since the different guidelines of the ERAS society were published, several studies
analysed how different items within these protocols could be optimized (12)(13). Interestingly,
only few studies analysed the impact of paramedical staffing on postoperative outcome. Some
authors suggested that an increase in the nurse-to-patient ratio decreases the postoperative
complications whereas others could not show any correlations. For example, a low nurse-topatient
ratio was associated with a high rate of complications after oesophageal resection in
one study (14)(15). To our knowledge, no studies analysed the effect of the nurse to patient
ratio within the ERAS institutions.
The aim of this study was to analyse the relationship between the nurse workload and
the occurrence of postoperative complications within an ERAS program for colorectal surgery.