Does a Longer Time Out of Bed Increase the Rate of Recovery for Functional Walking Capacity After Colorectal Surgery?

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To the Editor:
We read with great interest the recent article by Fiore et al,1 and appreciate their efforts to determine whether staff-directed facilitation of early mobilization within an enhanced recovery program (ERP) increased out-of-bed activities during the hospital stay, and improved patients’ outcomes. However, we would like to highlight 3 concerns regarding this work.
First, this study clarifies the benefits of staff-directed facilitation of early mobilization for step count by actigraphy and self-reported time out of bed; however, the study could not determine whether there was a significant difference between the 2 groups in the proportion of patients who achieved the mobilization target (at least 6 hours out of bed) as measured by actigraphy, which must be analyzed further in the study. We are also interested in additional information on the subgroup analysis of patients who achieved the mobilization target as measured by actigraphy, and those who did not achieve the target, regardless of intervention. Was the functional walking capacity of patients who achieved mobilization targets better than that of patients who did not achieve the targets? Did the time out of bed, as measured by actigraphy, correlate positively with the recovery rate for functional walking capacity? Such information might contribute additional evidence for the direct beneficial clinical effects of postoperative mobilization, and help clinicians to facilitate early mobilization.
Second, early mobilization is 1 of the key elements associated with improved outcomes, and the most common reason for ERP deviation,2 but it is only 1 of more than 20 perioperative care components that are recommended by the Enhanced Recovery after Surgery Society.3 It has been reported that increased adherence to ERP care components was associated with successful early recovery, and also a reduction in postoperative morbidity and complication severity.4 Providing information regarding the differences between the 2 groups for the other perioperative care components might help readers better understand the results.
Third, one-third of patients in the facilitated mobilization group were not able to achieve the mobilization target, although this group was allocated specific resources to overcome a lack of manpower, which was the main barrier to adherence to early mobilization. Major barriers for ERP were recently identified, and include the need for patient education, increased communication and collaboration, and better evidence for the success of ERP intervention.5 To improve the clinical practice of ERP for colorectal surgery, we would like to know more as to why some patients could not achieve the mobilization target in a facilitated mobilization group.
Elucidating the aforementioned factors might help in interpreting the results better, and in establishing a better ERP and early mobilization program for colorectal surgery.
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