As physicians continue to refine pain management protocols to best support patients and improve postoperative outcomes, enhanced recovery after surgery programs have become more prevalent.
Information and guidance on enhanced recovery protocols are released through the Enhanced Recovery After Surgery Society, an international nonprofit that develops and publishes guidelines for surgical procedures, such as colorectal, orthopedic, gynecological, cardiac, and oncological. Becker's Hospital Review recently spoke with two experts from Cardinal Health about the benefits of ERAS protocols for patients and hospitals, as well as challenges associated with ERAS adoption. The interviewees were:
- Rosemarie (Rosie) Squeo, MA, BSN, RN, senior consultant, clinical operations
- Tina Keller, BSN, RN, senior consultant, clinical operations
Note: Responses have been edited for length and clarity.
Question: What are the primary benefits of ERAS protocols for patients?
Rosie Squeo: ERAS guidelines represent a paradigm shift in surgical care with benefits for patients, such as:
- Eliminating overnight fasting and instead prescribing a carbohydrate drink for patients before surgery.
- Utilizing minimally invasive approaches instead of large incisions.
- Managing fluids to seek balance instead of giving large volumes of intravenous fluids.
- Avoiding drains and tubes or removing drains and tubes early.
- Early mobilization and serving drinks and food the day of the surgical procedure.
Emerging evidence has shown ERAS protocols help shorten the postoperative recovery period, manage patients' pain, decrease postoperative complications and result in increased patient satisfaction. Also, they do not adversely impact postoperative quality of life measures such as sleep quality, pain, and fatigue.1
Q: What are the primary benefits of ERAS protocols for hospitals?
Tina Keller: ERAS protocols have been adopted by healthcare organizations to provide an evidence-based approach to promote positive patient outcomes and reduce costs. Implementation has resulted in reduced length of hospital stay by 30 to 50 percent, while decreasing incidence of complications (including surgical site infections), and decreasing readmissions and lowering costs.
ERAS protocols are designed to optimize the patient's health before, during and after surgery with coordinated care protocols throughout the continuum of care. There are five key goals of these protocols: decrease hospital length of stay, get patients mobile faster, manage pain, decrease postoperative complications, and increase patient satisfaction.
Q: What challenges have you encountered when implementing ERAS protocols? How did you overcome them?
RS: Challenges include a lack of coordinated care and lack of patient adherence to the ERAS protocols.
ERAS protocols often challenge traditional surgical doctrines. To address team acceptance, every team member must understand the benefits of these protocols. The period during initial implementation can be the most difficult to achieve team compliance with the ERAS protocols. In a study interviewing nurses, surgeons, and other team members about reasons for noncompliance, team members cited issues include lack of nursing staff, resources, and communication.
According to multiple studies, patient adherence to ERAS protocols correlates with reduced postoperative complications. Impaired compliance was found to increase risk of SSI and other postoperative complications as well as length of stay and costs.2
High compliance with the ERAS protocols requires involvement of all team members. A multidisciplinary team approach allows team members to set their priorities for protocol items related to their specialty. Implementing the protocols with the involvement of all parties (anesthesia, surgeon, PT, preop, discharge planning, physician office staff, etc.) gains buy-in. Investigating barriers within specialties can be beneficial to understanding any underlying causes for noncompliance.
Having a dedicated ERAS coordinator provides one point of contact to ensure communication and coordination between all parties, which helps ensure patient education before, during and after surgery.
Having a bundled kit with the necessary products for the patient, such as carb-loading drinks, can help drive compliance with the protocols. This will eliminate the need for hospital departments, the physician office or the patient to gather these items; all items will be conveniently supplied.
Q: What recommendations do you have for clinicians who support ERAS protocols? How would you recommend getting started with ERAS?
TK: Successful implementation of ERAS protocols requires collaboration among multidisciplinary team members who are willing to embrace change and have a clear understanding of these protocols and how to implement them. Success of protocol implementation depends on team support, patient education and modifying the postoperative setting.
The team may want to become involved with the ERAS Society, which can provide support, research and education. It is important that all staff are educated on the benefits to the patient and hospital when implementing ERAS.
RS: Successful ERAS implementation occurs as a process that evolves from leadership; leaders create a climate for change, engagement, and empowerment of those involved. Successful strategies to implement ERAS include ensuring physicians and support staff fully embrace change and engage patients.
Another key to successful implementation is selecting an ERAS program facilitator to provide guidance, implement rules and regulations, manage the logistics of the perioperative team and train new personnel. Fostering positive attitudes and behaviors is essential among the multidisciplinary team.
___________
(1)Echeverria-Villalobos, Marco MD*; Stoicea, Nicoleta MD, PhD*; Todeschini, Alexandre B. MD*; Fiorda-Diaz, Juan MD*; Uribe, Alberto A. MD, MSP*; Weaver, Tristan MD*; Bergese, Sergio D. MD, FASA*, A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States; The Clinical Journal of Pain: March 2020 - Volume 36 - Issue 3 - p 219-226
(2) Liang Li,#1 Juying Jin,#1 Su Min,1 Dan Liu,1 and Ling Liu1; Compliance with the enhanced recovery after surgery protocol and prognosis after colorectal cancer surgery: A prospective cohort study. Oncotarget. 2017 Oct 27; 8(52): 90605.