In 1995, Danish physician Henrik Kehlet, M.D., published a revolutionary paper documenting the recovery of eight elderly patients who had undergone elective colonic resections for cancer. The procedure typically kept patients in the hospital for 12–15 days. Under Kehlet’s care, they were discharged in two or three days.
Although Kehlet accomplished something groundbreaking, his methods were simple. He optimized patients for their surgeries by educating them, setting clear expectations about the procedure and recovery, and equipping his team to provide patient-centric care. Together, these steps laid the foundation for what is now called Enhanced Recovery After Surgery, or ERAS.
More than 30 years later, enhanced recovery is slowly yet steadily gaining momentum in the United States. ERAS is the umbrella term for a bundle of nearly 20 perioperative recovery protocols, many of which overturn long-accepted practices.
“It’s been dogma for decades that patients were not allowed to eat or drink for at least eight hours before surgery,” says Valerie Norton, M.D., chief operations executive physician for Scripps Mercy Hospital, San Diego and Health-Trust Physician Advisor. “It turns out that’s wrong. The evidence shows just the opposite—if you let patients drink clear fluids until two hours before surgery, they get better faster, go home sooner and have fewer surgical site infections.”
Other ERAS protocols include keeping a patient warm before and during surgery—no small task considering thin hospital gowns and heavy air conditioning—and getting them walking shortly after an operation. Enhanced recovery also encompasses multimodal pain management techniques to minimize opioid use and prevent addiction.
Though hospitals may have adopted various enhanced recovery practices over the years, ERAS bundles these best practices.
“Enhanced recovery protocols enable a patient-centered approach with physicians and clinicians thinking about what patients will most want to know about an upcoming surgery,” says Mikio Nihira, M.D., clinical professor of obstetrics and gynecology at the University of California Riverside School of Medicine and a HealthTrust Physician Advisor.
ERAS Success at Scripps Health
HealthTrust awarded its 2017 Innovation Grant to Scripps Health for perioperative opioid stewardship and ERAS initiatives—and a year later, the team has been busy putting the award to use. Scripps team member Valerie Norton, M.D., reports that the in-kind portion of the grant is being used to create two patient education videos, one on pain management and the other on ERAS protocols.
“We give patients so many things to read—it seems like reams and reams of paper,” she says. “These videos are another way to approach the same material in a way that’s really going to stick with patients.” The Scripps team also used the cash grant to launch and support a robust opioid stewardship program.
Over the past year, implementing ERAS protocols at Scripps Health has shortened length of stays by up to 50 percent. Adoption continues to increase across units: “We went from zero percent last year to 60 percent of bariatric surgeries that are now ERAS protocols,” Norton says. She reports that patients are thrilled to be up and moving faster, and back home sooner.
For their part, nurses love it, too. “My vision is for the nurses to be the drivers for this process,” Norton says. “A lot of enhanced recovery is just about very careful attention to the environment the patient is in: keeping them warm, getting them up and walking, letting them drink fluids. To the extent that we can put this on autopilot, the more success we’ll have.”
Doctors put patients at ease and help them optimize their recovery by communicating what to expect before, during and after a procedure. Enhanced recovery promotes education about everything from the level of pain a patient can expect to how much support they’ll need once discharged.
“If patients are armed with a good mental model of how capable or incapable they will be following surgery, they can arrange with family members for the support they need,” Nihira explains. Perhaps more important, if they’re mentally and emotionally prepared for postoperative setback, they can maintain motivation on the road to recovery. As Nihira tells his patients, “Pain is part of surgery, and not all pain is bad.”
Prior to their procedure, most surgery patients spend very little time in hospitals. Their concerns tend to revolve around matters that surgeons and nurses might overlook: where to park, what their copay will be, how much the procedure will hurt.
“As surgeons, we tend to focus on the technical aspects of our performance, and we have a limited understanding of the patient’s individual experience,” Nihira notes. Yet patients are eager to learn the details of their hospital stay and become more comfortable with the entire experience—before, during and after their time on the operating table. ERAS takes these details into account and equips hospital staff to answer questions and prepare patients in a more holistic way.
While education and accurate expectations help patients feel at ease, a speedy discharge and recovery have the greatest impact on patient satisfaction. This is where enhanced recovery protocols can make a difference. By implementing a bundle of best recovery practices, doctors significantly reduce their patients’ hospital stays and recovery time. This makes for happier patients and cuts costs for hospitals by limiting stays and readmittance. “
ERAS is a win-win-win scenario,” Norton says. “Patients like it better, there’s better quality of care and recovery, and it lowers costs for the hospital.”
Enhanced recovery can lead to what Nihira calls “wildly successful” results. To illustrate, at Magee-Womens Hospital in Pittsburgh, the use of ERAS protocols bumped a 40 percent same-day discharge rate to a 93 percent same-day discharge rate—in a single year. Yet despite its transformational potential, hospitalwide adoption can be slow going.
“It’s hard to get people to change their processes, especially if their unit doesn’t benefit from the change,” Nihira adds. For example, multimodal pain management may require a new pain control drug or device. Frequently a hospital unit such as the pharmacy will incur these expenses, but it won’t necessarily experience the benefits of releasing a patient earlier. Successfully adopting ERAS protocols requires buy-in from the entire hospital—something that takes time and staff education.
Hospitals willing to build a mature ERAS program can expect to see changes as dramatic as those Kehlet first introduced in 1995. The adoption process has been slow thus far, but committed health systems are realizing the benefits of an ERAS initiative—limited hospital stays, reduced costs and happier, healthier patients being released—faster than they anticipated.
To learn more, visit the American Society for Enhanced Recovery