Enhanced recovery after surgery (ERAS) programs, an important component of the Perioperative Surgical Home (PSH), are helping patients better prepare for surgery and recuperate faster afterward, according to 2 new studies presented at Anesthesiology 2016, the Annual Meeting of the American Society of Anesthesiologists (ASA).
ERAS programs employ a variety of methods to ease the effects of surgery and fast track patient recovery. Treating postoperative pain is a major aspect of ERAS and more effective pain management through combination therapy has changed the way patients are having surgery and being discharged.
ERAS programs are one aspect of the PSH, a patient-centred, physician-led, team-based model of coordinated care that spans the entire surgical experience, from the decision to have surgery to discharge and beyond, in a standardised way.
The ERAS program at Rush University Medical Center, Chicago, Illinois, helps patients having minimally invasive knee replacement leave the hospital sooner with less pain, research suggests.
The study included 243 patients having knee replacement surgery who were provided a combination of pain medications that act by different mechanisms to control pain, rather than relying on one type of pain medication, as is the standard.
Researchers assessed the patients’ pain throughout their stay using an 11-point scale. While typically about 60% of knee replacement patients nationwide have moderate to severe pain the day after surgery, in the Rush study, only 4% had that level of pain and 29% reported having no pain at all during the entire hospital stay. Patients in the study were discharged an average of 15 hours after surgery. Nationwide, knee replacement patients are hospitalised for an average of 3.7 days, according to a 2012 Medicare analysis.
“Comprehensive collaboration between the physician anaesthesiologist and surgical team enables us to discharge patients earlier with the same outcomes but less pain,” said lead author Asokumar Buvanendran, MD, Rush University. “Using multi-modal therapies and ERAS principles have revolutionised pain management.”
The ERAS program at Beaumont Health, a health care system in Royal Oak, Michigan, features a patient education (prehabilitation) class prior to surgery. Patients who participated in the class before having colorectal surgery said they were better prepared and had an improved understanding of their goals for pain control and how to manage them compared with those who did not take the class, researchers found.
On the second day after having colorectal surgery, 228 patients were given a 10-question survey about their preparation for surgery and involvement in their care: 160 had attended the prehabilitation class and 68 had not. Of those who took the class, 91% said they felt prepared for surgery versus 80% of those who did not take the class; 95% of those who took the class said they felt encouraged and enabled about recovery due to the information they received in the class versus 82% who did not take it; and 90% of class participants felt they were involved in decision making about their surgical care versus 81% of those who did not take the class.
Since the implementation of ERAS, early outcomes show length of stay has decreased from a week to 2 or 3 days and patients are taking fewer opioids for pain after surgery.
“We believe patient education is a foundation of the ERAS model and should be a standard part of the pre-surgery protocol,” said lead author Larry Manders, MD, Beaumont Health. “Some surgeons initially were sceptical but after seeing the patient benefits, all are now believers in ERAS and providing patient education prior to surgery.”
The 2-hour group prehabilitation class scheduled several weeks before surgery focuses on nutrition, physical conditioning, mental health, and expectation management. Participants learn the importance of a well-balanced diet, are encouraged to do simple exercises at home to improve strength, muscle tone, and flexibility, and learn stress-relieving techniques such as focused breathing and meditation. Nurses who taught the classes explain that opioid use should be limited due to side effects that may slow recovery. Patients also are given a preoperative carbohydrate drink, nutrition supplements that enhance the immune system, a spirometer to increase their lung capacity, and strict instructions to increase their physical activity.