Enhanced recovery after surgery (ERAS) pathways have been shown to improve clinical outcomes, reduce hospital length of stay (LOS) and reduce cost, with likely no increased risk for readmissions. However, as Andrew Gorlin, MD, of the Department of Anesthesiology at Mayo Clinic in Phoenix, explained at the 2016 American Society of Anesthesiologists Practice Management meeting, a paradigm shift from “clinician-focused” to “patient-centered” care is needed for successful implementation.
“Integration, coordination and standardization of care are at the heart of any ERAS program,” said Dr. Gorlin. “We need to come to the patient as an integrated whole, where all understand both the big picture as well as the practitioner-specific components of care.”
The ERAS Pathway: A Review
Henrik Kehlet, MD, the so-called father of ERAS, pioneered “fast-track” surgical pathways in the late 1990s and showed that it was possible to safely reduce hospital LOS for patients undergoing colon resection to as little as two days. These fast-track or “enhanced recovery” pathways are standardized, evidence-based care protocols that can be divided into three distinct phases (Figure).
Figure. The stages of an ERAS pathway.
CHO, carbohydrate; PONV, postoperative nausea and vomiting
In the preoperative phase, the focus is on risk assessment and medical utilization—getting patients “as healthy as they can be” through exercise, good nutrition and smoking abstinence. Management of expectations through daily care maps helps to improve compliance, and patients are hydrated with clear fluids up to two hours before induction.
“Maintaining glycogen stores will help the patient to deal with metabolic stress downstream,” said Dr. Gorlin.
Intraoperatively, minimally invasive surgery is a key component, along with short-acting anesthetics. Excessive fluid administration, which can cause a lot of perioperative problems, is avoided, and opioid-sparing techniques are used.
“Opioids are very bad actors, postoperatively,” said Dr. Gorlin. “They cause a million different complications, including constipation, ileus, respiratory problems and delirium.”
Finally, in the postoperative phase, the necessity of routine tubes, catheters and drains is questioned. “In a lot of cases, there’s not good evidence that these do anything,” said Dr. Gorlin, “and for nasogastric tubes, there are good data showing that they do harm.”
Early diet and ambulation also are emphasized. “Clinicians are no longer waiting days to feed patients,” said Dr. Gorlin. “And no more bed rest, either. Getting patients up and out of bed is important.”
What ERAS really comes down to, said Dr. Gorlin, is improving clinical outcomes while reducing hospital LOS and cost.
“Multiple studies show improved pain scores and return of gut function, along with fewer complications. That right there is enough to look into these pathways. But studies have also shown a reduction in perioperative length of stay and costs.”
According to Dr. Gorlin, ERAS pathways can help anesthesiologists support the transition from fee-for-service to value-based payments.
“The role of the anesthesiologist in our profession is evolving and expanding,” he explained. “These pathways represent an opportunity for us to demonstrate our value to our hospitals.”
Dr. Gorlin and his colleagues analyzed outcomes from the first 99 patients who were enrolled at Mayo Clinic in 2013, and they were pleased with the results. “Our LOS dropped in open cases by over 2.5 days, and our LOS dropped in laparoscopic cases by more than one day,” he reported.
In addition to these reductions in hospital LOS, Dr. Gorlin and his colleagues were able to achieve cost reductions across multiple services, including pharmacy, the operating room and lab.
Implementing ERAS Pathways
Despite the aforementioned benefits, Dr. Gorlin acknowledged several barriers to ERAS adoption, including lack of awareness of new evidence-based practices. There also are concerns about time-consuming bureaucratic processes, as getting a pathway up and running requires time and stamina. Finally, said Dr. Gorlin, physicians are fairly independent-minded people; there’s going to be resistance to standardization and “recipe medicine.”
Beyond the philosophy of change, development of an ERAS program requires a “clinical champion” and broad, multidisciplinary support and participation. “It’s hard for an administrator who’s not working clinically to start one of these,” said Dr. Gorlin. “You need someone on the ground taking care of patients.”
If not the primary leader, said Dr. Gorlin, an anesthesiologist must be heavily involved, and buy-in and support from departmental leaders is essential. “You have to have everyone on board and on top of it,” he advised.
After the pathway is developed, fine-tuned and critiqued, the last stage is evaluation—gathering data and auditing results.
“You need to know for sure that you’re doing what you think you’re doing,” said Dr. Gorlin. “A lot of people think they’re doing enhanced recovery, but they’re actually not, because they’re not watching their outcomes and seeing if their processes are actually happening.”
As in life, there’s always room for improvement. “This is a continuing quality-improvement project,” he concluded. “Once the pathways are set up, that doesn’t mean it’s set in stone. You have to continually reevaluate, go back and tweak it, and rework it.”
Joseph William Szokol, MD, chairman of the Department of Anesthesiology at NorthShore University HealthSystem in Chicago, said, despite the proven benefits of an ERAS pathway, getting anesthesiologists and surgeons on the same page can be a challenge.
“At our institution, surgeons are not really into the idea, because they’re not measuring length of stay yet,” said Dr. Szokol, “so I think it’s really organization-specific. But the data are out there: If you employ ERAS, your patients perform better and leave the hospital sooner, and you also save costs. Whether or not we can get surgeons and anesthesiologists together, though, is the question. It’s a great opportunity for the perioperative surgical home—for us to work together for patient care.”