Although enhanced recovery pathways are beginning to gain a foothold in the inpatient arena, their place in the ambulatory setting is only now evolving, particularly for cancer patients. Research shows, however, that procedure-specific enhanced recovery pathways can be successfully implemented in outpatient centers, with marked success in terms of reduction in lengths of stay and increased patient satisfaction.
“As we all know, ERAS [enhanced recovery after surgery] is a multimodal care pathway designed to reduce stress and help patients get back to normal as soon as possible,” said Anoushka M. Afonso, MD, assistant attending at Memorial Sloan-Kettering Cancer Center, in New York City.
“We’re talking about the entire surgical journey, beginning at the outpatient clinic and moving onward through surgery, the PACU [post-anesthesia care unit], and even when they go home. And our goal was to enhance and optimize their recovery at each step along the way, even though they were outpatients.”
To help achieve that goal, clinicians at the institution set out to develop enhanced recovery pathways for four surgical procedures performed at the Josie Robertson Surgery Center, their new freestanding ambulatory surgical hospital: mastectomy with and without reconstruction, robotic prostatectomy, robotic and laparoscopic hysterectomy, and thyroidectomy.
Not surprisingly, enhanced recovery pathway program development included an extensive literature review and collaborative, multidisciplinary efforts.
As Dr. Afonso explained, although the guiding principles of enhanced recovery pathways are designed for inpatient care, most are applicable to the outpatient setting as well. Preoperatively, patient optimization is critical in ambulatory care, and includes education, proper nutrition and avoidance of prolonged fasting.
“Counseling patients and empowering them is the most important part of this process,” she said. “We also optimize them with preoperative medications; all of our patients get gabapentin when they come to the surgical center for preemptive analgesia.”
Intraoperatively, goal-directed fluid management and standardized multimodal analgesics and anesthetic regimens play as vital a role in the outpatient arena as they do for inpatients. “Nausea and vomiting prophylaxis is critical here,” Dr. Afonso said.
In the postoperative period, early resumption of diet and early mobilization play paramount roles for ambulatory patients. “Use of nonopioid oral analgesics and avoiding fluid overload are very important, especially in the ambulatory setting, allowing them to move faster as they go back home.”
As Dr. Afonso reported at the 2016 annual meeting of the American Society of Anesthesiologists (abstract A1303), the researchers used length of stay to measure success of the enhanced recovery pathways. As a control, the same procedure types were performed by the same surgeons with the intent of discharging all patients the next day, but without specific pathways. Use of enhanced recovery pathways in the outpatient setting resulted in significant improvement (Table).
While there are certainly elements common to all enhanced recovery pathways, Dr. Afonso was quick to note that there is no one-size-fits-all approach when it comes to these complex care models. “You have to realize that when you create your own pathway, it really has to adhere to the culture of your institution,” she explained. “What is done at one institution may not work at another.”
Implementing pathways that are specific to individual surgeries is another element of success, she pointed out. “We created four different teams with four different surgical services.” For example, while perioperative paravertebral and pectoral blocks were deemed important in breast surgery patients, transversus abdominis plane (TAP) blocks were flagged as potentially important in gynecology patients, when indicated.
Special considerations for head and neck surgery patients included:
- limiting intraoperative fluid management to help minimize the risk for dilutional hypocalcemia;
- 4% lidocaine (2 mg/kg) administered via endotracheal tube during surgical closure to decrease coughing during emergence;
- postoperative benzocaine lozenges; and
- 8 mg of dexamethasone to reduce airway edema.
In urology patients, the pathways called for restricted hydration (1-2 mL/kg per hour) prior to bladder closure.
“The take-home point is that development of each pathway really improved surgical care and decreased length of stay for our patients,” Dr. Afonso said. “So it seems that ERAS can make a difference, even in an ambulatory setting.”
Tailoring Enhanced Pathways Important
Monica Harbell, MD, told Anesthesiology News that it seems a natural progression for enhanced recovery pathways to extend to ambulatory settings. “ERAS principles can be readily applied to ambulatory settings, particularly avoiding prolonged fasting, giving multimodal nonopioid analgesics and regional anesthesia whenever possible, and utilizing aggressive PONV [postoperative nausea and vomiting] prophylaxis,” said Dr. Harbell, assistant clinical professor of anesthesia and perioperative care at the University of California, San Francisco School of Medicine. “These will all contribute positively to patient experience and facilitate a speedy recovery in the ambulatory setting.
“I think Dr. Afonso’s team is wise to tailor the ERAS pathway for each individual type of surgery, as different procedures may have different considerations and priorities for recovery,” she added.
Dr. Harbell noted further that there are a variety of measures that can be examined to determine the efficacy of enhanced recovery protocols in the outpatient setting, including opioid consumption, pain scores, incidence of PONV and post-discharge nausea and vomiting, 30-day readmissions, morbidity and patient satisfaction.