ERAS Protocols, Although Challenging, Proliferate at U.S. Hospitals

Author: Bob Kronemyer

Anesthesiology News

Patients undergoing colorectal surgical procedures are by far the most likely to be enrolled in an adult enhanced recovery after surgery (ERAS) protocol in the United States, according to a survey.

“Early ERAS efforts focused mainly on colorectal patients, but recently have expanded to other surgical specialties,” said presenting author Sunitha Singh, MD, the ERAS coordinator at Stony Brook University Medical Center, in New York. “We did this survey because little is known about the popularity of ERAS among various surgical procedures.” Survey results were presented at the 2019 Annual Congress of the American Society for Enhanced Recovery (poster 37).

In total, 148 completed surveys were returned, representing 88 hospitals. The most popular adult ERAS programs were:

• colorectal, 88.6%;
• gynecology, 51.1%;
• orthopedics, 48.9%;
• surgical oncology, 38.6%; and
• urology, 35.2%.

• spine, 23.9%;
• bariatric, 22.7%;
• plastic, 22.7%;
• obstetrics, 20.5%;
• thoracic, 15.9%;
• ENT (ear, nose and throat), 14.8%;
• vascular, 11.4%;
• cardiac, 9.1%;
• other (6.8%); and
• craniotomy (1.1%).

“We were not surprised to find colorectal as the most prevalent service line,” Dr. Singh said. “Given the available literature, we also expected popular programs to include gynecology, orthopedic and surgical oncology.”

The investigators were pleasantly surprised to discover the large number of pathways being developed for ERAS. “This shows that ERAS pathways can be developed for a variety of surgical services, and encourages us to continue to find ways to optimize patient care and outcomes for most surgical patients,” Dr. Singh said.

“Our survey can serve as encouragement for hospitals to expand their ERAS efforts to multiple surgical procedures and perhaps consider developing a program in an area they had not considered,” Dr. Singh said.

Dr. Singh and her colleagues believe there is already consensus about the benefits of initiating ERAS programs across multiple surgical procedures. “We think future areas of focus in ERAS will be determining what elements of the bundles are essential and determining how best to ensure there is high-quality implementation in each program,” Dr. Singh said.

Dr. Singh said single ERAS programs can rely on manual data collection. “But hospitals with more ERAS programs will need to leverage the use of information technology (IT), such as order sets and measuring compliance/outcomes, due to the large volume of patients,” she said.

Programs Improve Care and Save Money

Anoushka Afonso, MD, the director of enhanced recovery programs for the Department of Anesthesiology and Critical Care at Memorial Sloan Kettering Cancer Center, in New York City, said despite the proliferation of ERAS programs in the United States, “there has been little tracking of surgical program adoption. It is important to take a step back and assess where ERAS programs have been successful in uptake and where there are still unmet needs. This can help direct resources, future research and implementation efforts.”

Data suggest that these pathways not only improve clinical outcome and quality of care but also reap significant cost savings, Dr. Afonso noted. “So, why aren’t all programs implementing elements of enhanced recovery amongst all surgical services? The strength of these programs relies on collaboration of many departments, individuals and continual process auditing. However, barriers to implementation occur both at an individual and institutional level, regardless of the benefits of these pathways.”

Strategies to increase participation, according to Dr. Afonso, are education and research to include more surgical subspecialties, increased participation with ERAS societies, and the involvement of leadership and administration to understand the value of these ERAS programs.