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Becky Eades is an acolyte for change.
She’s an advanced practice nurse practitioner with Bon Secours St. Mary’s Hospital who is a lead, along with Clinical Nurse Specialist Ashley Henry, for the facility’s enhanced recovery after surgery (ERAS) program.
Enhanced recovery is a multi-disciplinary protocol being implemented by surgical programs across the country. The standardized care protocol reduces the stay and enhances the quality of life for the patients, says Dennis Cohen, a surgeon at St. Mary’s and Richmond Community Hospital and an ERAS advocate.
St. Mary’s has used enhanced recovery protocols on about 450 colorectal patients and about 130 to 140 bariatric patients, according to Eades. Their team has also helped extend the concept’s use to Bon Secours Memorial Regional Medical Center and to Bon Secours St. Francis Medical Center.
Patients are out of the bed and standing in the recovery room under these protocols. They’re up walking the night following a surgery. “Our patients look better, and they’re healthier,” says Eades. There’s less reliance on opioids to control pain, so patients avoid the confusion and dizziness that come with their use, and may avoid developing dependencies.
Most patients are released three days after their procedures, says Eades. Before ERAS, patients were released five or six days following an operation.
Cohen brought the idea to St. Mary’s after learning about it at a conference in 2015. Eads says the protocol was enticing because of its associated outcomes, including fewer days in the hospital for patients and less opioid use for pain control. Overall, enhanced recovery boosts the general well-being of a patient. “We really want to do what’s right for our patients,” she says.
Colorectal surgeries have been a common starting point for hospitals in establishing enhanced recovery programs, but any surgery patient could benefit from enhanced recovery concepts, according to Cohen. He said he’d like to see it expanded to include cancer surgeries.
St. Mary’s began enhanced recovery with colon or bowel surgery patients, then added bladder patients, and last December the hospital began using the protocol with bariatric procedures. The St. Mary’s team gained input from all areas of care when coming up with its protocol, says Eades. “Having people from all those areas greatly helped the buy-in, and they know it better than we do,” she says. “If they feel they are a part of it, it’s a big help.”
Meetings initially were held twice weekly, then weekly. The sessions are critical in sharing data and insights, which keeps the program finely tuned. “That keeps us moving forward,” says Eades.
They’ve also drawn from the ERAS Society in Europe and from ERAS USA.
ERAS was developed in Europe about 15 years ago and has become the standard of care in the United Kingdom, according to Michael J. Scott, division director of Critical Care Anesthesiology and a professor in the Department of Anesthesiology at Virginia Commonwealth University.
For all its benefits, enhanced recovery has been slow to catch on in the United States. VCU Health began deploying the protocol about two and a half years ago, says Scott. In November and December, VCU played host to an inaugural world congress on enhanced recovery in pediatrics, a field that has been late to embrace the protocol. Scott was an organizer for the event and an author on a 2017 review article on the protocol in the journal JAMA Surgery.
ERAS is not just about the medical team, it’s more about the patient, according to Scott and Cohen. Patient education and involvement are crucial. “The whole idea is to make it patient-focused,” says Scott. “It empowers people, basically.”
Most any patient could benefit, and it’s actually better in patients who may not be able to tolerate surgery as much, such as the elderly, says Scott. “It reduces stress,” he says.
At St. Mary’s patients are involved throughout, beginning with pre-operation and testing. St. Mary’s provides each with checklists in patient handbooks, so they can check off steps as they are reached.
Enhanced recovery work begins well before a procedure, with health care providers helping the patient become as fit as possible. Scott notes that this may mean providing people who are unable to eat or have cancer with nutritional supplements before their procedures, correcting anemia, or ensuring that someone with diabetes has their numbers under control and is in optimal health. He says this can be a crucial but often overlooked step and can be a lifesaver: A patient who is nutritionally impaired has a three times higher mortality rate.
The protocol reduces the risk of major complications following surgery. Post-surgical complications greatly reduce life expectancy. Also, the faster the recovery, the better the long-term health following a procedure, according to Scott.
Enhanced care calls for optimizing patient heath pre-procedure so they can better withstand the stress and heal quicker and more efficiently; it reduces stress during surgery by little steps such as keeping the patient warm, and afterward patients are encouraged to get moving as quickly as possible, to eat and to sleep, too, something that can be rare in many other hospital situations with alarms and too-frequent check-ins by healthcare providers.
“All together, it makes a big difference,” says Scott.
As with any procedure involving a team of people, multiple steps and extensive data keeping, enhanced recovery protocols can be complex. But the results show it’s worthwhile, and, Cohen notes, “it was surprisingly not difficult at all” for the program to gain an enthusiastic buy-in from participants.
