Clinicians are always looking for ways to improve patient recovery and quality of life, but sometimes the biggest improvements start with the smallest of changes.
Since the summer of 2014, a group of BWH anesthesiologists, surgeons and nurses involved in colorectal surgery have come together to compile and commit to those small changes, implementing an “Enhanced Recovery After Surgery” (ERAS) protocol at the hospital. These changes – such as giving patients a carbohydrate drink before surgery, precisely managing fluid delivery during surgery, mobilizing the patient sooner and more – have added up to major improvements in patient outcomes and quality of life. Patients who are on the ERAS pathway have lower rates of complications after surgery, such as cardiac events and site infections, and are well enough to leave the hospital an average of one-and-a-half days earlier than their counterparts.
“The results we’ve seen are phenomenal,” said Ron Bleday, MD, section chief of BWH’s Division of Colorectal Surgery. “As clinicians, it’s encouraging to see our patients benefiting from these changes. This is good for us and for our patients – everyone wins.”
“This makes our work so much more rewarding. Anesthesiologists often fly under the radar, but here, we can see the tremendous effect that we can have on patients’ outcomes,” said Matthias Stopfkuchen-Evans, MD, of the Department of Anesthesiology, Perioperative and Pain Medicine.
The story of how ERAS came to be implemented at BWH begins with the intersection of a surgeon and anesthesiologist’s paths. Stopfkuchen-Evans attended a conference in 2012 that sparked ideas for how anesthesiologists could help improve the ease of recovery for patients. That same year, Bleday attended meetings with BWH’s Chief Financial Officer (CFO) Michael Reney, MBA, and Chief Medical Officer (CMO) Stanley Ashley, MD, to discuss ways to reduce complications after surgery.
When Bleday approached Stopfkuchen-Evans to talk about reducing IV fluids delivered during surgery to help improve patient outcomes, Stopfkuchen-Evans seized upon the opportunity to bring some of the changes he heard about at the conference to BWH.
“I thought, ‘This is a great opportunity. Let’s do that and more – let’s start ERAS,’” said Stopfkuchen-Evans.
With support from the CFO and CMO, Bleday and Stopfkuchen-Evans enlisted the help of others involved in perioperative, operative and post-operative care, including nurses and educators to implement a new protocol for Bleday’s patients receiving elective colorectal surgery.
Sarah Thompson, MSN, RN, a nurse educator on 15CD in the postoperative area, and her colleague Elizabeth Doane, MSN, RN, a nurse educator on 15AB, have been involved in the rollout of the ERAS pathway for colorectal patients since its introduction. Along with Lauren Wolf, RN, a staff nurse in the Post Anesthesia Care Unit, they developed a checklist to keep track of multi-disciplinary responsibilities that span preoperative, perioperative and postoperative care.
“ERAS works,” said Thompson. “We’ve seen that the patients who are on the ERAS pathway really do better;they have less pain, less nausea, less complications and go home sooner. I am a true believer in this modern, evidenced-based approach to managing surgical patients.”
One aspect of the pathway that usually pleasantly surprises patients is that instead of requiring them to fast for 12 hours before surgery, they are given a clear liquid rich in nourishing carbohydrates and electrolytes to drink before surgery.
Stopfkuchen-Evans says many patients like the drink, and it allows them to go into surgery feeling satiated and less anxious. After surgery, patients complain less about hunger and thirst and report less nausea and vomiting. The carbohydrate drink also reduces metabolic stress, which helps speed recovery.
As part of the preoperative process, the team runs through a checklist with each patient, assessing and managing a patient’s risk and pain. During surgery, the amount of IV fluid an anesthesiologist administers is carefully calibrated using a doppler monitor that helps the anesthesiologist tailor fluid replacement to each individual patient. Too much fluid can lead patients to gain more than 20 percent of their body weight, causing them feeling bloated and water logged and leading to complications and slower recovery.
Fewer opioid narcotics are given since they can slow gastrointestinal function and cause other problematic side effects, but other pain management methods are used.
After surgery, patients are helped to sit up in bed and dangle their feet. They are given sips of water and can often advance to a regular diet on their first day after surgery. They are also given gum – chewing it not only gives the patients something to do but also may help the gastrointestinal tract recover.
The ERAS team also tries to engage patients in their recovery process, keeping them actively involved. “Patients have really gotten on board – they want to be part of the process,” said Wolf. The team has patients keep a log of what they are eating and drinking and what their pain level is – valuable information and feedback for the physicians, but also helpful for patients to see their progress.
“Our patients feel so good so fast that they are sometimes surprised when we tell them they are well enough to leave – the log helps them to see the progress they are making,” Wolf said.
ERAS began on a trial basis with 40 elective surgery patients, increasing to 70 patients as the team started to see promising results. The team compared their recovery to that of patients who had received similar colorectal surgeries the year before, prior to when ERAS was implemented.
“After the first 70 patients, we saw a decrease in the length of stay by one-and-a-half days. Their bowel woke up a day to a day-and-a-half faster so that they were eating a regular diet. Surgical site infections and cardiac complications dropped by two-thirds,” said Bleday.
Bleday described the science behind these impressive results: administering less fluid means less swelling (edema), allowing the immune system to get to the site of a wound faster and promote healing. Extra fluid can also put stress on a person’s heart, sometimes leading to arrhythmias. Decreasing the fluid administered during an operation can avoid placing this stress on the patient.
Based on these results, hospital leadership has recommended making ERAS the default protocol for all colorectal surgeries, with the potential to expand into other surgical areas such as urology or gynecology in the future.
“ERAS is all about applying evidence to what we do every day, and there’s so much we stand to gain from that,” said Stopfkuchen-Evans. “We’ve been able to bring different disciplines together to put this into place and that kind of collaboration is what we’ll need to continue expanding the practice of ERAS at the hospital.”