Julie Crowell, BSN, RN, (left) helped cardiac surgery patient James Mitchell take his first steps after surgery.

Thanks to the work of a multidisciplinary team, cardiac surgery patients are benefiting from an Enhanced Recovery After Surgery (ERAS) pathway after coronary artery bypass grafting, isolated aortic valve replacement and mitral valve repair or replacement.

ERAS pathways are evidence-based guidelines designed to facilitate faster, safer and more comfortable recovery after surgery. They have been widely adopted by various specialties at the Brigham to improve patient care and fast-track postoperative recovery. This article is the first in a series of stories about the Brigham’s pioneering efforts to improve patient recovery.

At the Brigham and around the country, ERAS pathways have led to important improvements in outcomes. Patients on these pathways have experienced fewer complications, such as surgical site infections, heart rhythm problems, blood clots and more. But what could this pathway look like for critically ill patients? Could ERAS work for patients undergoing heart surgery? In 2017, the Brigham’s multidisciplinary Cardiac Surgery team sought to find out.

“Postoperative care after cardiac surgery is quite extensive, and patients need to be intubated for a long period to be stabilized,” said Tsuyoshi Kaneko, MD, of Cardiac Surgery. “There have been a lot of advances in postoperative management in other fields, but our patients are less stable than colorectal or urology surgery patients, for example.”

The Cardiac Surgery division has a rich tradition of innovation, having performed the world’s first successful valve surgery in 1923 and the first heart transplant in New England in 1984. With the same spirit of inquiry and dedication to improving care, team members decided to develop an ERAS protocol for patients undergoing heart surgery, becoming one of the first Cardiac Surgery teams in the country to do so.

“Surgeons and anesthesiologists have long deliberated on the benefits of individual maneuvers like opioid reduction, early extubation and early ambulation, but no real action was ever taken,” said Prem Shekar, MD, chief of the Division of Cardiac Surgery. “The Cardiac Surgery ERAS team that developed the protocol was able to synthesize all of these into a pathway, and, with the involvement and support of patients and their families, physicians, physician extenders, nursing staff and the entire cardiac surgical team, have been able to successfully implement this with remarkable results.”

To date, more than 100 patients have participated in the pathway, undergoing surgeries including coronary artery bypass grafting, isolated aortic valve replacement and mitral valve repair or replacement.

The protocol has yielded substantial improvements in patients’ recovery, including:

• decreased length of stay in the intensive care unit, from 41 hours to 26 hours
• shorter intubation time of 3.6 hours compared to 4.9 hours
• a trend toward decreased hospital length-of-stay without readmission
• no increased risk of bleeding, stroke, atrial fibrillation or 30-day readmission

A “Team Sport” in Cardiac Surgery

Establishing this protocol and criteria among many stakeholders took about six months.

“We can’t change the essential aspect of surgery, so we focused on adjusting preoperative education, the medications a patient receives during surgery and the postoperative recovery period in the intensive care unit,” said Kaneko.

This required the perspective and input of every member of the interprofessional team, including surgeons, anesthesiologists, perfusionists, nurses and others.

“Cardiac surgery is really a team sport,” said Dirk Varelmann, MD, cardiac anesthesiologist. “There are lots of teams involved, and we all need to have the same goals and work toward them together. We want to make cardiac surgery as good an experience as it can be by minimizing side effects and discomfort and helping patients get through the process swiftly.”

The cardiac anesthesia team explored different medication options that would help patients wake up sooner after surgery.

“We sought to minimize the use of opioids,” said Varelmann. “Rather than giving a fixed dose of an opioid, we titrate it to the length of the surgery and adjust it according to the patient’s weight and age. We’ve added other agents, including intravenous Tylenol, during the procedure. Our approach has been to limit opioids, which can have side effects including drowsiness and constipation, while keeping patients comfortable with a multimodal pain strategy.”

The team also set goals for preoperative and postoperative care, including patient education and early ambulation and extubation.

Culture Change in the ICU

Nurses play an essential role in helping patients achieve their goals in the intensive care unit (ICU), including sitting up on the bed within 12 hours and walking within 24 hours following surgery. Previously, patients undergoing open heart surgery stayed in bed for 48 hours postoperatively. “As long as patients are stable, we want to change our mindset and see if they can ambulate early,” Kaneko said.

Andris Soble, BSN, RN, of the Cardiac Surgery ICU, noted that the initial success of ERAS patients was encouraging to staff. “After implementing early mobility and ambulation, in addition to the use of non-narcotic interventions for pain control, we saw results including quicker transfers of patients out of the intensive care unit and discharged to home,” he said.

That led to nurses taking the program a step further. “We are encouraging early ambulation for all patients, even if they are not on the ERAS protocol, because of the benefits it offers,” said Cardiac Surgery ICU Nursing Director Maria Bentain-Melanson, MSN, RN. “The mobility of all of our patients has improved with this program.”

Patients who are candidates for the ERAS protocol learn about it during a preoperative clinic visit so they are prepared for what to expect. “Patients are often surprised to hear that we want them to be walking within a day and that their breathing tube will come out two hours after surgery, but knowing this beforehand has an enormous effect on their participation,” Kaneko said. “Everyone wants to recover quickly.”

Varelmann said that getting out of bed earlier is also good for a patient’s mindset. “Being able to walk around the unit creates some feeling of success for the patient; it shows that they are recovering,” he said.

Looking Forward

In the spring, Cardiac Surgery nurses won first prize with a poster reflecting the multidisciplinary team’s success with the ERAS protocol during the 2019 American Association of Thoracic Surgery’s annual meeting. The team plans to continue studying the protocol and its benefits with an eye toward examining cost benefits and improved outcomes.

Based on the success of patients within the protocol, the Cardiac Surgery team has also broadened its inclusion criteria to focus on more complex patients, including those undergoing double valve surgeries and aortic surgery. The team is also focusing on the addition of protocols to further improve the ERAS program.

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