Enhanced Recovery After Surgery (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 second in a series of stories about the Brigham’s pioneering efforts to improve patient recovery.
For Sara Lupica, the need for surgery came as a complete shock. Lupica was at a routine visit at a melanoma clinic when her physician expressed concern about an unexpected lump. “She was feeling my abdomen and said, ‘Where did this come from? I’ve seen you within the last six months, and it wasn’t here before,’” Lupica recalled. With her hands, the physician completed a physical exam. She then called for scans. When the results came back, Lupica received alarming news: She had a large, pelvic mass and would need to have an abdominal operation to have it removed.
“I went from having no plans for a procedure before those scans to, within two weeks, having a complete hysterectomy, minus the removal of my ovaries,” said Lupica.
For many patients, the thought of major surgery is overwhelming. In addition to anxiety or concern about the procedure itself, it can be daunting for patients and their loved ones to keep track of all the steps they should take before and after surgery to improve the likelihood of a swift and smooth recovery. To help patients like Lupica, Kevin Elias, MD, a gynecologic oncologist at the Brigham, has developed recoupERAS, an app designed to guide patients on their path to postoperative recovery. For Lupica, the app helped her at every stage.
“The app was fabulous,” she said. “As a patient, you have so many questions. Rather than waiting for someone to call you back or relying on a Google search for information, this app gives you the information you need when you need it. When you’re at a doctor’s appointment, it’s hard to absorb all the information you receive. But here, I could sit back and think in my own home.”
App in Action
The Division of Gynecologic Oncology began implementing ERAS in 2015 and tracks dozens of metrics for every surgical case, including primary stay outcomes, readmissions, complications and more.
“We were able to see very quickly that there was a direct correlation between following the prescribed guidelines and outcomes for patients,” said Elias. “Patients who followed all of the guidelines had very few complications, very short hospital stays and very successful outcomes.”
But Elias and colleagues also realized that there was a split among their patients. Some patients came in well-prepared for what to expect on the ERAS pathway. They knew what their diet was supposed to look like and expected to be up and walking not long after waking up.
“But we also had patients who, even though we were sure we had told them what to expect, would give us a sideways glance when we prompted them to walk. Patients would ask, ‘What do you mean I’m supposed to be up and out of bed or going home soon?’” said Elias.
The team saw a disconnect between the results for the two groups.
“If patients understood the protocol, they recovered well, but for the patients whom we were teaching on the spot, they hadn’t quite gotten there,” said Elias. “So, we thought we needed a better way of giving patients information about recovery.”
Elias designed an app that would offer up patient-friendly resources in the weeks and days leading up to and following surgery. The app’s home screen features a countdown until the patient’s surgery, a daily to-do list and links to videos timed to the phases of a patient’s care. The app helps coach a patient through their preop care, with questions about exercises and diet as well as printable and video resources that can provide advice and instructions. Following surgery, the app provides tips and guidance for recovery.
The app also includes videos, featuring clinical staff members, answering questions such as, “Where should I park?” and “Who will manage my pain?” to help patients know what to expect.
For patients like Lupica, the resources were both informative and reassuring as she prepared for surgery.
“I’m really into fitness, so it tied into what I was doing already and had tips about diet, fluids, movement and activity,” said Lupica. “I didn’t want to take narcotics, but my assumption was that I’d have to take heavy pain medications after the surgery. The app explained that I’d be on non-opioids — analgesics and acetaminophen. I was really happy about that.”
Elias and colleagues are now also tracking outcomes for gynecologic oncology ERAS patients who are using the app, comparing those with high engagement (average of 43 logins) to those with low engagement (average of five logins).
So far, they have had about 30 patients in each group. Many outcomes were the same; both groups had a median length of stay of three days and similar rates of minor complications. Meanwhile, other metrics showed a marked improvement for those using the app. The readmission rate for patients in the high-engagement group was 4 percent, versus a readmission rate of 14 percent for those in the low-engagement group. In addition, the care for highly engaged patients reduced hospital costs by almost 20 percent.
Lupica, who was in the high-engagement group, had a smooth recovery. Her surgeon, Michael Muto, MD, was pleased with both her outcome and how well the app worked for her.
“ERAS breaks all of the rules of what we’ve been taught,” said Muto. “The conventional wisdom is no eating before surgery and no walking around after surgery. It’s hard for some of our patients to come around to the idea that we want them mobilized immediately, they can eat whatever they want and we want them dangling their feet off the bed the day of their surgery. There are a lot of evidence-based steps that we take, but it’s hard to know which one is most impactful. It’s like a secret sauce, which is why we want patients to be on board with every step.”
Beyond Gyn Onc
The Division of Gynecologic Oncology shares its metrics on outcomes with other divisions and departments around the Brigham that follow the ERAS pathway. And, beginning later this year, they will now be sharing the recoupERAS app too. Elias has received funding through the Brigham Care Redesign Incubator and Startup Program (BCRISP) to create a version of the platform for several other service lines, including obstetrics, which follows the ERAS pathway for elective Cesarean sections.
“ERAS is a win-win. It’s better for patients and it’s better for the hospital,” said Elias. “Our hope is that this app will help guide patients through this process, supporting ERAS efforts across the Brigham.”