Surgery prep, recovery poised for revolution

Enhanced Recovery After Surgery - which starts well before surgery, involves better communication, more liberal eating and drinking and new approaches to pain management
April 11th, 2017

Enhanced Recovery After Surgery, designed to better prepare patients for surgery and speed their recoveries afterward, is coming to UCHealth University of Colorado Hospital.

Touchstones of the Enhanced Recovery After Surgery program are shown.
Some Enhanced Recovery After Surgery touchstones, courtesy of the American Association of Nurse Anesthetists.

ERAS, as it’s known, has European roots and an impressive track record. A recent review of ERAS programs in more than 20 countries found them to shorten hospital stays by an astonishing 30 to 50 percent, with similar reductions in complications – in addition to reducing hospital readmissions and costs. Among other benefits for patients, ERAS means less thirst and hunger before surgery, less anesthetic and fewer opiate-based painkillers to slow them down after surgery, and more ease in getting out of bed, back home, and on the road to recovery sooner.

Given this rainbow of benefits and the fact that ERAS has been around for about 20 years, the obvious question: what’s been the holdup? History and habit, it turns out. As a group of physician scholars put it in 2011, “Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.”

So six years hence, very few U.S. hospitals are doing ERAS. That’s changing at UCHealth, thanks to the work of a UCH team led by Christine Woodman, BSN, MSA, and Katie Conyers, NP. After more than a year of laying the groundwork, they’re poised to launch ERAS at UCH this April with pancreatic cancer surgery patients, with the aim of rolling it out for all inpatient surgeries going forward.

Katie Conyers, NP, and Christine Woodman, RN, the driving force behind University of Colorado Hospital's new Enhanced Recovery After Surgery Program, are shown.
Katie Conyers, NP, and Christine Woodman, RN, were the driving force behind University of Colorado Hospital’s new Enhanced Recovery After Surgery Program.

Let’s talk

Woodman is the nurse manager of the hospital’s Pre-Procedure Services, which gets people ready one to two weeks before their surgery. Conyers is a nurse practitioner in the unit and does medical assessments and planning for the more complex patients undergoing surgery. More than a year ago, they and others started working on ERAS as a project with the Institute for Healthcare Quality, Safety and Efficiency (IHQSE). The IHQSE is a collaborative effort between University of Colorado Hospital, Children’s Hospital Colorado and the CU School of Medicine and College of Nursing that gives health care providers hands-on training in leading comprehensive process improvement projects and delivering safe, high-quality care efficiently.

This is a photo of Dr. Steven Zeichner.
Dr. Steven Zeichner

“We became interested in this because it was a more comprehensive program for patients as they go through their surgical experiences and connect with all of the departments involved – from the time they make the decision to have surgery to the time they go home and beyond,” Woodman said.

Faculty from the CU School of Medicine’s Department of Anesthesiology have played important roles, Woodman said. Steven Zeichner, MD, worked to develop protocols and has been a consistent presence in developing the program; Tamas Seres, MD, who has helped ERAS move forward, too, she added.

This is a photo of Dr. Barish Edil, surgical oncology chief and the pancreatic surgery lead at University of Colorado Hospital.
Dr. Barish Edil, surgical oncology chief and the pancreatic surgery lead at University of Colorado Hospital.

Pancreatic cancer surgery patients will be the first to roll into ERAS. Woodman, Conyers and colleagues chose this cohort for a couple of reasons. First, UCH’s pancreatic cancer patients are already part of a streamlined multidisciplinary clinic that brings diverse providers to the table quickly and efficiently. Second, Barish Edil, MD, the surgical oncology chief and the pancreatic surgery lead at UCH (he is among the few surgeons in the world capable of doing highly complex Whipple procedures laparoscopically), was enthusiastic about ERAS from the moment they brought it up. With ERAS, those involved in patient care before, during and after surgery integrate more tightly as a team, he said.

“We talk about what we think is best for our patients, and that communication leads to a standardized way of caring for them that’s evidence-based – not based on dogma,” Edil said.

That same communication will pay dividends once ERAS rolls out, he added.

“It will allow us to step back and see what works and doesn’t work, and allow us to improve and optimize,” he said. “Ultimately, I think it’s going to lead to better outcomes and health care cost savings.”

Eat, drink…

That’s all behind the scenes. Patients will notice some big differences, though. For example, the UCH standard now is to have patients stop eating solid food at least eight hours before surgery and drink nothing in the four hours beforehand. With ERAS, the prevailing standard is to let patients eat until six hours before the procedure, and then give them an eight-ounce clear-liquid carbohydrate drink immediately before surgery. That’s because patients do better with the extra hydration and blood sugar, research has shown. Of course, given that pancreatic cancer surgery focuses on the digestive tract, Edil and colleagues will be conservative in their adoption of this particular part of ERAS, Woodman said. But as the approach becomes established, she anticipates the approach will become a mainstay at UCH and across UCHealth.

Intravenous fluid volumes will be standardized during surgeries, which will help avoid problems with wound healing that too much hydration can cause – as well as cardiovascular issues that too little hydration can bring, Woodman said. They’ll have patients drink fluids just after surgery, and will reintroduce food earlier, too – as soon as the day of surgery, as compared to the two or three days abdominal surgery patients typically wait now. That will help kick-start the digestive tract, Woodman said.

While making sure patients feel minimal pain, ERAS involves big changes in anesthetic approaches and pain management. One will be to minimize the use of opioids painkillers after surgery. Opioids can cause nausea and slow down the gut – the opposite of what pancreatic cancer patients need after surgery. Epidural-type pain blocks and non-narcotic pain relievers such as tramadol will be in the mix, Woodman said. Just as importantly, less-woozy patients can get up and move sooner, which brings faster recovery, Conyers added.

“We want the patient to be as comfortable as they can be, so they can get up and walk on the first evening of surgery,” she said.

Another big piece of ERAS at UCH will involve patient and family education and “prehabilitation.” The education piece will encompass new, thorough multimedia tutorials, checklists and narratives about what to expect before, during and after surgery. Prehabilitation involves working with patients in a variety of ways, such as making sure things like lab samples and electrocardiograms have been done well in advance. Prehabilitation can also include such things as referrals to smoking-cessation, exercise and weight loss programs, and diabetes-management programs, which can help make patients more resilient during surgery and speed healing and recovery, Woodman said.

There’s much more to ERAS, and as the program becomes the standard across UCH – and, eventually, all UCHealth hospitals – more refinements lay ahead. One thing is certain, though, Woodman said.

“By challenging some of our longstanding beliefs on how to care for surgical patients, it’s changing the way we’re doing surgical care,” she said.