Nothing by Mouth

Enhanced recovery after surgery protocols challenge the traditional tenets of surgical care, using evidence-based recommendations to reduce complications and speed recovery

BY KIMBERLY MCGHEE

Nothing by mouth. Administration of generous IV fluids. Opioids for pain. Bed rest.

These age-old guides for the care of surgical patients were based on the best intentions for the patients’ well-being but not, as it turns out, on good evidence. Instead, they put patients at greater jeopardy, making complications more likely and delaying recovery. Enhanced recovery after surgery (ERAS) initiatives strive to improve outcomes by replacing time-worn but ill-supported practices in the care of patients before, during and after surgery with ones grounded in evidence. Their ultimate goal is to reduce patients’ stress response to surgery, which can cause biological changes, such as catabolism and insulin resistance, that delay and complicate recovery. Minimizing surgical trauma and maintaining good physiological functioning in the patient can help guard against such stress. Studies have shown that ERAS initiatives can reduce hospital length of stay by 30 percent and general complications by 40 percent or more.¹

“Patients who are kept without food or even water are stressed and almost in a starvation mode when they come into surgery. Because of that, they would get a lot of extra fluid when they arrived at the OR,” explains ERAS nurse navigator, Geri Johnston, M.S.N. “We were keeping people without anything and then giving them too much all at once—that can cause fluid imbalance and slow down recovery.”

In addition to ensuring that patients are properly nourished and hydrated before surgery by avoidance of fasting and use of liquid carbohydrate supplements, common ERAS elements are a preference for minimally invasive surgery and regional anesthesia and early resumption of food, drink and activity, as early as the day of surgery. Use of nasogastric tubes, drains and catheters is minimized to promote the return to normal eating and greater mobility. Pain is carefully controlled, but opioid use is discouraged because it can compromise bowel function and prolong recovery and because of its potential for addiction.

Johnston was hired as the ERAS nurse navigator in April 2016 after promising results were achieved by an ERAS initiative for pancreatic surgery, one of the first in the country, led by MUSC Health gastrointestinal surgeon Katherine A. Morgan, M.D. Length of stay was cut by two days and the cost of surgery by more than $4,000 in the first year of the initiative.² Johnston’s mission was to facilitate the rollout of initiatives in other surgical specialties, including colorectal surgery, orthopaedic surgery (joint replacement), gynecologic surgery and cardiac surgery. In its first year of implementation, the colorectal surgery protocol, under the leadership of surgeon Virgilio George, M.D., and anesthesiologist Laura L. Roberts, M.D., shaved three days off patients’ length of stay and dramatically reduced the percentage of patients receiving opioid medications for pain control (from 75 to 10 percent; unpublished results). Protocols and order sets are also in place for gynecologic oncology and are expected by the end of the year in all of gynecology, orthopaedic surgery and cardiac surgery.

The care provided by any team is constrained by the decisions made earlier in the care pathway and in turn has consequences for the later care of the patient. ERAS initiatives work in part because they strive to implement evidence-based recommendations across the continuum of care. Specialty-specific protocols help to guide treatment, education materials are developed for patients, and order sets are programmed into the electronic health record to standardize care.

Although these initiatives are typically championed by the surgeon and anesthesiologist, they are crafted and implemented by multidisciplinary teams representing all of the units providing the patient’s care. Participation of bedside caregivers is particularly important for the success of ERAS, because they implement the initiatives and can help patients understand how the changes help speed recovery.

“Everyone has to work as a team and understand the protocol and how patients are going to get better sooner, or it’s not going to work,” says Johnston.

Another key ingredient to a successful ERAS initiative is sustainability. Frequent audits of outcomes can reveal lack of adherence to ERAS protocols and motivate continuous process improvement. Protocols too will evolve as the evidence changes, meaning that the team must be prepared to adapt.

But the payoff for patients is undeniable.

“There is a lot of evidence showing that this is an improved way to take care of patients. This is how we are going to go forward with patients having surgery,” says Johnston.

References

_{1. Greco et al. World Journal of Surgery 2014 38:1531-1541.

2. Morgan KA, et al. J Am Coll Surg. 2016 Apr;222(4):658-664.}