Episode #23 Enhanced Recovery and Patient Safety

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

While you are listening to the show today, grab your favorite clear carbohydrate loading beverage, like Gatorade, because we will be discussing the ERAS article from the June 2019 APSF Newsletter, ERAS: Roadmap for a Safe Perioperative Journey by Rebecca Blumenthal.

Before we dive into today’s episode, we’d like to recognize Merck, a major corporate supporter of APSF. Merck has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Merck – we wouldn’t be able to do all that we do without you!”

I also want to remind you about an exciting research opportunity.  The APSF is working with the Foundation for Anesthesia Education and Research or FAER to help promote the upcoming Mentored Research training grant. This is a two-year, $300,000 award that aims to help anesthesiologists develop the skills and preliminary data they need to become independent investigators in the field of anesthesia patient safety. If you are interested in pursuing the APSF/FAER mentored research training grant will need to submit a Letter of Intent prior to submitting a full application. The LOI submissions will open December 1, 2020 and close January 1, 2021. More information can be found on our website and I will include a link in the show notes.  https://www.apsf.org/grants-and-awards/apsf-faer-mentored-research-training-grant/

Are you ready to hit the road to learn about enhanced recovery and patient safety? Before we get to the article, I reached out to the author, Rebecca Blumenthal and asked her a couple of questions. Blumenthal is the Vice Chair of Innovations in the Department of Anesthesiology, Critical Care, and Pain Medicine at North Shore University Health System in Chicago and Clinical Assistant Professor at the University of Chicago Pritzker School of Medicine. I asked Blumenthal why she felt so passionate about this topic and I will let her kick things off.

[Rebecca Blumenthal] “ERAS protocols are evidenced-based, multidisciplinary and collaborative approaches to perioperative care based on scientific principals used to optimize preop, intraop and postop care. As vice chair of innovation, it has been my role to champion the implementation of ERAS protocols in multiple surgical subspecialties at North Shore University health system beginning with colorectal surgery. Over the course of the past 4 years, I have led the design and roll out of 8 unique ERAS protocols at North Shore. Each Protocol has resulted in significant reduction in length of stay, perioperative complications, opioid usage, and cost. On a personal note, leading the North Shore ERAS efforts has been time-consuming, at times challenging, but it has been extremely rewarding. All of our ERAS patients are satisfied with their pain management and overall perioperative care and recovery. Our hospital system appreciates that ERAS patients have experienced improved outcomes as well as reductions in complications and length of stay. Finally, in the midst of the US opioid epidemic, I am proud that our ERAS programs have had the added benefit of a 75-90% reduction in opioid usage.”

And now, let’s get to the article. Blumenthal starts the article off with a summary about ERAS programs. The benefits include improved patient safety and patient satisfaction with plans for improved pain control with a speedy recovery and decreased complications and hospital length of stay. ERAS protocol have been implicated in decreasing opioid usage in our surgical patient which is so important as we learn more about the risks of opioid usage and the opioid epidemic with the resultant misuse, abuse, and diversion of these commonly prescribed opioid medication. This is such an important area of anesthesia patient safety since patients may be prescribed opioid for the first time when they come to the hospital for a surgical procedure to treat acute pain following the procedure, but up to 10% of opioid-naïve patients will then go on to become chronic opioid users. What is the harm in prescribing just a short course of opioids to help treat pain after a surgery or procedure? We now know that even a short course of opioids can increase the risk for chronic opioid use. And we may see this in inpatients as well since patients who require high doses of opioids during their hospital stay are at higher risk for continuing to use high doses of opioids after hospital discharge. There is a big call to action for hospitals, clinicians, health systems, and patient safety champions to discover alternative options for perioperative pain control. This is where ERAS initiatives come in to play with evidenced-based and multidisciplinary approaches to improve pain control and decrease opioid usage with the overall goal to improve or enhance patient recovery.

Where did this idea come from? It was developed in Denmark in the late 1990’s by Dr. Henrik Kehlet who was a colorectal surgeon. He proposed that the combination of several evidenced-based interventions such as thoracic epidurals, early nutrition and early ambulation could all work together to help improve patient safety and enhance patient recovery. Evidence-based interventions are the foundation of successful ERAS protocols. Armed with the available literature, hospitals and patient care teams can begin the hard work to create ERAS protocols that are institution-specific, but this is no small feat. Some of the limitations for ERAS implementation include cost, resource availability, time, administrative support, no ERAS champions to support the rollout and maintenance, buy-in from all providers, involved quality managers, and appropriate ancillary support services. Blumenthal offers examples of some of the resource availability challenges at her institution including hiring additional anesthesia technicians, buying more ultrasound machine to facilitate the increased placement of regional blocks, and providing appropriate support for surgery and anesthesia professionals.

It is a lot of work, but it is so worth it for improved patient safety with a resultant reduction in perioperative morbidity, complications and re-admission rates as well as patient satisfaction with improved rehabilitation and recovery after surgery. To top it all off, ERAS protocols are associated with a significant reduction in perioperative opioid usage.

Let’s take a closer look at some of the general components of an enhanced recovery program. There is a wonderful chart that accompanies the article and I will include it in the show notes as well. We have to start at the beginning. The preoperative phase includes the following: Preoperative Education and Optimization, preoperative fasting guidelines and carbohydrate loading, elimination of mechanical bowel preparation, and thromboembolism and antimicrobial prophylaxis. Preoperative education helps to set appropriate expectations about the upcoming surgery and anesthesia plan which has been shown to decrease fear and anxiety. Other benefits for this education includes faster discharge from the hospital by encouraging patients to participate in early oral intake and early ambulation with improved respiratory mechanics and decreased complications. Patient education may occur in person in the surgeon’s office when the surgery is scheduled, but it can also be done with a phone call, or a pamphlet, or even online materials including a dedicated ERAS website or a combination of these resources. Don’t forget about patient optimization with medical optimization of comorbidities including anemia, diabetes, and hypertension as well as cessation of smoking and alcohol for at least 4 weeks leading up to surgery when time allows. Some patients will also benefit from prehabilitation with preop dietary changes, relaxation techniques, sleep hygiene, and exercise to improve functional capacity before surgery and enhance recovery after surgery. Another important component of ERAS is carbohydrate loading with a clear drink 2 hours before surgery. This step goes a long way to decrease discomfort and anxiety from fasting as well as to maintain lean body mass and muscle strength and promote early return of bowel function and decrease insulin resistance. Don’t forget about incorporating surgical site infection and venous thromboembolism bundles into the ERAS protocol to help improve patient safety.

From here, let’s move into the Intra-operative phase which includes the following components: multimodal non-opioid analgesic and antiemetic medications, regional anesthesia, maintenance of normothermia and euvolemia, and minimizing the placement of and early removal of drains, foleys and NG tubes. Postop nausea and vomiting is common after surgery and anesthesia and can lead to decreased patient satisfaction and longer length of stays, so multi-modal therapy for the prevention of PONV is effective and an important component of ERAS. Careful temperature monitoring and maintaining normothermia can help to prevent wound infections, bleeding, cardiac events, and delayed recovery. Another component of ERAS is volume management to maintain euvolemia and avoid fluid overload which can decrease pulmonary and renal complications and promote earlier return of bowel function.

Once we have left the operating room, the enhanced recovery continues and this phase of care is so important for a fast and safe recovery without complications. Postoperative components including early mobilization and ambulation, which may even start in the PACU, early nutrition, and multimodal non-opioid analgesics. Early nutrition may lead to improved insulin resistance, muscle function and wound healing and decreases the risk for pneumonia, sepsis, ileus, and surgical site infections. And let’s get our patients moving since early mobilization improves muscle strength and functional organ recovery and patient satisfaction with decreased pulmonary and thromboembolic complications.

Patients with cancer who require surgery can benefit from ERAS protocols with a faster return to their preoperative functional status and quicker return to their oncologic therapy and this can lead to improved patient outcomes and survival especially for patients with breast, lung, pancreatic, liver, and metastatic colorectal cancers. ERAS protocols can make surgery for safer for patients with cancer by decreasing opioid usage which may lead to decreased cancer recurrence and improved quality of life.

When you hear ERAS, do you think “multimodal analgesia?” This is a vital component of all ERAS protocols which often includes several non-opioid analgesic medications as well as additional techniques to minimize opioid usage and some patients may not need any opioid medications for pain management. With the implementation of multi-modal approach to pain management and decreased opioid usage, we have seen better pain control and decreased opioid side effects including nausea, vomiting, pruritis, sedation, respiratory depression, ileus, urinary retention, and opioid addiction and dependence. Options for multimodal analgesic therapy depends on the surgery and patient and may include peripheral nerve blocks or neuraxial techniques and non-steroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, gabapentin, ketamine, lidocaine, steroids, alpha-2 agonists and magnesium. This was a great review of ERAS protocols and implementation.

Before we wrap up, I asked Blumenthal what she hopes to see going forward with regard to ERAS and patient safety?

[Blumenthal] “As I have discussed in my June 2019 APSF article, ERAS care maps and standardization can improve outcomes and safety for patients in the perioperative period. ERAS programs are clinical care bundles that are based on multiple evidenced-based interventions. It is critical that rigorous science and pathophysiological principles continue to be applied in the future expansion of ERAS protocols for all surgical subspecialties. Moving forward, with appropriate resources and support, I hope to see expansion of ERAS protocols to all surgical subspecialties leading to significant reductions in opioid usage, complications, and length of stay as well as improvements in patient satisfaction. At the end of the day, the multiple components of ERAS programs create a standardized framework and roadmap that lead to a safe and satisfying perioperative experience and outstanding evidenced-based anesthetic care.”

Thank you, Blumenthal! We certainly have come along way with our knowledge of enhanced recovery after surgery in the past few years and it is exciting to see what we can do with this standardized framework and roadmap that not only improves patients experiences but also offers safer anesthesia care!

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Plus, you can find us on twitter and Instagram!  See the show notes for more details and we can’t wait for you to tag us in a patient safety related tweet or like our next post on Instagram!! Follow along with us for anesthesia patient safety pictures and stories!!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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