Enhanced recovery after surgery (ERAS) programs are gaining ground with recent data showing that they improve outcomes. The programs consist of multidisciplinary, evidence-based protocols implemented in the perioperative period to provide standardized patient care.
Like other changes in healthcare delivery, adopting ERAS programs takes time and effort. Despite positive results from international ERAS programs, the US has been slow to adopt them, in part because of their costs. ERAS programs also can be difficult to implement because they require a shift to a multidisciplinary model that integrates the departments of surgery, nursing, and anesthesia into one pathway.
Johns Hopkins Hospital in Baltimore, a leader in the movement, has implemented ERAS programs in several different surgical specialties based on success with reducing length of stay and improving patient satisfaction. Leaders from Johns Hopkins recently shared their experience with OR Manager.
Elizabeth C. Wick, MD, FACS“Our approach has been successful, but it required a revamping of how we deliver care,” says Elizabeth C. Wick, MD, FACS, associate professor of surgery and colorectal surgeon at Johns Hopkins. “That involved building a dedicated team, which takes a financial investment,” she says.
Johns Hopkins was one of the first US hospitals to initiate an ERAS program for colorectal surgical patients. Since then, the program has been adapted to hepatectomy, cystectomy, and gynecologic oncology procedures. In addition, the ERAS team has developed a financial model to evaluate costs of implementing and maintaining an ERAS program.
After 6 months, the ERAS program for colorectal surgery resulted in a 45% reduction in length of stay, and patient satisfaction scores improved from the 37th percentile to the 97th percentile.
In 2010, the rate of colorectal surgical site infections (SSIs) at Johns Hopkins was 27%. Dr Wick and colleagues assembled a colorectal Comprehensive Unit-based Safety Program (CUSP) team, which did extensive process improvement work and reduced SSIs to 18%, but did not reach the institutional goal of 15%.
While discussing strategies to further reduce the SSI rate and longer than expected length of stay, CUSP team leadership proposed an ERAS program.
In August 2013, Dr Wick and colleagues created a colorectal ERAS team comprising a surgery leader, a nursing leader, and two anesthesiology leaders (one anesthesiologist and one certified registered nurse anesthetist).
“The program really is a multidisciplinary collaboration where everyone is equal and everyone’s voice is heard,” Dr Wick says.
The anesthesiology portion of the ERAS program, developed by anesthesiologist Christopher L. Wu, MD, and colleagues, was implemented in February 2014. This part of the program required the greatest paradigm shift because anesthesia personnel had not been a part of CUSP, which focused on the:
• outpatient area (ie, mechanical bowel preparation with oral antibiotics, patient education, and chlorhexidine washcloth bathing)
• presurgery holding area (ie, patient warming)
• OR nursing practices (ie, sterile technique).
“We completely changed the type of anesthesia we give for ERAS patients,” says Dr Wick. “We now give total IV anesthesia with epidurals for open cases and regional blocks for laparoscopic cases, and we have cut way back on the narcotics we give.”
A cornerstone of the ERAS pathway has been the judicious use of intraoperative IV fluids. Though there is no set rate for intraoperative fluid infusion, there is a protocol to guide fluid resuscitation and avoid excessive fluid infusion.
In addition, all patients now go to the preanesthesia testing clinic to get oriented to the type of anesthesia they will be given.
Tracie Cometa, BSN, RNThe intraoperative piece of the program is so important, notes Dr Wick. Traditionally when people think of an ERAS program, they think of preoperative and postoperative processes.
After working closely with anesthesia and OR nursing colleagues, however, Dr Wick says, “I really think the OR team is a big part of the positive results we have seen. A lot of the dyes are cast in the OR for the complications we see later on.”
The IV anesthesia and regional blocks are making a difference, but it’s also important to make sure the patients are warm, pay attention to antibiotics, pay attention to sterile technique, and get everyone to do their part, says Dr Wick.
“We play a big part in the reduction of SSIs,” adds Tracie Cometa, BSN, RN, staff nurse on the colorectal ERAS team. “Even though what we do as nurses in the OR may not be particular to ERAS, it is so important in the whole scheme of things and in our role as patient advocates,” she says.
Everyone on the ERAS team is encouraged to speak up, says Cometa, which she says gives her the confidence to speak up whenever she sees something that might compromise sterility.
“We all want to protect the patient from an SSI,” she says.
The OR has a custom checklist for ERAS patients that is included in the intraoperative briefing. “We have incorporated discussion of the anesthetic plan, which is something we never did before, as well as patient warming,” says Cometa.
Warming for colorectal patients is challenging because the patients get cold very quickly, notes Cometa. The room is kept at 72°F, and upper body warming blankets are used. Cometa says they recently trialed forced-air warming blankets that go under the patients.
“They warm the patient much faster, and we hope to use them in the future,” she says.
In the end, the OR needs to be at the table in ERAS programs, says Dr Wick. “The OR piece is key to how the patients recover—whether they get cold, lose a lot of blood, or if there is a break in sterile technique. All of these things make a difference.”
Using data from the literature and 6 months’ experience with the ERAS program, Dr Wick and colleagues developed a financial model to evaluate the potential annual net cost savings of implementing an ERAS program.
Key variables considered were:
• potential costs of implementing the program
• reduction in total length of stay
• per-day reduction of direct variable cost from decreased length of stay
• annual number of patients eligible for the ERAS program.
To estimate the cost savings associated with the decrease in length of stay, only direct variable costs were considered. Direct variable costs represent potential savings from decreasing the use of certain materials and services, such as laboratory, pharmacy, radiology, and respiratory care.
Direct variable costs are believed to be under the provider’s control compared with indirect variable costs, which include labor and overhead.
Because the business plan for ERAS implementation depends in part on the volume of procedures, the financial model was developed for 500 cases, which is the annual number performed at Johns Hopkins.
Separate models also were developed for 100 and 250 procedures per year for three community hospitals that are part of the Johns Hopkins system.
The main categories for costs used in the model were implementation costs, capital expenses, and annual personnel expenditures, materials, and depreciation costs.
The total first-year costs were $552,783, which included:
• Site visits/training course—$10,000.
• Surgeon/anesthesia/nursing leadership time (year 1 only)—$135,839.
• Capital expenses, equipment—$50,000.
• Project manager—$126,094 (annual)—the project manager collects and monitors the data to make sure the program is on track and shares the data with the frontline providers.
• Acute pain nurse—$113,900 (annual)—the pain nurse makes rounds on patients postoperatively and makes sure the patients are receiving multimodal therapy and sparing the narcotics.
• Preoperative support—$56,950 (annual)—all patients now go through the preoperative testing clinic, which required additional personnel.
• Patient education materials—$10,000.
• Carbohydrate drinks/nutrition supplements—$25,000—colorectal patients drink a 20-ounce carbohydrate-based fluid (eg, Gatorade) at least 2 hours before surgery to prevent reduced postoperative insulin resistance and decrease postoperative nausea and vomiting; the drink is provided to them free of charge to improve compliance.
• Disposable materials related to fluid therapy monitor or other ERAS equipment—$25,000.
The costs were offset by savings in the first year of $948,500, for a net savings of $395,717.
Costs were further reduced to about $357,000 in the subsequent year because of fewer costs associated with leadership for implementation and capital expenses.
Mean reduction in length of stay ranged from 0.7 to 2.7 days, and there were corresponding cost reductions ranging from $830 to $3,100 per day. Further savings were gleaned from a decrease in lab use, radiology testing, and postoperative medications.
“Patients use fewer services because they do better,” says Dr Wick. “They are less nauseated, more mobile, and they have fewer complications.”
Setting up an ERAS program in a US academic hospital is more costly than for international programs because of increased costs of personnel, which are significantly higher in the US compared with those of foreign counterparts, says Dr Wick.
Additional staff (ie, pain nurse, project manager, and preoperative personnel) were hired for the Johns Hopkins program. In addition, frontline providers were paid for the time they spent working on the program.
In most cases, patient care- related business plans are funded by clinical revenue. However, at Johns Hopkins, the money saved from the reduction in budgeted inpatient surgery days associated with the implementation was partially used to fund the additional personnel.
“Our approach was successful, but I think the message is that to be successful we had to revamp how we deliver care, and that meant adding personnel to do it right,” says Dr Wick. “It takes more than Sunday workers.”
Investing in successful implementation of a sustainable ERAS program in colorectal surgery has now spread to other specialties. Adaptation to hepatectomy, cystectomy, and gynecologic oncology procedures has been done with minimal incremental investment. ✥
Kehler H, Buchler M W, Beart R W, et al. Care after colonic operating—is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg. 2006;202:45-54.
Miller T E, Thacker J K, White W D, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014;118:1052-1061.
Stone A B, Grant M C, Roda C P, et al. Implementation costs of an enhanced recovery after surgery program in the United States: A financial model and sensitivity analysis based on experiences at a quaternary academic medical center. J Am Coll Surg. Published online January 6, 2016.
Thiele R H, Rea K M, Turrentine F E, et al. Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220:430-443.
Wick E C, Galante D J, Hobson D B, et al. Organizational culture changes result in improvement in patient-centered outcomes: Implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg. 2015;221:669-677.
Wick E C, Hobson D B, Bennett J L, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215:193-200.
Wu C L, Benson A R, Hobson D B, et al. Initiating an Enhanced Recovery Pathway program: An anesthesiology department’s perspective. Jt Comm J Qual Patient Saf. 2015;41(10):447-456.