Retooling Recovery: Emerging Evidence Sparks Interest in Enhanced Surgical Protocols

In the 1990s, Denmark and later much of western Europe adopted a concept called “enhanced recovery after surgery” (ERAS) in which hospitals implement evidence-based pre-, peri- and post-surgical protocols that address inflammation, metabolism, endocrine function, pain and potential surgical/anesthetic complications. First came ERAS programs for colorectal and major abdominal surgeries. Gastrointestinal, orthopedic, gynecologic and other surgical fields followed as adherence to ERAS protocols was found to shorten hospital stays by 30 to 50 percent while decreasing readmission rates and costs (JAMA Surg 2017;152[3]:292-98). 

Over the past decade, U.S. hospitals also embraced ERAS in many specialties. While cardiac surgery was slow to come on board, it has been “gaining traction” recently as heart surgeons increasingly take note of its positive impact on patient outcomes, says Daniel T. Engelman, MD, medical director of the heart, vascular and critical care unit at Baystate Medical Center in Springfield, Mass., and president of the ERAS® Cardiac Society. Formed in 2017 by a group of cardiac surgeons and anesthesiologists, the Springfield, Mass.based nonprofit aims to “optimize the perioperative care of cardiac surgical patients through collaborative discovery, analysis, expert consensus and dissemination of best practices,” according to its website, erascardiac.org

Why the slow start? 

Engelman and other sources say U.S. cardiac surgeons and their hospitals have hesitated over ERAS protocols for multiple reasons. Some believe ERAS isn’t a good fit for cardiac surgery. Judson Williams Jr., MD, MHS, executive director of the heart and vascular department at WakeMed Health and Hospitals in Raleigh, N.C., explains: “Evidence base notwithstanding, the traditional mindset around cardiac surgery—that the procedures are so involved and the patients so complex in terms of risk factors—[persuaded many cardiac surgeons] that the ERAS pathways are too difficult to apply in the cardiac specialty.”

Tackling cardiac ERAS can be overwhelming because it requires “involvement from multiple disciplines, just because of the complex nature of the surgery,” acknowledges Kevin W. Lobdell, MD, professor and director of Regional CVT Quality, Education and Research at Atrium Health in Charlotte, N.C. “More people create a need for more organization and coordination.”

There’s also the natural human tendency to resist change. “Many claim they’ve been doing things a particular way for so many years and it’s worked, so they question why they should change things now,” Engelman says. “They have their preferred procedures for doing things, and that’s that—whether it’s the way they prepare patients for surgery, the regimen the patients are on, the way they close the chest post-surgery or anything else.”

The biggest hurdle, however, is that data to validate use of ERAS in cardiac patients has begun to emerge only recently and additional evidence supporting the value of some protocols is still needed, according to Engelman. That’s changing, he adds, noting that the ERAS® Cardiac Society's “Guidelines for Perioperative Care in Cardiac Surgery” was among JAMA Surgery’s top-talked-about articles of 2019 (154[8]:755-66). The document compiles 22 recommendations and grades each according to class (strength) and level of evidence (LOE). As the society's recommendations summary table shows, nine of the recommendations earned a class I (strong) designation and eight received LOE grades of A or B-randomized. 

Meanwhile, the literature on specific cardiac ERAS protocols is growing. For example, a single-center study found median estimated time reductions of 3.4 hours to postoperative extubation and 19.4 hours in length of stay when the hospital employed protocols collectively aimed at minimizing postoperative opioid use; guarding against postoperative lung injury, pneumonia and delirium; and decreasing time to extubation  (J Thorac Cardiovasc Surg, online June 7, 2019).

Williams decided to try cardiac ERAS at WakeMed in 2016 after learning that a significant percentage of cardiac surgical morbidity outcomes are determined by pre- and postoperative care rather than what happens in the operating room. A year later, WakeMed became the first U.S. hospital to implement a suite of cardiac ERAS protocols that resemble those subsequently recommended by the ERAS® Cardiac Society in JAMA Surgery

Since adopting ERAS for all of its cardiac surgeries, WakeMed has reduced its length of hospital stay from a median of seven days to six days. Median time in the ICU has declined from 43 to 28 hours, and ICU readmission rates have dropped from 5.1 percent to 3.6 percent. Additional clinical benefits include reducing the reintubation rate from 5.3 percent to 4.1 percent; cutting gastrointestinal complications, such as prolonged postoperative ileus requiring medical therapy, by approximately 50 percent; and decreasing opioid use from to 29 to 21 mean milligrams of intravenous morphine equivalents (J Thorac Cardiovasc Surg 2019;157[5]:1881-8).

Williams says he can’t quantify WakeMed’s cost savings from cardiac ERAS but believes it is “substantial” due to the reductions in length of stay, readmissions and complications. He also points to gains in patient satisfaction, from 86.6 percent pre-ERAS to 91.8  percent after implementation of the protocols (J Thorac Cardiovasc Surg 2019;157[5]:1881-8).

How-to strategies 

Surgeons at the forefront of implementing cardiac ERAS protocols in the U.S. shared strategies they recommend to make implementation manageable. 

1. Ease into it  

Lobdell, of Atrium Health, stresses the importance of initially opting for a few protocols, “instead of every single recommendation.” This approach, he says, makes it easier to garner buy-in from affected departments as well as the C-suite, where resistance to a major overhaul of protocols may be considerable. When Atrium Health began incorporating ERAS protocols, the team focused first on early extubation, goal-directed therapy and glycemic control.

2. Pick the right protocols 

Engelman, too, recommends a gradual approach while also urging careful selection of “the low-hanging cardiac ERAS fruit.” The less complex protocols should generate minimal pushback from stakeholders, he says, suggesting early ambulation and extubation, reduced opioid administration combined with multimodal analgesics administration, and deep vein thrombosis prophylaxis with heparin or a similar agent. 

“It’s important to keep in mind that not all [individual cardiac ERAS measures] may be appropriate for every hospital, or [they] may need to be adjusted because of the patient population,” Williams says. For example, cardiac patients in a hospital that serves many economically disadvantaged patients may have different prehabilitation needs than patients at hospitals with a more affluent patient base.

3. Build a multidisciplinary team

Implementing cardiac ERAS protocols requires big changes, which is why Lobdell recommends establishing multidisciplinary teams that include staff from all of the affected departments. “Without teams,” he says, “a state of disorganization—as well as a feeling among staff that they aren’t valued—is bound to happen.” 

With a multidisciplinary team in place, sources explain, everyone’s interests and concerns are represented. Staff members who feel they are being heard tend to be more invested in the changes and less inclined to resist. 

4. Choose champions 

Personal preferences and/or training may lead cardiac surgeons and anesthesiologists to resist the standardization of the pre-, peri- and postoperative practices that come with cardiac ERAS adoption, sources observe. They note that appointing champions from each group, rather than just one cardiac ERAS champion, is the most effective strategy for breaking down resistance because practitioners are more receptive to change when there is a champion from their own specialty.

At WakeMed, champions from surgery, anesthesiology, nursing and pharmacy initially facilitated agreement on the cardiac ERAS protocols. They have since added an intensivist champion. No protocol was adopted until every objection had been overcome and the measure passed muster with all parties. This meant presenting data on the efficacy of each protocol. For example, to ease colleagues’ wariness about giving patients a carbohydrate drink before surgery, an anesthesiologist provided clinical evidence about the overall benefit of the practice.

5. Assign a coordinator or nurse champion

CVB sources agree it’s essential to appoint a cardiac ERAS coordinator to oversee staff education, troubleshooting and monitoring during and after the transition to cardiac ERAS protocols. Otherwise, they say, problems may go unnoticed or unaddressed, training may not be uniform and necessary adjustments to different components of the cardiac ERAS program can fall to the wayside. 

Because many of the cardiac ERAS protocols are performed by nurses and depend on peer-to-peer training, it’s wise to consider a nurse or nurse practitioner for the coordinator's job, advises Williams. 

6. Court the C-suite 

 Persuading the C-suite to get on board with cardiac ERAS can be a tricky proposition, sources told CVB. “There isn’t any hard data yet about the cost savings to be had from ERAS on the cardiac side specifically, and considerable work on building evidence around some of the protocols remains to be done,” Engelman says. “But that will come. In the interim, we can start talking about the general reduction in the cost of care that will come with better outcomes and about how better outcomes lead to greater patient satisfaction—which is critical in an [era of] value-based care.”

Pointing out that cardiac ERAS’ potential to enhance patient care and increase patient satisfaction may make it a competitive differentiator for hospitals could also help to get the C-suite on board, Engelman adds.

7. Commit to quality improvement 

Sources stressed that success with cardiac ERAS—no matter how many protocols are implemented—cannot be achieved without initiatives to ensure smooth operations going forward. WakeMed’s cardiac leadership team, which initially met frequently to address challenges and tailor the standardized electronic health record to include the protocols, still convenes monthly. Members discuss their effectiveness, tackle new concerns and consider program modifications.  

WakeMed’s nurse champion maintains an ongoing role in the program, ensuring that new staff are properly educated, communicating concerns about possible adjustments to the protocols to the appropriate parties and overseeing how patients’ response to the protocols is monitored, among other duties. Clinical pharmacists lead audits and monitor opioid use, and dedicated analysts collect data on length of stay, readmissions and clinical outcomes. The team is developing an auditing system for identifying and addressing areas where compliance with ERAS protocols could be raised.

“Continuous quality improvement by monitoring clinical outcomes and sharing them within individual institutions and beyond, as well as by assimilating what should be a growing body of evidence to support cardiac ERAS, will make the model sustainable,” Williams concludes. “We’ve been slow to [embrace] cardiac ERAS in the U.S., but we’re picking up the pace.”