JUNE 13, 2024
Originally published by our sister publication Anesthesiology News
Patient-centered care designed to minimize postoperative complications, improve outcomes and accelerate recovery has made significant progress since the pioneering publication of Beecher and Todd in 1954.1 In the ensuing period, a better understanding of the surgical stress response and perioperative inflammatory–immune milieu, as well as pharmacotherapeutic discoveries, advances in physiologic monitoring and widespread use
Originally published by our sister publication Anesthesiology News
Patient-centered care designed to minimize postoperative complications, improve outcomes and accelerate recovery has made significant progress since the pioneering publication of Beecher and Todd in 1954.1 In the ensuing period, a better understanding of the surgical stress response and perioperative inflammatory–immune milieu, as well as pharmacotherapeutic discoveries, advances in physiologic monitoring and widespread use of safe regional anesthesia practices have contributed to the success in reducing intraoperative mortality.
Beginning in the late 1990s and gaining momentum in the early 2000s, our surgical colleagues in Europe advocated for incorporating regional anesthesia techniques to minimize the surgical stress response. They also wanted to reduce the routine use of tubes and drains, while questioning the delayed resumption of oral fluids and solid intake in the immediate postoperative period. These concepts, initially termed fast-track surgery,2 have since come to be embraced by anesthesiology and surgical fraternities across the globe as enhanced recovery after surgery (ERAS).3
To further explore this evidence-based approach to surgical care, Vijaya Gottumukkala, MD, the president of the American Society for Enhanced Recovery and Perioperative Medicine (ASER PM), selected a panel of experts for a roundtable discussion and asked them several questions of his own choosing.
Gottumukkala: While every phase of a patient’s surgical journey can contribute to better outcomes, I feel the preoperative and postoperative phases are the most important. Getting the patient in the best possible shape for the surgical procedure with medical optimization and prehabilitation will minimize the risk for postoperative medical complications. Similarly, triaging the patient to an appropriate destination—depending on the acuity of postsurgical care needed and their risk for postoperative complications—will help us institute risk-adjusted pathways with rapid rescue interventions.
Afonso: All the phases are important, but I think the postoperative phase can really change the trajectory of patient outcomes. Inadequate nutrition, ambulation, pain control and wound care can hamper the recovery process. In fact, incomplete recovery can actually lead to long-term complications. Additionally, patients go back to different social support networks after discharge. These social determinants of health may significantly shape a patient’s journey in the postoperative period.
Gan: Preoperative optimization, which involves mentally and physically preparing the patient for surgery, and identifying and managing comorbidities such as diabetes or hypertension, can reduce the risk for complications. Next, intraoperative management is critical for minimizing surgical stress and optimizing patient outcomes. Finally, optimal postoperative care with close monitoring plays a crucial role in facilitating early recovery and preventing complications.
Cologne: Having a team that allows for a seamless transition among the various phases of a patient’s recovery (preoperative, intraoperative, postoperative) to occur is key to improving outcomes. All too often, these phases are approached in silos rather than as different aspects of the same recovery plan. When done properly, this can greatly minimize the potential for adverse events.
Pratt: Pathway components in each phase of care are equally important. With integrated clinical teams, phases are no longer independent of one another; patients and caregivers experience a continuum of care. Our priority should be hardwiring core enhanced recovery tenets within that continuum.
Gottumukkala: While there have been some very compelling studies on the efficacy of ERAS, the recent publication (J Surg Res 2024:298:371-378) is particularly impactful in my mind. While this was a single-center, prospective observational cohort study in pediatric pectus surgery, the authors showed an overall ERAS protocol compliance of 89% at 12 months, which is remarkable. They demonstrated that sustaining an ERAS protocol is as integral to the process as its initial implementation, and that requires commitment to following science fundamentals with periodic monitoring.
Afonso: All of the Perioperative Quality Initiative (POQI) and ASER PM collaborations—which include topics from reduction of pulmonary complications, surgical site infection reduction, to optimal analgesia—have been quite impactful. They all have great infographics and are a real resource for healthcare staff to improve patient care (www.aserhq.org/web/ education-POQI.php).
Gan: The POQI and ASER PM have jointly published a series of consensus guidelines and recommendations addressing best practice for various aspects of enhanced recovery and perioperative medicine. These consensus manuscripts are important because they provide the latest evidence-based practice recommendation from various experts in the field, and can be accessed free of charge (https://thepoqi.org).
Cologne: I’d have to go with a joint publication of clinical practice guidelines by the American Society of Colon and Rectal Surgeons and the Society of Gastrointestinal and Endoscopic Surgeons (Surg Endosc 2023;37[1]:5-30). This document very nicely outlines the current recommendations and the evidence surrounding their use, and it serves as a very useful quick reference guide to anyone doing enhanced recovery.
Pratt: Enhanced recovery can provide a standard for reducing racial disparities. One example would be where Sutton et al demonstrated enhanced recovery implementation was associated with reduced ICU readmission and postoperative length of stay for minority patients after isolated coronary artery bypass surgery (J Cardiothorac Vasc Anesth 2022;36[8 pt A]:2418-2431). Consistently employing evidence-based practices for all patients can help to eliminate health disparities.
Gottumukkala: Most programs get started with the interest and the enthusiasm from a few clinical champions. However, these efforts quickly fade if there is not a proper foundation and structure in place for pervasive and sustainable change. To overcome these challenges, the champions must be supported by an engaging leadership team to help with the administration, as well as data-driven rapid cycle improvements by creating dashboards for process measures and key performance indicators (outcome measures).
Afonso: Staffing shortages in the healthcare industry have significantly impacted all aspects of patient care, and in all phases. Staff are stretched thin, making it difficult to medically optimize patients or educate them about nutrition, wound care or any additional counseling. Challenges in delivering standardized care and inadequate care coordination with limited personnel compromise patient outcomes. Unfortunately, there is no easy solution to this vast problem. Nevertheless, multipronged solutions like staff cross-training, technology integration and prioritizing ERAS programs can improve efficiency and patient results despite such limitations.
Gan: Some of the challenges include resistance to change, resource constraints, need for interdisciplinary collaboration, and lack of patient education and engagement. Providing comprehensive education and training to healthcare providers about the evidence supporting ERAS, as well as the benefits of implementing such protocols, can help overcome some resistance to change. Fostering a culture of collaboration, teamwork and mutual respect among healthcare providers is essential for successful ERAS implementation.
Cologne: As a colorectal surgeon, it is all the “buts” (pun intended): But my patients are sicker; but that won’t work here; but that takes too much effort. A good champion will be able to work through these using a small pilot program, then use data to bring others on board. Every journey begins with a single step.
Pratt: Competing priorities is a leading challenge. With clinicians involved in various quality improvement efforts, time may not be allocated to execute key ERAS practices. Working jointly on overlapping quality projects, as cross-functional teams, can save time while improving outcomes. Implementing evidence-based mobility programs improves not only surgical outcomes but reduces injurious falls and increases throughput.
Gottumukkala: It is all about patient education and engagement. A well-informed and engaged patient will be empowered to be an active partner in their surgical journey for better outcomes. With the extensive use of smartphones and apps, we must leverage that technology for better engagement with our patients. Additionally, utilizing our electronic health record to develop compliance tracking for process measures and performance indicators for outcome measures will be helpful to develop rapid cycle improvement initiatives.
Afonso: Technology in the healthcare landscape has been moving at a rapid pace. Telehealth platforms are beneficial and can be utilized for patient education and additional support for ongoing needs after discharge. Automated reminders can help patients with medication regimens and follow-up visits. Wearables give real-time data in the perioperative period and can send feedback directly to the healthcare team. When patients fall off the pathway, timely intervention can potentially prevent complications and costly readmissions. Technology can empower patients to take an active role in their recovery process.
Gan: Technology can significantly improve patient engagement and compliance with care pathways in perioperative medicine. These include mobile applications, which can provide medication reminders, symptom tracking and direct communication with the healthcare team. Integrating remote-monitoring devices, such as wearable activity, into care pathways allows healthcare providers to remotely monitor patients’ progress and adherence to recommended behaviors. These real-time data can facilitate early identification of potential complications and prompt intervention when necessary.
Cologne: We have only started to scratch the surface of technology. As the expense of these adjuncts comes down, and they become more integrated in the electronic health record (and potentially mandated or improves the gathering of mandated data for reporting purposes), we will see a dramatic shift to using these adjuncts. The key will be protection of privacy concerns and expense, both of which are a large part of why I don’t think it has happened just yet. But stay tuned!
Pratt: The first step is evaluating what platforms your health system and patients/caregivers have today. Meeting staff and patients/caregivers where they are aid in clinician adoption and patient engagement. Leverage what you have and then build upon it.
Gottumukkala: It is my hope that patient-centered, recovery-focused, outcomes-driven, value-based care will be baked into our routine practice, and we would not have the need to call enhanced recovery anything special. As for perioperative medicine, our focus should be to address the surgical and periprocedural needs, and the health of our patients. We should include other clinician groups and develop this multidisciplinary program to enhance health outcomes for our patients and improve population health.
Afonso: As technology is moving at a rapid pace, integration of artificial intelligence will be a powerful tool for safer and individualized perioperative practices. Not only will we be able to analyze large amounts of data, but we will be able to offer predictive modeling and risk stratification for our patients to optimize care with potential cost-saving strategies.
Gan: I think we are likely to see significant advancements and widespread adoption. Over the past two decades, ERAS programs have improved clinical outcomes and reduced healthcare cost; however, postoperative mortality beyond hospital discharge and morbidity are still high, and there are significant opportunities to reduce those. Machine learning algorithms will probably be used to analyze large data sets of patient outcomes, surgical techniques and perioperative interventions to identify patterns and optimize care protocols.
Cologne: As clinical care becomes more sophisticated, integration systems will allow a more targeted approach to customize programs, particularly involving prehabilitation and identification of at-risk patients. These are the areas that have the greatest potential for outcome improvement, especially in light of an aging patient population. Decision aids can also help drive these changes and educate clinicians.
Pratt: Enhanced recovery will become embedded within healthcare training programs as the strategy to achieve quality outcomes. Clinical pathways and protocols should be the work, not more work.
For anyone looking to learn more about ERAS programs, including how to implement one in your hospital, ASER PM’s 2024 annual meeting will be held at The University of Texas MD Anderson Cancer Center, in Houston, September 19-21. This year’s program will specifically discuss key principles of, as well as the latest advances in, enhanced recovery and perioperative medicine. For more information, go to www.aserhq.org/2024/ . Additionally, you can connect with ASER PM on Facebook and X, and reach them directly at info@aserhq.org.
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