OR Excellence Award Winner

You've probably heard of ERAS — the acronym for Enhanced Recovery After Surgery — but you might not know the buzz-worthy concept involves standardizing patient care to optimize outcomes, send patients home sooner after surgery and lower readmission rates. Texas Health Presbyterian Hospital in Dallas has earned the 2018 OR Excellence Award for Pain Control for using those abstract ideas to develop an opioid-sparing pain control program that has achieved some tangible — and impressive — results:

• Patient-controlled analgesia pump use before implementation of the ERAS pathway was about 37%. By June of this year, zero ERAS patients received PCA pumps to manage their post-op pain.
• During early implementation of the ERAS pathway, patients received just over 150 morphine equivalent dosing through post-op day 3. The ERAS program helped slash that amount in half.

That reduction in morphine equivalent dosing is important because leadership at Presbyterian Hospital launched the program in 2016 during the nation's opioid crisis. That year, according to the U.S. Department of Health and Human Services, 116 Americans died every day from opioid-related overdoses and 11.5 million people nationwide misused prescription opioids. The opioid crisis was a major factor in the decision to launch the ERAS pathway, according to Nikita Preston, BSN, RN, nurse manager of the hospital's bariatric unit. "We want to get surgical patients into and out of the hospital with a reasonable amount of pain that they'd be able to manage at home," she says.

Concerns about getting patients hooked on opioids is an important consideration, but the powerful painkillers can also cause a host of more common post-op complications — such as PONV, prolonged ileus and respiratory depression — that can slow recoveries.

To limit the use of opioids, Presbyterian Hospital relies on a multimodal pain management protocol that includes administering gabapentin and IV Tylenol before surgery. The protocol also involves the use of ketamine, dexmedetomidine, neuraxial anesthesia and transversus abdominis plane (TAP) blocks. Anesthesia providers closely monitor fluid levels during surgery to limit risk of post-op complications such as ileus and fluid overload that can cause issues with edema, increase post-op pain and delay discharges. All of those elements are important to the success of the hospital's multimodal pain management efforts, but administering a lidocaine infusion during surgery has proven to be the key to reducing patients' post-op pain.

"We want to get surgical patients into and out of the hospital with a reasonable amount of pain that they'd be able to manage at home."
- Nikita Preston, BSN, RN

Anesthesia providers begin the drip during surgery and continue it for 1 hour post-op if patients' pain is not well controlled. IV lidocaine has been shown to reduce the need for opioids, decrease overall pain and increase patients' mobility after surgery.

Side effects associated with IV lidocaine are rare and it's affordable (about $3 per bag). Patients who receive the analgesic report lower pain scores and are able to ambulate safely sooner after surgery, says Susan Cooper, BSN, RN, CPAN, CNML, nurse manager of Presbyterian Hospital's OR and PACU.

"There's a lot of literature supporting the use of IV lidocaine, and our real-world experience has supported those findings," she adds.

Patient-pleasing protocols

The hospital launched the ERAS pathway to position itself on the cutting edge of care with a concept that promised to reduce the amount of opioids needed to manage post-op pain. Today, members of the surgical team praise the pathway for getting patients to emerge from surgery in less pain and more engaged in their own care. There were some growing pains along the way, however. For example, patients traditionally go NPO the night before surgery, but patients in the ERAS pathway are permitted to drink clear liquids up to 2 hours before their scheduled procedures.

"It's engrained in nurses that patients have nothing to eat or drink after midnight, so there was some initial anxiety among the staff when caring for ERAS patients," says Ms. Preston. "Implementing the program demanded a culture change."

But as the staff's comfort level grew, they began to see a positive impact on patient care and realized they could manage post-op pain without relying on opioids as the first-line treatment option, says Ms. Cooper.

Putting patients on the ERAS pathway begins in surgeons' offices, where they receive information about preparing their bodies for the physiological stress of surgery. Providers from numerous departments and specialties then coordinate their efforts to manage blood sugar levels in diabetic patients, help smokers kick the habit and encourage imbibers to limit their alcohol intake. Optimizing patients for surgery beforehand prepares them for faster discharges.

Part of that education involves setting realistic expectations about the pain they'll feel after surgery. Staff tell patients that surgery will hurt, but they coolly reassure them that the surgical team has a proven plan in place to minimize their discomfort.

"They're comforted by that," says Nina Costilla, MSN, RN-BC, the hospital's nurse manager of GI services. "They like hearing that they're going to be OK."

She also points out that patients who understand pain management protocols realize they won't be pumped full of opioids and are therefore more likely to respond to other forms of non-opioid analgesia.

Before Presbyterian implemented its ERAS pathway, patients complained about receiving inadequate pain management. They said they had no knowledge of their care plan and didn't know what to expect on the day of surgery and during the initial days of recovery. They're now active participants in their own care and show up for surgery understanding exactly about how their pain will be controlled.

"They don't arrive asking for opioids," says Ms. Costilla, "because we address and discuss that long before they arrive in the OR."

Patients who are more informed before surgery and more comfortable afterward are generally more satisfied. That's borne out at Presbyterian Hospital, where patient satisfaction scores have steadily climbed from 72% to 78% in the 18 months since they began their journey down the ERAS pathway.

Not done yet

Presbyterian Hospital recently launched a mobile phone app that sends patients reminders about the elements of the ERAS pathway and prompts them to self-report various aspects of their care before and after surgery. The app is another way the hospital encourages patients to take ownership in their pain management. It's also part of the hospital's desire to team with surgeons to make sure patients recover from surgery quickly, successfully and comfortably.

Ms. Costilla points out that the ERAS pathway is part of the hospital's larger and ongoing effort to improve the patient experience. "Focusing on patient needs is the right thing to do," she adds. "It builds trust and lasting relationships between your facility and the patients within your community."

The ERAS pathway is currently used only for colorectal surgery patients. It's taken Presbyterian Hospital several years to enhance the protocols to the point where leadership is comfortable implementing the pathway in other service lines, but the program is gaining momentum and several other specialties are poised to implement it. The hospital is also serving as a model for eventually launching similar pathways in facilities across the rest of the Texas Health system.

"It's a great program, and it's only going to get bigger and better," says Ms. Preston. "We're excited about being part of the group that laid the groundwork for its success, and we're looking forward to pushing the processes across the health system because it really does have a significant and positive impact on the patient experience." OSM