Should ERAS Be the Standard of Care?

The answer is “Yes” if your facility thoughtfully crafts and properly executes these opioid-sparing protocols.

In the public consciousness, postoperative recoveries are so frequently associated with opioid misuse that TV dramatizations and documentaries about it litter the streaming landscape. But as the opioid crisis has raged on in America, progressive surgeons, anesthesiologists and other healthcare experts have been hard at work on opioid-sparing surgeries. The guiding light for these efforts is a methodology known as Enhanced Recovery After Surgery (ERAS), which continues to gain prominence in the industry.

Based around multimodal anesthesia techniques, evidence-based ERAS pathways have been built, and increasingly are being utilized to address the challenges often associated with patient recovery. Are these pathways effective, however? How well do they reduce postoperative patient pain and help prevent opioid addiction? We spoke to three noted anesthesiologists who believe ERAS protocols should be a universal practice in surgery.

Origins of ERAS

The principles of ERAS date back to the late 20th century, with the concept introduced in Denmark for colorectal patients by Professor Henrik Kehlet. In a 1997 article in British Journal of Anaesthesia, he wrote, “while no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction.”

Multimodal interventions are at the heart of ERAS protocols, which not only claims to reduce opioid use and decrease patient pain, but also reduce lengths of stay and help patients more quickly resume activities such as eating, drinking and using the bathroom.

Originally called “fast-track surgery,” in 2001 it was dubbed ERAS with the formation of the Enhanced Recovery After Surgery Study Group that included Professor Kehlet. That group initially focused on colorectal surgery, but two decades later, ERAS has evolved to embrace numerous different specialties and procedures. “There are ERAS protocols for vascular surgery, thoracic surgery, cardiac surgery, urologic surgery — every surgery,” says Alan Kaye, MD, PhD, DABA, DABPM, DABIPP, FASA, clinical professor of anesthesiology and pain fellowship director at LSU Health New Orleans.

Major benefits

ERAS protocols typically target management of anesthetic dosages, addressing perioperative pain with analgesia rather than opioids. After over two decades of utilization, ERAS has delivered impressive results, not only from a clinical standpoint but also a financial one. According to a 2021 article in Journal of Clinical Medicine, “ERAS reduces length of stay by an average of 2.35 days and healthcare costs by $639.06 per patient, as identified in a 2020 meta-analysis of ERAS across multiple surgical subspecialties.”

Dr. Kaye defines ERAS as any pathway that has reduced post-op opiate consumption and hospital stays. He says ERAS reduces stress and risks of complications, while enabling quicker emergence and recovery and earlier mobilization. Michael Aziz, MD, professor and vice chair for clinical affairs with the department of anesthesiology and perioperative medicine at the Oregon Health and Science University School of Medicine in Portland, feels that the fundamental goal of ERAS is earlier discharge of patients following surgery. “Most of the practice changes that have come with ERAS protocols have been with that focus in mind,” he says. “Any time a patient can get on their feet and moving and get home is better than staying in the hospital where they remain at risk for a host of heterogenic complications such as infection.”

ERAS is often portrayed as a postoperative opioid-sparing pain management strategy, but the real work begins preoperatively. Dr. Aziz suggests that ERAS’ efficacy can be further improved through preoperative interventions he calls “pre-habilitation,” which includes getting the patient in the best physical condition possible through exercise, smoking cessation and improved diet and ensuring the patient’s hemoglobin can maintain oxygen delivery by employing techniques such as iron therapy.

The other big preoperative benefit of ERAS is the ability for providers to set and manage the patient’s expectations for pain, says Dr. Aziz. By both physically and mentally preparing the patient for what’s to come in terms of pain management while employing multimodal and regional anesthesia techniques both intraoperatively and postoperatively, the patient will be less likely to request or abuse opioids, if they are even used intraoperatively or prescribed postoperatively, he adds.

Putting ERAS into action

A growing body of literature supports ERAS’ effectiveness, but there is still pushback regarding the protocol among many cautious facilities, surgeons and anesthesia providers. How can ERAS champions get everybody on board?

Bronwyn Southwell, MD, assistant professor with the University of Minnesota Center for Learning Health System Science’s department of anesthesia in Minneapolis, and a clinical integration lead in its Evidence Synthesis Unit, recalls how her institution implemented ERAS as a universal standard of care.

“We have 11 hospitals in our system, and we noticed that individual divisions like colorectal were coming up with an ERAS protocol on their own,” she says. “In some cases, it was just one motivated anesthesiologist or surgeon. Each of those individual protocols kind of followed the ERAS guidelines but had their own little mix on it.

“In an effort to standardize best practice care across the whole system,” Dr. Southwell continues, “we convened an ERAS steering committee to take every interested surgical division and say, ‘What have you done so far? Let’s make this adherent to the ERAS guidelines. Let’s refine it to make sure we’re doing what you all set out to do, but also create a standardized ERAS care map that encompasses all [of its] truly evidence-based elements.’”

The result was 10 “care maps” across 10 surgical divisions created by a spectrum of clinicians, quality improvement specialists and methodologists based on their reviews of related evidence and literature. According to Dr. Southwell, these electronic documents, housed on the health system’s intranet, lay out each phase of care (pre-op, intra-op and post-op) as well as associated tasks that must be handled by different practitioners in each phase.

Empowered nurses are key

UP & AT ’EM Tell patients their surgeon needs them to get up and walking soon after surgery, while emphasizing that this activity could result in them being discharged sooner.

Dr. Southwell said ERAS protocols can be even more effective when perioperative nurses are engaged and educated as a vital component of the process. At her health system, for example, ERAS effectiveness has “plateaued” due to nurses not squaring the circle of the protocol.

“They’re only getting the patients up and out of bed maybe 50% of the time on the first day of surgery, and the patients are only eating maybe 60% of time on postoperative day one, when our target is 80%.” The problem, she feels, may be lack of input into the ERAS process from the nursing staff, as the care maps were created with participation from other provider types — physicians, evidence reviewers, pharmacists and epidemiologists.

“We need the perspective of nurses because it’s very difficult to force a patient to get out of bed and eat on the night after having a big surgery,” she says. “We realized that maybe there’s a big problem there. We need to find a way to empower nurses to have that conversation with patients when they’re saying ‘No, I don’t want to get out of bed. It hurts too bad. I’m not doing it.’ We need to give nurses some tools to make that easier. If we can increase the rate at which the nurses are implementing these postoperative care measures, maybe we can reach our targets. Maybe we haven’t done a good enough job of educating the nurses on ERAS. Some of them don’t even know what it is.”

Dr. Southwell says coaching nursing staff to be more assertive with patients can better ensure the success of an ERAS procotol. She suggests they learn to utilize tactics such as telling patients their surgeon strongly advises them to do an activity such as walking right after surgery, emphasizing that this could result in them being discharged sooner.

“Nurses are part of the solution,” agrees Dr. Aziz. “Surgeons need their nursing partners to facilitate all this care preoperatively, intraoperatively and postoperatively. They have opportunity for input because they hear the patients’ concerns. The better we can center our care around patients’ needs, the better we’ll achieve the surgeon’s goals: safe surgery with good recovery.”

Why ERAS should become a standard practice

Drs. Kaye, Aziz and Southwell are among a growing number of healthcare professionals who believe ERAS should be an industry standard. “It is evidence-based, patient-centered, multidisciplinary, and is reducing patients’ surgical stress response,” says Dr. Kaye. “It’s optimizing their physiologic function and it’s facilitating recovery from surgery. There’s no downside to needing less opiates. There’s no downside to leaving the [facility] quicker when it’s appropriate. ERAS should not only accelerate recovery times, but also improve outcomes and reduce healthcare costs, which is important to everyone.”

The ultimate goal should be for your facility’s surgeons to embrace and evangelize ERAS to rest of your providers.

“Surgeons drive care initially, so [ERAS] pathways need to be driven from them initially,” says Dr. Kaye. “I think all surgical services should think about which procedures we have that are common. How can we as surgeons approach them commonly so every surgeon isn’t doing surgery a different way?” He says surgeons should get their anesthesia and perioperative teams aligned with the ERAS concept and secure their involvement in defining ERAS protocols by offering suggestions for various procedural pathways. “It takes some work,” he says.

“The evidence supports ERAS, and high-quality randomized controlled trials support the benefit for patients in a lot of different metrics,” concludes Dr. Southwell. “I’ve had colorectal surgery myself, and from a patient perspective, ERAS is great. It improves the speed of recovery and gets you back to normal faster. And that’s what patients really want.” OSM