Enhanced Recovery After Surgery (ERAS) programs are all the rage now. Facilities are finding that not only do these multimodal perioperative care pathways increase patient satisfaction and get them on the mend faster, but they could also help curb the opioid crisis.

Over the last 5 years, multiple unique ERAS programs have been implemented at the University of Virginia Health System in Charlottesville for different surgical procedures. "From the literature and evidence, we knew that there were lots of options outside of opioids that manage pain just as well or better," says Bethany Sarosiek, RN, MSN, MPH, CNL, the program's coordinator. "But enhancing patient care was always the main goal of implementing our ERAS programs."

"Our initial reason for trying to reduce opioid use was the side effects such as nausea, constipation and sleepiness," adds Linda Martin, MD, the lead surgeon for the thoracic program at UVA. "Then, as we started rolling out our programs, we became more aware of the epidemic." So, not only are patients benefiting from reduced side effects, but their communities benefit from less opioids being in circulation.

Counseling the patient

One of the 5 tenants of ERAS is involving the patient in her own care, and Ms. Sarosiek would argue it's the most important one. "Multimodal pain management is also important but it's not the-end-all-be-all," she says. "You can do everything right — limit opioids and use non-opioid pain medications — and all the patient will want to do after surgery is sit in bed, because that's what they think they are supposed to do. Educating patients makes them motivated to get out of bed earlier, which helps them recover faster. That's our goal with pre-operative patient education — to set the right expectations ahead of time."

The key that makes their pre-op education so successful is the handbook that goes home with each patient. The handbook is specific to the type of surgical procedure the patient will undergo and becomes a handy reference before and after surgery.

"The main thing is, we don't assume our patients know what is going to happen throughout the process," says Ms. Sarosiek. "We give patients the right information at the right time before surgery, before they're on pain medications and before anesthesia."

The handbook is placed in a ?-inch, 3-ring binder and ranges from 26 to 43 pages in length, depending on the procedure. Each binder costs about $6 to put together. They worked with their marketing and patient education departments to develop the correct phrasing and found that writing at a 5th or 6th grade level, as well as using bullet points and checklists that contain small pieces of digestible information, was the best way to present the information.

A new handbook is designed for each surgical service and all the perioperative areas — physicians, anesthesia, nurses, pharmacy and physical therapists — are involved in putting it together. The handbook goes step by step through the operative experience with input from all the key players involved in the process. How do they figure out the right information to include?

They ask one question to each team involved: What are the most common things patients ask you about before and after surgery? "Involving the clinic nurses in the development of the handbooks is crucial since they are the ones fielding all the calls," says Ms. Sarosiek.

But there is another benefit to including different areas of the perioperative experience. "It ensures their buy-in," says Ms. Sarosiek.

The benefits of patient education are clear in how the patients are involved in their recovery. "Patients ask their nurse when they are getting out of bed post-op instead of waiting to be told," she says. "We've empowered them to ask about their care. The biggest thing patients give up when they come in for surgery is control and it's a scary thing. Giving them that control back by informing them is the key to ensuring success with their recovery."

The patients also receive education about what to watch out for when they are home after surgery. For example, some patients are sent home with a chest tube after thoracic surgery. The handbook details how patients should care for the site and how to handle certain situations that may arise such as the tube falling out or becoming disconnected.

"We try to give patients all the information they need to prevent them from being readmitted after a procedure," explains Ms. Sarosiek. "And if there is something they're not sure of, they always have the handbook that they can go back and reference."

Pain management

Patients are educated on pain management as well. The goal here is to make sure patients know what to expect after surgery and what they will be able to do in the days following discharge. It is made clear that they won't be completely pain free, but that they should be comfortable and be able to perform daily activities such as eating, walking and showering, says Ms. Sarosiek. There is even a checklist in the handbook outlining chores or things patients should do around the house before surgery to make their lives easier post-op. For example, patients are asked to think about items they use most often in their homes and place them between chest and waist level so they don't have to reach high or low. This reduces the possibility of straining their incisions, which would cause additional pain and make them more likely to reach for more pain medication.

"We tell our patients that pain control is very important, but it's better if you can get by with less," says Dr. Martin. After surgery, they keep the patients on a regular regimen of non-opioids, but they do offer opioids as an option if the patients think it's necessary. "We've found the need for things like Percocet have gone way down with the program. Some haven't needed any at all, which was a surprise to us," explains Dr. Martin. In her thoracic surgery program, one group of patients had a 74% reduction in opioid use and another group had a 59% reduction.

The decrease in use is a product of the education they do before the procedure and some of the steps they take during and after surgery. They noticed a big difference after a thoracic procedure if they removed the chest tubes earlier than before. If no air, blood or chyle (a milky fluid of fat droplets and lymph) is draining from the tube, it can be removed safely. The patients who had their tubes removed earlier were in less pain and got on their feet much faster than if the tubes were removed based on traditional criteria, says Dr. Martin.

"One common criteria used is to look for less than 200 cc of anything — pleural fluid or blood — coming out of the chest tube per 24 hours and no air leaks. This often led to tubes being in place for 5 or more days after lung surgery," she explains.

Their use of opioids during surgery was also drastically reduced with the implementation of this program — signaling that a multimodal approach is an important part of the success of any ERAS program. Before the patient is put to sleep for a thoracic procedure they are given an anti-inflammatory drug like Tylenol, Celebrex and Gabapentin. The idea is that these medications will be in effect before they go to sleep and also when they wake up from surgery, explains Dr. Martin.

The patients are also injected with liposomal bupivacaine, which numbs the nerves along the incision and chest wall and lasts for 3 to 4 days post-op. "We used to give epidurals, which used narcotics, but they didn't always work and required additional tubes and monitoring," says Dr. Martin. "Then we were having to come up with alternative ways to manage the patient's pain." They do rib blocks now, numbing up anywhere there will be an incision or a drain.

After surgery, the patients are kept on regular doses of the non-opioid medications they were given before surgery. This serves as their baseline and keeps them comfortable when they are discharged — which happens much faster now, says Dr. Martin. "Patients would much rather recover at home than in the hospital," she explains. "But we're not discharging them before they're ready. We've given them the education they need to recover at home confidently. The whole purpose of the patient education is to reduce the physiological and mental stress of surgery by knowing what to expect. The unknown is much scarier than the known. So even if the known isn't fantastic — for instance that they're having cancer surgery — it's still better than the unknown."

The combination of patient education and multimodal pain management is a strong team-up in the fight against the opioid epidemic. OSM