Purpose: The NMVAHCS is striving for innovation, with the implementation of an enhanced recovery after surgery (ERAS) protocol: best practice.
Background: Literature supports the reduction of intraoperative instability, post-operative ileus and complications, length of stay (LOS), readmission, and an increase in patient satisfaction. LOS is reduced by 2 days, complications decreased by 50%, readmissions reduced by 8%, with an average cost savings of $2,800-$5,900 per patient: depending on ERAS compliance.
Methods: Implementing an ERAS protocol requires engaging a multidisciplinary team comprised of the patient, surgeon, anesthesiologist, and support services. The surgeon/anesthesiologists attended ERAS educational conferences, ongoing seminars educated the teams. Updated patient instructions eased patient understanding. All colorectal cancer patients are enrolled. Ineligibility is due to severe renal dysfunction, or emergency procedure.
Protocols for each of the perioperative phases were created. Preoperative includes pre-habilitation, smoking cessation, pulmonary toilet, and low volume PEG-Gatorade bowel prep with modified Nichol’s prep. Patients drink a clear carbohydrate (CHO) drink 2 hours prior to induction of anesthesia. Intraoperative includes tight glucose and temperature control, goal-directed fluid therapy, pain management with regional and opioid sparing multimodal analgesia, as well as a minimally invasive approach. Postoperative includes avoidance of tubes and drains, early ambulation and pulmonary toilet, CHO drink, narcotics avoidance, and preemptive treatment for nausea and vomiting.
Outcomes are LOS, readmission, opioid use, complications, infection, return of bowel function, and patient satisfaction. Charts are reviewed for compliance and outcomes are recorded.
To sustain the practice, we have templated notes and orders sets to streamline each step of the process: alerting providers to educate patients and staff at each point of the process. Signage has been created to assist the patient and nursing staff in meeting milestones.
Results: From June 2017 to May 2018, 29 patients were enrolled ERAS protocol. PCAs were avoided, reducing ICU stay and overall cost. Patient satisfaction markedly improved with regional pain control, early CHO drink, early ambulation, and removal of Foley. LOS was not significantly affected due to long distance patients and ileostomy teaching, but did decrease by 1 day on average.
Conclusions: Successful ERAS implementation requires an engaged team.