Enhanced Recovery After Surgery Program at University Hospitals Improves Outcomes and Lowers Costs

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Protocol recently recognized with Patient Engagement Best Practice Award from the Ohio Hospital Association

UH Clinical Update | May 2022

An innovative program at University Hospitals to empower patients to take a more active role in their pre-surgery care and post-surgery recovery is yielding notable results, creating shorter hospital stays, less use of opioids, fewer post-surgical infections and lower costs for patients. The protocol first implemented at UH Cleveland Medical Center and now in use at all hospitals in the UH system – Enhanced Recovery After Surgery (ERAS) – recently won the Patient Engagement Best Practice Award from the Ohio Hospital Association and the Ohio Patient Safety Institute for 2021.

Key elements of ERAS at UH are:

  • Pre-operative counseling to set expectations with patients and families
  • Optimizing pre-operative and post-operative nutrition
  • Minimizing the use of narcotic pain relievers after surgery
  • Promoting early mobility after surgery, getting patients up and walking as soon as possible

Each surgery patient at UH also receives an ERAS kit mailed to their home before surgery, customized for his or her particular needs. UH absorbs the cost of the kit – patients are not charged. It may include high-protein nutritional drinks for the days pre- and post-surgery, carbohydrate-loading drinks for the night before and morning of surgery, exercise bands and instructions developed by UH physical therapists, a pedometer, incentive spirometers and additional education material about surgery for the patients to read and keep with them.

It’s all about optimal preparation for what is the grueling ordeal of surgery.

“Undergoing surgery is basically like running a marathon,” says Heather McFarland, DO, FASA, System Director of the Anesthesia Value Network and Vice Chair of Clinical Operations, who is leading the ERAS project at UH, along with Soozan Abouhassan, MD, a critical care anesthesiologist, and Ronald Charles, MD, a colorectal surgeon.  “You know how marathon runners carb load before they run a marathon? We do the same, with carb-loading drinks that patients take before surgery.

So far, the ERAS protocols are making a measurable difference for UH patients.

 “All of these efforts have contributed to a decreased length of stay for our ERAS patients in our first tier service lines, Colorectal, Cardiac and Gynecology, with anticipation of the others to follow by the end of the year,” Dr. McFarland says. “Decreased narcotic usage is under way at the academic medical center by increasing the use of nerve blocks and multimodal therapy, early data shows promising advances in that direction. In fact, post-operative narcotic usage is down by over 60 percent. Evidence for surgical site infections and readmissions demonstrate a positive downward trend. All of this work is also being put towards a national ERAS certification by the end of the year.”

Once certified, UH will be one of just five ERAS-qualified centers in the U.S.

Another important feature of ERAS at UH is the “Passport to Home” booklet that lists goals for patients’ pain management, nutrition and physical activities to aid in their discharge from the hospital and ultimate recovery. Designed with patient input, it takes patients though a daily list of tasks to complete prior to their discharge. When these tasks have been completed, a stamp or signature of completion is given in their passport, as a pass for them to leave the hospital.

“This encourages the patients and their loved ones to engage in their recovery,” Dr. McFarland says. “The goals are there and they can check them off as they complete them. This also allows the patients and their families to have an understanding of what it will take for them to be discharged home and to allow for robust discussion with their entire care team as to how they are progressing.”

A unique feature of ERAS protocols at UH is how many surgery service lines have adopted them. Service lines employing them currently include Colorectal, Cardiac, Gynecology, Obstetrics, Orthopaedics, Thoracic, General Surgery Specialties, Plastics, ENT, Transplant and Urology.

“We are quite comprehensive,” says Dr. Charles.  “Many hospitals have one service line, maybe two. It’s notable for a hospital system to take an initiative, where the entire organization is moving towards that direction.”

Even more surgery service lines will be added soon.

“We've been approached by other service lines that are really excited about what they've seen, and so we're working right now with Podiatry, Neurosurgery and Vascular Surgery,” Dr. Abouhassan says.

The UH ERAS team says they’re enthusiastic about what these protocols have already achieved for UH patients – and for what the future holds for patients going forward.

“Our patients are benefiting from implementation of ERAS across the health system,” Dr. Charles says. “We have seen that in decreases in length of stay, readmissions and surgical site infections. ERAS are a unique set of protocols that are 100% evidence-base driven that across the board have consistently been documented to improve patient outcomes not only from a clinical standpoint, in terms of safety, but also patient satisfaction. It involves every aspect of the patient care as it relates to initial visit all the way to the end of the patient experience. Again it's not just my opinion versus somebody else's opinion. These are evidence-based guidelines that we try to adopt and follow that document positive outcomes very consistently.”

“With education, patients really develop an ownership of their surgical process from beginning to end, and knowing what's happening really helps them decrease their anxiety and participate in the initiatives that are being set forth and really take ownership over their care,” adds Dr. Abouhassan. “I’ve seen that throughout the process. It's nice that the hospital has been behind us this whole time.”

“This really allows our patients to be active participants in their care, which really gives them a sense of calmness about what they're doing coming into surgery,” says Dr. McFarland. “To quote the aphorism, action is the antidote to anxiety.”

For more information about ERAS protocols at UH, please email Heather.McFarland@UHhospitals.org, Soozan.Abouhassan@UHhospitals.org or Ronald.Charles@UHhospitals.org.

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