When I first heard about ERAS (Enhanced Recovery After Surgery), I was in clinical practice as a Nurse Practitioner in general surgery. When the surgeon described its concept to me, I remember thinking this would turn conventional surgical wisdom upside down. Now, after attending the ERAS® USA Society conference in New Orleans with a theme centered around patient reported outcomes, I can see that it certainly has done just that.
So, what is ERAS?
It’s not a new concept; in the 1990s it was called “fast-track” surgery. ERAS as a movement was started in Sweden by two surgeons in the early 2000s who began discussing peri-operative care of the surgical patient and how it could be improved. This was prompted by the concern over continued variation in perioperative care and the connection to post-operative complications. Their collaboration quickly grew to form the ERAS® Society. According to their website, the mission of the ERAS® Society is “to develop perioperative care and to improve recovery through research, education, audit and implementation of evidence-based practice.” Their specialty-specific guidelines are being implemented in healthcare facilities all over the world and have grown from their first in 2005 focused on colon surgery, to over 20 guidelines developed today.
Why is it different?
It’s a multidisciplinary approach focused on the patient, involving a multimodal way to resolve issues that cause complications and delay recovery. Protocols are grounded in evidence-based literature and promote interactive and continuous audits of outcomes. Compared to long-standing protocols, major changes include reduced fasting time prior to surgery, implementation of multimodal anesthesia techniques, and less opioid use both intra and postoperatively.
Ultimately, recovery starts in the pre-operative period – we “pre-habilitate” patients to ensure they are fully-optimized for surgery. These methods empower the patient and makes them a partner in their care.
What results have we seen?
Literature abounds with astounding reports including of outcomes such as decreased Length of Stay (LOS),1 reduction of surgical site infection rates2, diminished opioid use.3 Healthcare facilities that implement ERAS protocols note increased patient satisfaction rates and cost savings.4 In an era of value-based care, these measures matter!
But all the metrics pale in comparison to one patient experience that occurred when I was involved in implementing a colorectal surgery ERAS protocol. The patient was a gruff gentleman, stoic – a farmer. I saw the fear in his eyes as we talked about his upcoming surgery to remove a cancerous tumor in his colon. His wife sat anxiously next to him, holding his hand and asking all the questions. I don’t think he said more than five words to me. We spent an hour together as I discussed the process and reassured both as we started the surgical journey together. On the day of surgery, I met him in the pre-op holding area. His expression was replaced with worry as he confided to me that he was concerned about his farm, particularly care of his cows. Although his son was doing the farm chores, he wanted to be home ASAP.
Surgery went well. With the ERAS protocol in place, he soon was eating, ambulating and taking over the counter (OTC) medications for pain. At discharge, his worry was gone, and I swear I saw a twinkle in his eye as he was wheeled out the door. I got a card from him about a month later with a simple “thanks”, along with a picture of him and the herd.
When we talk about the effect of ERAS on the surgical patient, it’s important to realize what a standardized team approach can accomplish. I look forward to the bright future of ERAS as the ‘movement’ continues to provide a coordinated effort to improve clinical outcomes and enhance the surgical experience, and to continued happy outcomes as with the farmer.
1 Pędziwiatr, Michał et al. “Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery.” Medical oncology (Northwood, London, England) vol. 35,6 95. 9 May. 2018, doi:10.1007/s12032-018-1153-0
2 Grant, MC et al. “Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcare-associated Infections: Results From a Systematic Review and Meta-analysis.” Ann Surg. 2017 Jan;265(1):68-79. doi: 10.1097/SLA.0000000000001703.
3 Meyer, LA et al. “Effect of an Enhanced Recovery After Surgery Program on Opioid Use and Patient-Reported Outcomes.” Obstet Gynecol. 2018 Aug;132(2):281-290. doi: 10.1097/AOG.0000000000002735.
4 Horattas, Mark C. et al. “Enhanced Recovery after Surgery Results in Enhanced Patient Satisfaction” Journal of the American College of Surgeons. 2017 Oct.;225(4):e67- e68.