A comprehensive Enhanced Recovery After Surgery (ERAS) programme at Kaiser Permanente's 20 Northern California medical centres involving nearly 9,000 surgical patients showed a decrease in hospital mortality among colorectal resection patients and increased rates of home discharge over discharge to skilled nursing facilities among hip fracture patients. The programme also resulted in a one-third relative reduction in postoperative complication rates and a 21 percent reduction in opioid prescribing rates.
"This study demonstrates the effectiveness of a systems-level approach to an enhanced recovery programme implementation, even across widely divergent target populations," said senior author, Dr Stephen Parodi, associate executive director of The Permanente Medical Group. "While prior studies have had limited ability to evaluate programme implementation at scale in real-world settings, we were able to evaluate care patterns in over 16,000 surgical patients over a two-year period. We were able to demonstrate the feasibility of large-scale ERAS programme implementation over a relatively short interval because of the collaboration of thousands of clinicians."
The study, ‘Enhanced Recovery After Surgery Programme Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System’, published in JAMA Surgery, was designed and led by a multidisciplinary team of clinicians, performance improvement staff and patient education teams. The programme focuses on improving pain management, mobility, nutrition and patient engagement.
"In my 24 years as a surgeon, this has been the biggest change in our clinical practice," said co-author, Dr Efren Rosas, surgeon champion for Kaiser Permanente's ERAS programme. "For decades, surgeries were guided by commonly held principles including no food after midnight the night before surgery, strong opioids for pain management and bed rest for recovery. The elements of an ERAS programme - alternative medications for pain control, avoiding prolonged fasting and encouraging walking - have been shown to reduce complications like blood clots, muscle atrophy, nausea, confusion, delirium and infection."
Pain management involves opioid-sparing interventions using pain-relief alternatives including intravenous acetaminophen, non-steroidal anti-inflammatory medication, intravenous lidocaine and peripheral nerve blocks. Patients are also encouraged to begin walking within 12 hours of surgery and maintain a daily goal of walking at least 21 feet within the first three days of surgery. Efforts to reduce prolonged pre-surgical fasting include the use of a high-carbohydrate beverage within two to four hours before surgery. Post-operative nutrition is provided within 12 hours after surgery.
To improve engagement in their care, an illustrated calendar is distributed to patients so they know what to expect from the night before surgery through hospital discharge. An informational video series also was designed to improve patient education and active involvement with recovery.
Programme implementation started in 2014 and was completed over the course of one year among two surgical populations: colorectal surgery and hip fracture repair. A total of 3,768 elective colorectal resection patients and 5,002 emergent hip fracture repair patients were included in the study, as were 5,556 comparison surgical patients for elective gastrointestinal surgery and 1,523 for other types of emergency orthopaedic surgery.
ERAS patients demonstrated significant gains after the implementation of the programme. The rate of early ambulation increased 34 percent and 18 percent among colorectal and hip fracture patients, respectively. Similarly, the use of early nutrition increased 26 percent and 12 percent in colorectal and hip fracture patients, respectively. The total dose of opioids also decreased significantly in both groups.
The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; p=0.04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, p=0.05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; p=.03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; p=0.007).
“Implementation of the ERAS programme successfully altered the process-of-care metrics for patients undergoing emergency hip fracture repair and patients undergoing elective colorectal resection across 20 hospitals,” the authors conclude. “In this study of more than 15 000 surgical patients, programme implementation was associated with significant absolute and relative improvements in hospital length of stay and surgical complication rates.”
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