At a Glance
- At UVA, Enhanced Recovery After Surgery protocols have proven to improve outcomes, speed recovery and better the patient experience overall.
- Cardiac surgery is the largest subspecialty at UVA to adopt ERAS.
- The opioid shortage was the catalyst that spurred the adoption of ERAS.
- Still early in its implementation, ERAS appears to provide cardiac surgery patients with equal or better pain management without the use of opioids.
UVA Health System introduced Enhanced Recovery After Surgery (ERAS) protocols in 2013 for patients having elective colorectal surgery. Soon, the program was expanded to other surgical subspecialties due to its proven potential to improve outcomes, speed recovery and better the patient experience overall. Fast forward to 2018, with a national opioid shortage looming, and ERAS became not just a promising effort to hasten post-op recovery, but also a necessity for effective pain control.
The opioid crisis was the catalyst that put change into motion for the Division of Cardiac Surgery, the largest and most complex subspecialty to adopt ERAS thus far. “We had implemented ERAS for eight other subspecialties, but had never gone through the process with an area as big as cardiac surgery with so many moving pieces,” says ERAS development coordinator Bethany Sarosiek, RN, MSN. “These are large operations, so patients are in the hospital longer and they transfer to a variety of units during their stay. To come up with a standardized process required a lot of discussions with every person who touches a patient so that we could incorporate their feedback and ensure buy-in.”
Initiating this effort from within the department was surgical fellow (now attending surgeon) Kenan Yount, MD, MBA. “This was something colorectal surgery had done successfully, so we had a framework in place, but it wasn’t being considered for cardiac surgery at that time,” he says. “We recognized that the opioid shortage was a crisis for patients around the country and we saw ERAS as an opportunity for us to improve pain management and outcomes.
“Through a multidisciplinary effort involving anesthesiologists, led by Karen Singh, MD; intensivists, led by Matthew Hulse, MD; and nursing, led by April Howell, RN, we worked to rebuild the cardiac surgery pathway from the patient perspective from the ground up.”
The ERAS Difference
Enhanced recovery is a method pioneered in Europe to develop standardized protocols for preoperative, intraoperative and postoperative care based on evidence-based practices that accelerate recovery. In early 2012, colorectal surgeon Traci Hedrick, MD, and anesthesiologist Robert Thiele, MD, brought enhanced recovery to UVA. Hedrick had been at a conference at the Mayo Clinic where Robert Cima, MD, presented his early successes with ERAS for colorectal surgery. And Thiele had just returned from a fellowship at Duke, where he studied with Tong Joo Gan, MD, one of the early proponents of enhanced recovery in the United States.
The key areas addressed by ERAS protocols that are common across the board include food and fluid intake, ambulation, anesthetic approach, pain management and patient education. Upon implementation within a new subspecialty, a comprehensive process review allows teams to tailor these pre-op and post-op practices to meet the needs of each type of patient. For cardiac surgery patients, ERAS protocols were customized to include:
Optimizing patients as far upstream as possible. Patients are evaluated prior to surgery to get a baseline of their health status. This includes meeting with a physical therapist, a nutritionist and others who can diagnose and address issues that may impede a post-op recovery, such as malnutrition.
Utilizing alternative pain management strategies. According to Yount, the cardiac surgery team now relies on opioid-sparing analgesics such as ketamine, acetaminophen and regional nerve blockade. As a result, they are circumventing the problem of limited opioid availability and setting patients up for a smoother recovery unhindered by common opioid side effects such as constipation and respiratory repression.
Revising sternal precautions or specifications for what patients can do after surgery. Once restricted for up to six weeks after a sternotomy, exercise is now recommended sooner for cardiac surgery patients. “Patients are now encouraged to be proactive with non-weight-bearing exercise and to use their arms,” says Yount.
Setting expectations for patients. Educating the patient about the procedure and recovery is a key piece of the ERAS puzzle. “Because we have a clear recovery pathway in place, we are setting the expectation for the patient ahead of time,” says Yount. “Making them part of their care program is a self-fulfilling prophesy: they will recover faster.”
ERAS for cardiac surgery just kicked off this month, so hard data on its impact and effectiveness is yet to come. Anecdotally, however, Yount says it appears to be a positive shift for cardiac surgery patients. “So far, we are seeing equal or better pain management without opioids,” he says. “We are seeing faster extubation and a quicker recovery out of the ICU.”
Check back in the coming months for an update on the progress of ERAS implementation at UVA.
To refer a patient to UVA Heart and Vascular Center, call 800.552.3723.