Enhanced Recovery After Surgery

It started in the 1990's when a surgeon in Denmark named Henrik Kehlet decided to try and figure out why his patients were not doing well. His research showed that the things we have been doing for years like not letting patient's eat/drink up till just before surgery, not letting them eat after surgery, not letting them ambulate, etc were all things that weren't helping patients, but making their recovery more difficult and lengthy. So he started letting his patient's have liquid up to 2-3 hrs before surgery, begin eating right after surgery, begin ambulating very soon, etc. and his patients did very well. He decided to call this Fast Track Surgery. Move ahead to 2002 in the UK when the new Parliament were coming in. On day one, they were told their healthcare system was bankrupt. To save their healthcare they put a team together to find an answer. After researching various hospitals they found the hospitals that were using Henrik Kehlet's Fast Track model were doing well. So being led my an anesthesiologist Monty Mythen, the UK decided they would adopt this systems as well, but decided to call it Enhanced Recovery After Surgery. They told the hospitals they would follow this model or their hospital would be closed. Many hospitals did follow this models and their patients did better, but the ones that did not, were closed and today the UK's healthcare system is still in place all thanks to ERAS.

There are 4 main principles of ERAS which are: Making the patient a partner in their own care, Having the patient in the best possible condition preoperatively, Giving the patient the best possible evidence-based management that minimizes surgical harm, and Giving the patient the best possible care enabling them to return to their normal level of activity as soon as possible. In order for ERAS to be successful, every department, from the surgeons office, to the Wellness clinic, to Pre-op, to OR, to PACU, and to the Nursing Unit must work together as a team. If pre-op doesn't give the correct Pre-op multimodal per pathway, then the patient is already behind on their multimodal. It turns into a chain reaction through-out each department. This is why it is so important for all clinical staff to have quick access to each pathway and know what their role consists of.

ERAS started at Novant in 2016

Colorectal

Before a surgeon can begin posting surgeries as ERAS, they have to first meet with Vicki Morton-Bailey, DNP, AGNP-BC, Director, Clinical and Quality Outcomes for PAA. She sits down with the surgeon individually and goes over the pathway as well as what is expected from the surgeon, their office, and their patients. Once the surgeon agrees to follow the pathway as written, they are then able to post cases as ERAS

The patient's ERAS journey begins at their surgeons office with their surgeon giving them a brief overview of what ERAS is and they are given an ERAS Pamphlet that gives them more information. From there, they are scheduled with the Wellness clinic for their PAT/PAV. During this visit, they receive full education by the RNs in the clinic, their Clearfast, and their Patient's Guide To ERAS" booklet (if applicable for service line-there is not a booklet for every service line/pathway at this time). All questions and concerns are address during this visit. Again, research shows that patients who are well educated before surgery, are made a partner in their surgical experience and know what to expect before, during and after surgery, do much better than those patient's that are not well educated.

Majority of the service lines will receive their education by the RNs in the Wellness Clinic. Bariatric and C-section patients are different. The Bariatric patient's receive their education in the surgeons office by the Bariatric Navigator RN. The C-section patients get some education in their OB's office but the full education is done by the patient completing a live Zoom class with NH's corporate patient education department.

The NH Corporate Education department developed a great booklet that is specific for each pathway. Within this booklet, it leads the patient through everything they need to know about what ERAS is, what is expected of the patient before surgery, during surgery, during recovery and once they return home. It helps make the patient a participant in their surgery which is one of the key aspects of ERAS. The patients are asked to bring this with them when they come for surgery. There are diaries in the back where the patient can document what they have eaten, when they ambulated, and how their pain is, while in the hospital. The nursing staff within NH is very busy and may not always know when a patient ambulated or how much of their meal the patient ate so the diaries can be very helpful to the nursing staff. The nursing staff can take the diary entries and document that information in Dimensions.

Clearfast is complex carbohydrate drink. Drinking Clearfast helps reduce the surgical stress response by reducing post-op insulin resistance, post-op infection, and post-op nausea and vomiting since the patients are more hydrated. It also helps the patient have reduced preop anxiety because they are more satiated..

There are two places the Clearfast can be documented. It can be documented on the Preop Checklist (all the way at bottom-it does not say Clearfast but says Carbohydrate drink). It can also be free typed in the last PO liquid Intake section (just type Clearfast; if this is a bariatric patient, please also type Emend here as well)

We have been/are working with Dimensions to get this added/have a specific place for documentation. Currently, this is being documented as a nursing note. This PONV score is a data point we collect for ERAS as well as being used by anesthesia to properly decide if PONV medication is needed for each individual patient.

The American Society of Anesthesiologists says patient may consume liquids 2 hours prior to surgery. We all know surgery start times may often change. They are either running behind or running ahead, possibly due to cancellation. Due to the possibility of surgeon running ahead of schedule, it was decided to go with 3 hours so if patient could go into surgery earlier, they did not have to wait due to Clearfast being consumed too close to new surgery time.

Since the Bariatric patients are more prone to PONV, Emend is a prescription medication the patient is asked to take prior to leaving for the hospital the day of surgery to reduce the risk of PONV.

The ERAS C-section pathway is open for Repeat C-section patients only. However, if the patient is a repeat C-section but would like to attempt TOLAC, they cannot be scheduled as ERAS. We do see, in the near future, beginning an ERAS pathway for primary scheduled C-section patients.

Yes, they can still move forward in the ERAS pathway if they did not drink their Clearfast. Sometimes the patient may present to their OB office for regular office visit and be sent straight to the hospital from OB office for an earlier than scheduled C-section or present from home due to water break, earlier labor etc. In these cases, it was out of the patient's control and drinking their Clearfast was probably the last think on their mind. If they do present to the hospital without drinking their Clearfast and anesthesia feels there is enough time before performing C-section, the patient can drink the Clearfast at the hospital. A supply of Clearfast is kept in L&D unit.

As much as we would love for every C-section patient to complete the ERAS Education Class, we do know that everyday life can sometimes get in the way. If the patient presents for their C-section and did not complete the education class, they can still move forward in the ERAS pathway.

18-24 hours

All of the ERAS pathways are based off Evidence Based Information. In the pathways that do not have TAP Blocks performed, it is because the evidence did not show it was beneficial to perform.

Multimodal is about taking non-opioid analgesic medication, starting the regimen in pre-op, using during surgery, continuing after surgery and after d/c. By giving these medications around the clock, research, as well as our data, show less opioid consumption during and after surgery. This translates into fewer opioid prescriptions upon discharge. One step at a time to reduce the opioid epidemic.

Yes. What is the key to multimodal success? Multimodal needs to be given around the clock, not skipped because the patient is sleeping or states they don't have pain AND by spacing them out/not giving at the same time. The multimodal medications we use in almost all pathways are: Tylenol, Toradol OR Celebrex, and Gabapentin. It is very important to space them out. For example: don't give Tylenol at same time as Toradol. Have at least 2-3 hours between administration. This may require making call to pharmacy so they can redo the dosing times. By spacing the meds a few hours apart, it ensures the patient receives another analgesic before the previous one has stopped working.

We see this a lot when collecting data. As told to us by pharmacy, there is a +/- 30 minute window on each side of the scheduled dosing time. If the Tylenol is ordered to be given at 0630, patient is at 3g/24hr limit, but will be outside this limit at 0645, please hold and dose after 0645. Too often, we see the Tylenol will be skipped completely instead of waiting 16 more minutes. If the patient is at their limit and the +/- 30 minute window doesn't alleviate this, please call pharmacy to reschedule. After this call, the Tylenol will be scheduled correctly to prevent patient dosing of >3g/24hrs.

One of the key points in ERAS is early ambulation. Phenergan can typically sedate patients. If the patient is sedated by the Phenergan, then this can postpone patient's from being able to ambulate as needed.

No. Currently we do not have any ERAS specific orders sets. The surgeons can make favorite order sets for their ERAS patients but they still have to add/remove with each orders set. This is why it is so important for the nursing staff to know specifics, especially the multimodal analgesic so if it is missed or ordered incorrectly, the RN can contact the surgeon early and have them correctly order multimodal. We know making this call to the surgeon is just one more "task" in an already busy shift, but in return, by correctly administering the mutimodal analgesic, it can reduce/eliminate PRN opioids given, allows patient to ambulate sooner, eat/tolerate food sooner, and be safely d/c sooner from hospital. However, we are working with Dimensions in the hopes of being able to develop specific orders sets per service line.

In the pathways, they specifically state patient is to ambulate in hallway a specific number of times each day depending on which post-op day it is. When we do audits of patient charts and see "up ad lib", this does not tell us the patient actually ambulated. This is why we request documentation as "Ambulated in Hall". We do not count "up ad lib" as ambulation in our data.

No, you do not have to document a distance that your patient ambulated for the purposes of ERAS. That MAY be necessary to fulfill DSC criteria, however. Some units are measured off with distances while other units are not. For ERAS data points, we do not have to have a distance, only need to see "Ambulated in Hall" documented under the Activity portion of the flow sheet. Now, with that being said, if you are told specifically by your unit/unit manager/charge nurse to document distance, this may be a requirement for your specific unit. Please clarify with your specific unit if they require a distance to be documented

Yes. There is specific administration criteria needed to know/understand prior to patient receiving, as well as, specific criteria for discharge. There is an Entereg 4P, so if you currently work within prep or on nursing unit with a pathway that administers Entereg and you have not signed the 4P, please talk with your manager/assistance nurse manager before moving forward. You will also see the dosing criteria within Dimensions when an order to administer is released. We have also been told in the past that nursing are not seeing this order, even when the surgeon states the order was placed. If you know this is required by your pathway and do not see the order, please contact surgeon ASAP. This is a very important medication for patients to receive.

Pathways go through many steps before being brought to all clinical staff and being initiated. It begins with Vicki Morton-Bailey, DNP, AGNP-BC, Director, Clinical and Quality Outcomes for PAA performing hours of literature searches (remember all pathways are evidence based). Once she has a draft, it is then presented to the Providence Anesthesiology Clinical Practice Committee and discussed with the pathway surgeon champions. Based on the conversations and additional review of the literature, revised versions are created which are then presented to various committees again before it is presented at a final Greater Charlotte ERAS committee meeting. After final approval, it is taken back to surgeons again to ensure they know what is expected of them and their office staff. Finally, it is brought to team members and education is provided before the go live date.

Yes! Every patient's chart that is scheduled as ERAS is audited individually by the PAA ERAS team and the data is collected in a database that allows for extraction of data to then be used in running reports on both patient outcomes and compliance to the protocol.

The data is used to run reports for all service lines. The data can be very specific or very vague. We can run data on certain locations or certain service lines, as well as run data just to see the progress on patient, nursing staff and MD compliance. This data is presented during the monthly ERAS meetings at each location

• PMC- all service lines except Total Joints

• BMC-Gyn, Colorectal

• CCOPs- Same day Gyn, Same Day Gyn-Onc

• COH- Spine

• HMC- Total Joint, Colorectal, Bariatric, Gyn

• MHMC- Gyn, C-section, Colorectal

• MMC-Bariatric, Gyn, Gyn-Onc, Colorectal, Mastectomy, Same Day Mastectomy

• RMC- Colorectal, Bariatric, Gyn

No. PAA is currently conducting ERAS at Nash General Hospital and is in the implementation phase with Iredell Memorial Hospital.