July 16, 2019

WakeMed Health & Hospitals "pioneered" the use of Enhanced Recovery After Surgery (ERAS) for heart surgery with dramatic results: ICU stays were cut nearly in half and readmission rates fell by 30%, Maria Castellucci reports for Modern Healthcare.

3 strategic benefits of surgery prep programs

Why hospitals are turning to 'ERAS' programs

Hospitals are increasingly overhauling pre- and post-surgery recovery by adopting ERAS, which require providers to follow evidenced-backed protocols before and after an operation.

The goal of ERAS, Castellucci reports, is to improve patient outcomes. The protocols been deployed in various surgical specialties and have been shown to reduce complication rates, speed up recovery, and reduce blood clots, nausea, infections, and length of stay. But it's only recently that hospitals have started applying ERAS to heart surgery patients, Castellucci reports

According to Judson Williams, a cardiovascular surgeon at WakeMed Health & Hospitals, cardiologists were hesitant to adopt the protocols because clinicians were focused more on the technical aspects of the surgery.

"The historical mindset around cardiac surgery was that the operations were so big and the patients were so complex that all of these enhanced recovery pathways were really too difficult to apply to cardiac surgery," Williams said.

But a few years ago, Williams saw research that prompted him to take a closer look at how ERAS could be applied to the field. The research showed 80% of morbidity outcomes for heart surgery are determined by pre- and post-operative care, while just 20% is the surgery itself.

"For me, as a surgeon, that was an inspiration to see what enhanced recovery could do for heart surgery," Williams said.

A change of heart at WakeMed

Bolstered with the data, Williams, along with cardiothoracic ICU nurse Gina McConnell, spearheaded the process of developing and applying ERAS to heart surgery patients at WakeMed. The duo worked for a year to gather research about ERAS that would be most useful for heart surgery patients. In 2017, Williams and McConnell began to consult clinical staff about potential protocols.

The first protocol the team agreed to implement was giving patients a carbohydrate-loaded drink two to four hours before surgery to help control blood glucose levels and reduce the risk of complications.

Initially, anesthesiologists weren't sold on the change, as the typical protocol requires patients to fast after midnight before surgery. To address anesthesiologists' hesitancy, the team assigned an anesthesiologist to explain evidence supporting the method until all staff agreed to the protocol.

In addition, clinicians started approaching pain with multimodal analgesia, or giving patients opioid-alternative painkillers from different drug classes, to cut down on opioid use after surgery. WakeMed also requires smoking and alcohol cessation counseling to ensure patients comply with the smoking and alcohol ban prior to surgery.

WakeMed's new after-surgery protocol also includes removing the tracheostomy tubing as soon as possible, breathing exercises, administering food between 12 and 18 hours after surgery, and mobilizing the patient.

Results

After employing ERAS for all types of heart surgery, the average length-of-stay in WakeMed ICU decreased from 45 hours to 28 hours, and ICU readmission rates fell by almost 30%. Opioid use decreased by 40%, Castellucci reports.

In addition, patients were less groggy and got out of bed more quickly after being administered fewer opioids, McConnell said.

Castellucci does not report the specific cost savings, but Williams said estimates show they're significant.

Since WakeMed adopted ERAS for heart surgery, other academic medical centers have too, and JAMA Surgery has published heart surgery ERAS guidelines, of which Williams is an author (Castellucci, Modern Healthcare, 7/13).

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