Improving Outcomes Via Enhanced Recovery After Surgery (ERAS)

By Dionisios Vrochides, MD, PhD, HPB Surgeon, Vice Chair of Quality and Outcomes, Department of Surgery

At Atrium Health, we’re at the forefront of using Enhanced Recovery After Surgery (ERAS) to improve surgical care and outcomes.

ERAS isn’t just another fast-track recovery-after-surgery program. It’s an evidence-based, patient-centered approach that uses multidisciplinary pathways to eliminate variation in care. This can decrease complications, length of stay, readmission rates and costs. Together with structured monitoring of outcomes and predictive analytics, ERAS significantly enhances our ability to practice value-based medicine.

As the nation’s first ERAS® Society-accredited center of excellence, we have implemented ERAS protocols in our hepato-pancreato-biliary (HPB), colorectal and urology programs, with orthopedic and head and neck surgery soon to follow. The results are so positive that we plan to extend ERAS to the rest of our surgical programs within the next two years.

Empowering Patients Before Surgery

One ERAS cornerstone is Preoperative Learning and Readiness in Surgery (POLaRiS) – a one-hour class that teaches patients and families everything they need to know about their upcoming surgery.

During class, patients meet their entire care team, tour the surgical floor and learn what to expect before, during and after surgery. They also receive information about the electronic platforms we use to record patient-reported outcomes, and they receive a FitBit, tablet or other device to help keep track of mobility and other key measures. This makes patients feel more confident and less stressed, which helps them stay engaged in their care and recovery.

The results have been remarkable. Since we integrated POLaRiS, we’ve seen increases in readiness for surgery and discharge, and decreases in length of stay and readmission. We’ve published these outcomes in major, peer-reviewed journals.

The Power of Predictive Analytics

Our ERAS initiative includes using predictive analytics to identify ways to improve care. For example, we record each patient’s care and track key data points such as their pain level after surgery and how quickly they return to work. Then we use this data to provide highly customized care, by creating predictive algorithms that reveal how modifying a pathway for a particular patient might improve their outcome.

We also use predicative analytics to improve patient education and pre-habilitation. For example, we could predict that a specific patient’s chance of infection after surgery is 50 percent, but if they were to quit smoking for more than four weeks, it would decrease to 35 percent.

ERAS in Action: Improving HPB Outcomes

We used ERAS guidelines to transform our HPB surgery service line. The key changes include:

• Pre-operative education: HPB patients learn about things like drain and pain management, recovery and home care expectations.
• A new medication approach: Every HPB patient now receives anti-nausea medicine, and we’ve reduced pain-management narcotics because they can slow down the gut, spark complications and lead to addiction. We intend to eventually eliminate these narcotics.
• New post-operative guidelines: Our guidelines for the post-operative period now include immediate mobilization and by-mouth nutrition.
• Analyzing outcomes: We monitor patient-reported outcomes (including quality of life and patient satisfaction) for at least 90 days after surgery. Then we use our data repositories and predictive analytics equations – which incorporate a form of artificial intelligence called “machine learning” – to improve these outcomes.
• Stratifying patients based on risk: We use predictive analytics to place people in low-, medium- or high-risk categories that dictate care. High-risk patients may need extensive pre-habilitation before surgery. On the other hand, low-risk patients may undergo extensive surgeries without receiving any laboratory tests or the painful blood draws that go with them. This makes our care more tailored and cost effective.

These and other changes have markedly improved our HPB outcomes. After one year of ERAS implementation, our readmission rate for Whipple procedures – one of the most complex abdominal operations – decreased from 25 percent to 18 percent. Our 90-day survival rate increased from 94 percent to 97 percent. And our median length of stay decreased from 11 days to 8 days.

The impact of ERAS extends far beyond clinical outcomes. In 2017, our HPB surgery program applied ERAS in 250 patients. This enabled a cumulative $1 million cost savings in laboratory expenses alone. Furthermore, the cost-benefit of reduced complication rates, length of stay and readmission rates is calculated to almost $10,000 per patient.

Interested in ERAS Certification?

Our multidisciplinary, ERAS implementation training team deploys to hospitals to train their staff and prepare them for ERAS® Society accreditation. To learn more about ERAS implementation training, please contact Allyson.Cochran@AtriumHealth.org or visit www.erasusa.org or www.erassociety.org