Defining the Scope of ERAS Protocols

Raoul Concepcion, MD: John, your role, essentially, is a quality officer with a large anesthesia group that is creating standardization of all these protocols. I think your perspective is interesting because you deal, obviously, in multiple healthcare systems, not just a single entity. Who are the key players, as you go in and try to develop an ERAS program? Who are the key players that you try to bring in to operationalize something like this?

John Dalton, MD: Well, as you pointed out, it takes everybody that’s going to touch the patient. As difficult as it is to come up with standardized protocols and to agree nationally, and even regionally, on what best care is going to be, the most difficult thing is the implementation. That’s because of the breadth of folks involved. In academics, it isn’t easy. But in private practice, particularly when you’re dealing with multiple systems, you can multiply that difficulty by the number of systems you’re in. As we’ve heard in lectures on the subject, “You’ve seen one, you’ve seen one. You’ve implemented a program in one place—you’ve done it once.” The principles apply to the next place, but you have to keep doing it at each place, and you’ve got to have everybody involved. You’ve got to have C-suite involvement, and you’ve got to have bedside involvement.

I like to think of it as you have to have top-down support. You also have to have bottom-up support. If you don’t have everybody on the same page, you will get a nurse who has done the same thing, conscientiously, for 30 years. They will take care of their postoperative patients—give a patient a large dose of Dilaudid, on the floor, because they’re hurting. They don’t understand what we’re trying to do with multimodal analgesia. The patient says they’re in pain. On the VAS (visual analogue scale) score, it’s a little higher. And as we know, ERAS patients are going to be a little higher on the VAS scores. So, they give them Dilaudid and you’ve got an ileus. That’s an example. You’ve got to have everybody involved—all of the stakeholders. You’ve got to have a “Why” discussion. Then, the education has to be complete.

Raoul Concepcion, MD: Sanjay, you were exposed to, probably, some early ERAS protocols as a resident. Then, you did your Fellowship. Now that you’re an attending at an academic institution, what’s been your experience? How has your thinking progressed as you are now implementing this (at a system level) at a major academic urologic institution?

Sanjay Patel, MD: When I started, a lot of how we took care of patients postoperatively was certainly dogma. We didn’t really have a system in place. Early in my training as a resident, I was fortunate to see the implementation of an early pathway in urology. I think the other specialties were already doing it—colorectal, namely. We decided to kind of implement that.

I saw a lot of the challenges and frustrations of trying to push out something new that’s foreign to everybody. As time went on, through my training and even as a Fellow, it continued to evolve in urology. As an attending, when I first started working, we didn’t really have an ERAS pathway. And so, a lot of my work initially, when I got there was just in trying to get the right people in place and lead them all into a room to talk about it—to have a discussion about what we have to do. Even then, we developed a pathway and we implemented it. I think the key thing for us has been in revisiting and auditing it, periodically. What happens is, even though it’s on the paper and it says, “Do A through Z,” they may not all be getting carried out. We found out that there’s a lot of challenges there, and we tried to address those as they came along. But, I think for me just seeing the whole progression, from seeing it start out as a resident and then doing my own work, that we definitely have seen the evolution of it. A key thing is revisiting it, periodically—making sure that it’s actually getting carried out how you want it to.

Raoul Concepcion, MD: When you finished your Fellowship and matriculated to Oklahoma, was it tough to get buy-in, as Dr. Dalton said, from all these other specialties? You’ve got to have nursing. You’ve got to have nutrition. As an institution—I guess we could ask everybody this—did you bring in surgical oncology, colorectal, gynecologic oncology as representation of their various disciplines?

Sanjay Patel, MD: When I first started out, we just decided to do it for cystectomy so I could get one thing going and then maybe roll it out to all of the different specialties—just figure out 1 line. There really wasn’t too much hesitation. I think that for certain people, who were there a lot longer and had been ingrained in their ways, it was a little harder to move that mountain, if you will. Some of the younger guys, and your guys, were willing to be on board. Certainly, that was something that we encountered. But the goal was to get one thing working—get it figured out and iron out the case. And then, once we got a system in place and had some nurses familiar with it, as well as the anesthesiology staff, the physical therapists, and the nutritionists all involved, then we could kind of laterally apply it to the various specialties.

Raoul Concepcion, MD: This may sound like a ridiculous question, but are there any surgical patients that are not a candidate for an ERAS protocol?

Traci Hedrick, MD, MS, FACS, FACRS: When we first started, for the first month or so, if the patient had end-stage renal disease, or something like that, we would not put them on it. But what we found is that the patients were doing so well. Why would we exclude those that have the highest predicted risk and could benefit the most from reduced fluid and reduction of opioids? In my situation, with colorectal conditions, no matter whether they’re having a small ileostomy closure or pelvic exenteration, and no matter their comorbidities, they should go on the pathway. But we do use our brains and customize the protocol, as necessary, to accommodate each patient.

Transcript edited for clarity.