Embedding ERAS in Post-Surgical Care

Enhanced recovery after surgery (ERAS) is a global initiative protocol to help patients recover as quickly as possible after major surgery. Its premise is that a combination of 3 factors—parenteral analgesia, the need for intravenous fluids secondary to gut dysfunction, bed rest caused by lack of mobility—keep patients in the hospital longer than necessary. With multidisciplinary coordination, it’s possible to reduce care time and complications. The journal Clinical Otolaryngology published an article by investigators from the University Hospitals Bristol in the United Kingdom that described ERAS program development for people undergoing surgery specifically for head and neck cancer.

This facility developed its program over 6 months. Their structured planning meetings included representatives from a number of disciplines including oral and maxillofacial surgeons, otolaryngologists, anesthetists, dietitians, physiotherapists, speech and language therapists and nursing staff. They relied on current evidence to develop consensus among the group and develop a program. Following program implementation in February 2014, they conducted a 12 month compliance study.

This ERAS program required patient to maintain a diary that in addition to requiring patient input, describes normal expectation in terms of pain, nausea and activity.

Clinicians focused on nutritional optimization, avoiding tracheostomy, and goal-directed fluid therapy. The facility used a postoperative pain management protocol specific to head and neck.

Although overall compliance with the protocol was excellent, clinicians explained the ERAS program pre-operatively to only 55% of surgical candidates. Other areas for improvement included encouraging pre-operative carbohydrate drinks, providing individualized goal directed-fluid therapy, prescribing post-operative opiates appropriately, and mobilizing patients within 24 hours of surgery.

The mean length of hospital stay was 14.6 days, which represented a 30% reduction compared to the previous year.

The investigators report that an ERAS program that is embedded in the care pathway can significantly reduce length of stay and complications for people undergoing head and neck cancer surgery.