How Post-Surgical Enhanced Recovery Programs Began

Raoul Concepcion, MD: Thank you for joining us for this MD Magazine^® Peer Exchange^®. Postoperative ileus is among the most common of complications that can occur following gastrointestinal surgery or cystectomy. The more severe cases can result in prolonged hospital stays and dramatically impact patient quality of life. Enhanced recovery programs (ERAS) were developed to help reduce mortality and morbidity, but protocols are not implemented consistently across many institutions in the United States. We have assembled a multidisciplinary panel of experts who are here, today, to discuss the benefits and barriers to adhering to this multimodal approach.

I am Raoul Concepcion, and I’m the director of the Comprehensive Prostate Center in Nashville, Tennessee. Joining me for today’s discussion are: Dr. Sanjay Patel, assistant professor for the Department of Urology at the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma; Dr. John Dalton, chief quality officer of PhyMed Healthcare Group in Nashville, Tennessee; Dr. Traci Hedrick, associate professor of surgery, co-director of the Enhanced Recovery after Surgery Program, and co-lead of the Digestive Health Service Line at the University of Virginia Health System in Charlottesville, Virginia; and Dr. Declan Fleming, chief of surgical oncology in the Department of Surgery and Perioperative Care at Dell Medical School, of The University of Texas, at Austin. Thank you for joining us today. Let’s begin.

I think we all recognize, knowing that we have representation from a number of different surgical specialties and, obviously, anesthesia, that a lot of things that we’ve done preoperatively, perioperatively, and postoperatively have been really based upon a lot of anecdotal evidence and a lot of personal experience. But, as we move into this post-MACRA (Medicare Access and CHIP Reauthorization Act) world—this transition from volume to value-based medicine and standardization—and when looking at metrics, outcomes, and standardization, I think something like this enhanced recovery program becomes very, very critical. Declan, you’re involved in the creation of a new medical school. Congratulations. There is an opportunity to really sort of move forward with operationalizing an enhanced recovery program. Can you tell us a little bit more about what your definition is? And, how do we, as institutions and as individuals, want to adopt this and adapt it? Tell us what’s involved.

Declan Fleming, MD: Well, it is a process. Enhanced recovery has to, by definition, include not only the surgeon and the anesthesiologist. It involves everyone in the hospital. It involves the patient and the patient’s family because, at any point in time during the recovery of a patient following surgery, if we’re not on the same page, if we’re not moving in the same direction, it takes very little to derail a process. We found that creating an understanding that this is a team project has been instrumental in becoming successful at implementing an enhanced recovery protocol. There are so many opportunities to think that we’re doing the right things and to go offline and begin to fall back to these old patterns that we have used for so many years. As I started my training, everything that I did, in taking care of patients following surgery, was basically based on things that my older mentors were telling me. It was dogma. They told me what they had been told, and what those before them had been told. In the 1990s, the introduction of laparoscopic surgery began to change people’s ideas about how long it should take for a person to recover from an operation. And open surgeons, not wanting to be outdone by their laparoscopic colleagues, began to say, “Maybe I can let my patients go from the hospital a little bit quicker. Maybe we don’t have to have a tube in every patient, every time.” All of this has driven forward a different way of thinking in taking care of patients in their recovery from surgery.

Raoul Concepcion, MD: Traci, you’ve been very involved in this from a national society—in terms of looking at the development of guidelines and surgeons, and anesthesia, and, again, this multimodality approach. Is that correct? Can you tell us about your experience in looking at this on a national level?

Traci Hedrick, MD, MS, FACS, FACRS: When I go and talk, a lot of times the first question that I get asked is, “What is it about enhanced recovery?” And “What 1 or 2 things can I adopt in my practice that can effect change?” What we try to tell folks is that it involves the creation of individual programs at each institution. There are basic tenets of advanced recovery. You want to limit opioids—that’s probably the most important aspect of it. You want to limit them out of intravenous fluids. And with that, you allow patients to eat and drink right away. You want to involve patients in their care. You want to encourage them to get up, immediately, after surgery. There could be hundreds of different ways to do that. You want to choose a pathway where you have buy-in from all of the different care providers at each institution.

Nationally, what we do, when we’re creating guidelines, is look at all of the evidence and try to drill down on what we think is the most important—what has been shown, from high-quality studies, to be effective. And then, we produce guidelines that can provide as a guide.

Transcript edited for clarity.