A rethink of how patients are cared for after undergoing surgery has led to better outcomes for patients and smarter use of resources at Hospital del Mar, Barcelona.
The approach, Enhanced Recovery After Surgery (ERAS), brings together surgeons, anaesthesiologists, nurses, nutritionists and physiotherapists to get patients back on their feet around three days earlier than standard post-operative care.
Miguel Pera, a surgeon at Hospital del Mar, said that by continuously studying patient outcomes and adjusting care protocols, multidisciplinary teams are accelerating rehabilitation. Surgeons remove drains and tubes earlier than the norm; pain specialists adopt an ‘opioid-sparing’ approach; and nurses encourage patients to be mobile and resume eating sooner.
A study by the colorectal surgery team led by Pera showed the number of days spent in hospital can be reduced from an average of 11.9 days to 8.8.
Length of stay is used as a marker for speed of recovery, but ERAS also focuses on quality of care and whether fast-tracked patients are subsequently readmitted. “We were able to reduce length of stay by three days, without increasing readmission rates,” Pera said.
“This translates to a saving of around €1,000 per patient. Fast-track programmes are safe, they decrease overall morbidity and should be part of routine care,” he told a Healthy Measures roundtable at the BioVision Conference in Lyon last month.
Barriers to adoption
While ERAS has been adopted in the UK and Scandinavia, and has been shown to be effective in several surgical specialities over the past 10 years, it remains well outside the mainstream in Spain.
“Despite the body of evidence supporting ERAS, the implementation of this protocol is still too low,” said Pera. “Barriers include lack of staff time, resistance to change, and a need to educate health professionals, patients and families.”
Plan Imprica, launched in January 2017 to analyse compliance with ERAS protocols in centres of excellence across Spain, is designed to generate national standards for fast-track recovery. The project, coordinated by Hospital Clínico Zaragoza and the Spanish ERAS group (GERM), will analyse results from several centres, allowing surgeons to study short- and medium-term outcomes for patients.
As part of the plan, members of newly-created multidisciplinary teams will take a 30-hour online course and a two-day placement at a centre of excellence.
What patients want
Patient feedback can play a central role in fine-tuning outpatient procedures such as varicose vein surgery. Clinics routinely collect information from patients several weeks after their operation, including their levels of pain, bleeding and how quickly they return to work.
However, these episodic checks are not as precise as getting ongoing feedback, Olivier Creton, vascular surgeon at Clinique Charcot in Lyon, told the roundtable. Seeing the need for an easy-to-use system that would allow patients to give ongoing feedback in the weeks after treatment, he co-founded a company, MedSynApps to develop MyHomeDoctor, an app that allows patients to complete daily questionnaires on their post-surgery health.
“Every day, patients are invited to connect to a secure server where they can provide relevant information on their postoperative period,” Creton said. “We don’t just get data on individual outcomes, we can also access global information that help us to improve our practice and can be used for clinical research.”
More than 2,000 patients have used the app to date. However, adherence falls from around 80 per cent on the first day to 50 per cent after one week, and 30 per cent at the end of the first month.
“The tool has shown us that some techniques are more painful than others,” says Creton. “For example, we learned that embolisation of a perforating vein generates significantly more pain than other procedures, and we have changed our analgesic protocol for this type of surgery.”
As use of the app increases and the volume of data collected grows, Creton’s team hopes to build an artificial intelligence system capable of predicting postoperative outcomes for patients, and adapting treatment accordingly. “If we can predict elevated levels of pain after surgery we would prescribe analgesics in advance,” Creton said.
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