A study of the programme, published earlier this month in JAMA Surgery, also showed decreased hospital mortality among colorectal resection patients and increased rates of home discharge, compared to discharge to skilled nursing facilities, among hip fracture patients.
Millions of inpatient procedures are performed annually and perioperative complications are common and costly, said lead author Vincent Liu, of the Kaiser Permanente Northern California Division of Research. “All-inclusive approaches to surgery like this ERAS programme aim to reduce the stress of surgery, reduce complications and maximise the potential for recovery,” he said.
The ERAS programme focused on improving pain management, mobility, nutrition and patient engagement.
“In my 24 years as a surgeon, this has been the biggest change in our clinical practice,” said co-author Efren Rosas, surgeon champion for the ERAS programme. “For decades, surgeries were guided by commonly held principles including no food after midnight the night before surgery, strong opioids for pain management and bed rest for recovery. ERAS, [using] alternative medications for pain control, avoiding prolonged fasting and encouraging walking [has] been shown to reduce complications like blood clots, muscle atrophy, nausea, confusion, delirium and infection.”
To improve engagement in their care, an illustrated calendar is distributed to patients so they know what to expect from the night before surgery through hospital discharge. A series of videos is available to improve patient education and active involvement with recovery.
Implementation of ERAS started in 2014 and was completed over the course of one year in colorectal surgery and hip fracture repair. A total of 3,768 elective colorectal resection patients and 5,002 hip fracture repair patients were included in the study. Their outcomes were compared to 5,556 patients having elective gastrointestinal surgery and 1,523 patients having other types of emergency orthopaedic surgery.
ERAS patients demonstrated significant gains. The rate of early ambulation increased 34 per cent and 18 per cent among colorectal and hip fracture patients, respectively. The total dose of opioids also decreased significantly in both groups. Length of hospital stay decreased significantly in both surgical groups and there was a one-third reduction in relative post-operative complication rates.
“This study demonstrates the effectiveness of a systems-level approach to enhanced recovery programme implementation, even across widely divergent target populations,” said senior author Stephen Parodi, associate executive director of the Permanente Medical Group.
“While prior studies have had limited ability to evaluate implementation at scale in real-world settings, we were able to evaluate care patterns in over 16,000 surgical patients over a two-year period. We were able to demonstrate the feasibility of large-scale ERAS program implementation over a relatively short interval because of the collaboration of thousands of clinicians.”
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care.
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