Revising standard surgery protocols to speed recoveries

Dr. Tonia Young-Fadok was always looking for innovative ways she and her colleagues at the Mayo Clinic in Phoenix could improve the quality of care for their colon and rectal surgery patients.

Their patients' lengths of stay and outcomes were on par with other high-performing hospitals, said Young-Fadok, who chairs the division of colon and rectal surgery. Still, she thought they could do better.

Then, several years ago at a conference in Oklahoma, Young-Fadok had a conversation that led her to champion radical changes to surgical practices that had been standard at her hospital and most others for decades. That conversation was with one of the leaders of the Enhanced Recovery After Surgery (ERAS) Society, a Sweden-based group that promotes evidence-based protocols to improve surgical care and speed recovery.

Young-Fadok said she initially was wary because other surgical streamlining efforts had been linked to higher readmission rates. “But I realized the evidence was there,” she said.

Created in the mid-1990s by a Danish surgeon, ERAS protocols aim to make surgery less physically debilitating for patients so they can leave the hospital sooner. Enhanced recovery has been shown in trials to improve lengths of stay and outcomes, and curb costs. Many European hospitals now use enhanced recovery protocols. But only a few U.S. hospitals have implemented them.

Many key ERAS protocols turn usual practices on their head. For instance, instead of fasting after midnight the night before surgery, patients are allowed to have a clear drink such as apple juice up to two hours before the procedure. They receive far less IV fluids and narcotics during and after surgery. They are encouraged to get up and walk around soon after the operation instead of lying in bed for several days. And they are allowed solid foods on the day of surgery, provided they tolerate fluids first.

The evidence base for enhanced recovery after surgery is strong, but “you have to change culture and that's not easy,” said Dr. Tong Joo Gan, chair of the department of anesthesiology at Stony Brook (N.Y.) Medicine and founder of the new American Society for Enhanced Recovery.

Before joining Stony Brook this fall, Gan spent two decades at Duke University, where he led the first implementation in the U.S. of enhanced recovery after surgery. That effort, focused on colorectal surgery patients, led to a two-day reduction in average length of stay, decreased readmissions, fewer complications and average savings of $2,000 per patient. Although the evidence is strongest for colorectal surgeries, enhanced recovery protocols are relevant for any major general abdominal surgery, Gan added.

Young-Fadok and her team focused on colorectal and gynecological surgeries when they launched the enhanced recovery program at Mayo Clinic in Arizona in July 2013, after six months of extensive planning and education. As an example of her careful groundwork, when she met with the chair of anesthesia, Young-Fadok printed out guidelines from the American Society of Anesthesiologists showing that clear liquids up to two hours before surgery are now allowed.

Her team also arranged for post-operative patient education to take place sooner given that patients would spend fewer days in the hospital. They collaborated with the information technology department to get customized order sets in the hospital's electronic health record. They educated dietary staff on the revised food rules. They worked with pharmacy staff on a new cocktail of preoperative pain medications. And they made sure nurses knew to get patients up and moving soon after surgery.

The hospital saw a 1.2 day reduction in average lengths of stay for laparoscopic surgery patients and a 2.6 day reduction for open-surgery patients, said Kripa Krishnan, operations administrator for the department of surgery. Costs per case fell 7% for laparoscopic procedures and 16% for open cases. “And we didn't see any increase in readmissions,” said Krishnan, who presented the results at the most recent meeting of the American College of Healthcare Executives.

Patients feel better, too, Young-Fadok said. They're not overloaded with fluids, their bowel function comes back sooner and they're not miserable from so much pain medication, she added.

The degree of uptake among the hospital's attending physicians has varied, Young-Fadok said. Although the enhanced recovery plan is the default option in the EHR, some physicians override it and stick with old practices. “I have some considerably senior attendings who still say, 'Let's not put this patient on enhanced recovery, let's wait on a bowel movement,'” she said. “I have to remind them that these practices are evidence-based.”

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