While the United States likes to think it is at the forefront of all things medical, there are some things in which we are very conservative and in which we lag. For years in Europe, surgeons have been following a protocol for surgical patients, called Enhanced Recovery Protocol, that involves letting them drink until two hours before surgery, getting them moving as soon as possible after, and using non-opioid pain killers as much as possible.
The results from this method was uniformly shorter stays, lower costs, fewer complications, happier patients and happier doctors. But here in America? The idea wasn’t taking off very quickly.
Traci Hendrick, MD, FACS, an assistant professor of surgery at the University of Virginia Health System in Charlottesville says she heard the method talked about a few years ago, in particular by a colorectal surgeon out of Mayo Clinic in Minnesota. “He presented his findings at a conference and it was just mind-boggling how well his patients did,” she says.
After talking it over with an anesthesiologist at the UVA’s 600-bed academic hospital, they spent about eight months developing a protocol using the tenets of enhanced recovery as developed in Europe.
They start with teaching for the patient that includes checklists of what will happen when, that the patient is encouraged to use to hold the medical staff accountable for what will happen. Anesthesiologists use spinal blocks rather than opioids during and after the operation. Patients are allowed to eat right after surgery in an effort to get their bowels moving again quickly.
“I knew from the first patient that our results would be good,” Hendrick says. “Usually, a patient is in the hospital after colorectal surgery for five to 10 days. The first three or four the patient looks awful and feels awful. The bowels have shut down and we’re giving morphine, which doesn’t do anything to help get things moving. Meanwhile, you hadn’t eaten since midnight before surgery, and if you were unlucky enough to have afternoon surgery, you’re starving, but you aren’t given any real food until your bowels move again, which they aren’t doing because we’re giving you all this morphine and not letting you move around. We know that those things together can lead to a lot of side effects.”
Elderly patients might become delirious, or they may vomit. Everyone is groggy throughout most of their stay, she says.
Under this protocol, though, patients can drink fluids within two hours of surgery and are encouraged to “carbo load” with an electrolyte drink. They are allowed to eat as soon as they awaken, are not given opioids if something else will work, and are out of bed as soon as possible. Hendrick says the difference in affect among the patients is amazing. They look less like death warmed over, and more like someone who just woke up from a nap. They aren’t groggy or listless. They are in a better mood.
The cost savings are significant. In a study of 207 patients, Hendrick found length of stay declined by two days, and IV morphine use was also considerably down, Hendrick says. Complications were down 17% over the course of the study, and patient satisfaction with pain levels improved by more than 50%. The average cost per patient declined by more than $7,100.
A lot of hospitals just pump fluids into patients without consideration of what the patient actually needs, Hendrick says. Their protocol uses a meter on the patient’s finger to tell them exactly how much fluid to push into a patient during surgery, leading to a decrease of about two liters per patient per surgery.
She says that while this is a “dramatically different way to care for patients,” and that “we are all often very set in our ways,” the data surrounding ERP is so strong she would bet that within five years this will be the standard of care, at least in colorectal surgery. “Although we are using it here in orthopedics and gynecology, too.”
She says that getting her anesthesiologist on board, creating a protocol, and presenting the data to physicians was instrumental in getting people to accept this radical change. “I think that’s the best thing about this: We are all working more as a team now.”
For more information on this topic, contact Traci Hendrick, MD, FACS, Assistant Professor of Surgery, Section Colon and Rectal Surgery, UVA Health System, Charlottesville, VA. Email: TH8Q@hscmail.mcc.virginia.edu.