By Joy Daughtery Dickinson
Surgery providers, outpatient and inpatient, are finding that the use of enhanced recovery pathways are allowing their patients to come out of the OR nearly "discharge-ready."
EXECUTIVE SUMMARY
Enhanced recovery protocols are allowing providers to discharge patients more quickly without additional complications or readmissions.
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A multimodal approach to medications helps avoid side effects that increase length of stay.
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Electronic medical records allow quicker documentation.
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Nurses must be comfortable with using clinical-based discharge criteria rather than time-based criteria.
"Using a pathway which includes evidence-based practices with excellent outcomes is key," says Terri Link, MPH, BSN, CNOR, CIC, ambulatory education specialist in the Ambulatory Surgery Division of the Association of periOperative Registered Nurses (AORN). "Quality, safety, and efficiency are what insurance companies are looking for and are what is best for our patients."
However, some facilities have been slow to change their practice, says sources interviewed by Same-Day Surgery. Staff and surgeons might be reluctant to buy in, warns Robert Cima, MD, colorectal surgeon and chair of the Surgical Quality Subcommittee at Mayo Clinic in Rochester, MN, and medical director of surgical outcomes research at Mayo’s Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The difficulty comes if different providers use different protocols, Cima says. "Some say you can drink [after midnight], some say not, and the nurse on the preadmit unit must sort through who’s who and what the rules are," he says.
The reasons for slow acceptance vary, says Traci L. Hedrick, MD, assistant professor of surgery in Section of Colon and Rectal Surgery at the University of Virginia in Charlottesville. "As surgeons, we don’t want to do anything we think may be changing practice without strong evidence," Hedrick says. "Sometimes we’re too reluctant to change. Sometimes it stops us from being innovative." Hedrick is one of those who is convinced that there is strong evidence. For elective colorectal resections at her facility, they reduce IV fluids and use early feeding, early ambulation, and elimination of IV narcotics, as well as "very active and engaged" patient participation. As a result, they have seen a 30% reduction in length of stay, while complications have been cut in half, from 30% to 15%. Readmissions have been reduced from 18% to 8%. Additionally, "just about every single response improved significantly" on their patient satisfaction scores, Hedrick says. Also, direct patient costs have been reduced about $6,500 per patient, she says.
What’s different?
For inpatients and outpatients, the key is to change routines so that patients can go home earlier, but not with increased complications or a greater likelihood of readmissions. This issue is especially important as the Centers for Medicare and Medicaid Services is tracking quality measures, and ultimately Medicare payment will be impacted by these quality measures.
The process must start with having the right patient and the right expectation by the patient, Cima says. "For example, someone who’s a chronic narcotic user won’t tolerate a procedure like someone who is not," he says.
The key to enhanced recovery protocols is using a multimodal approach to medications by using medications from different classes of compounds, says Rebecca S. Twersky, MD, MPH, professor and vice-chair for research, Department of Anesthesiology, at State University of New York (SUNY) Downstate and medical director, Ambulatory Surgery Unit, SUNY Downstate Medical Center and at Bay Ridge, both in Brooklyn. The goal is that by using different medications, providers will minimize the side effects for any individual medication, Twersky says. While some providers have been taking this approach for years, now providers are using even more non-opioids in the place of opioids, she says. Those non-opioids include IV acetaminophen, IV ibuprofen, and IV ketorolac, coupled with nerve blocks or regional anesthesia preop or postop. "We’re using them pretty much on everybody so we can avoid opioids in the recovery period," Twersky says.
The result? "Patients are experiencing smoother postop courses in the recovery area," Twersky says. The patients appear to have less need for opioids, she says. "We haven’t used morphine in our recovery room for quite a while," Twersky says.
Enhanced Recovery Pathway for Colorectal Surgery
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An evidence-based, multimodal program to reduce postoperative stress responses and organ dysfunction so patients recover more quickly, easily, and naturally.
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Key tenet is that improving patient health before surgery results in faster, less traumatic recovery.
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Avoids traditional preoperative fasting and bowel cleansing.
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Allows patients to eat and drink shortly after surgery.
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Pre-emptively treats pain and nausea before surgery.
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Avoids fluid and sodium overload during and after surgery.
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Limits use of intravenous narcotics postoperatively.
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Benefits include shorter hospital stays, improved outcomes, and fewer long-term complications.
Source: Mayo Clinic, Rochester, MN.
Cima’s protocol includes pre-emptive analgesia, Cima says. Before his patients even go into the OR, they’re given Cox-2 inhibitors (Gabapentin) and acetaminophen. Also, "we’re strong users of regional anesthetics as a supplement to general anesthesia," he says. They also use a local anesthetic at the end of the procedure and occasionally a long-acting anesthetic. "As soon as the patient is in recovery, we give oral pain medicine," Cima says. As a result, for colectomies, the length of stay has improved from 7% of patients leaving postop day two to 44% of patients leaving on that day. Complications have lessened, and readmissions are unchanged, Cima says. (See his enhanced recovery protocol, above.)
Appropriate pain management is always important, but even more so in ambulatory surgery when patients are discharged earlier, Link says. "Regional blocks are common and an effective way to manage postoperative pain," she says. "Less narcotics are used and, as a result, the risk of nausea and vomiting postoperatively is less." (To see how anesthesia changes helpeimprove length of stay for pediatric knee surgeries, see story)
Twersky says because monitored anesthesia care (MAC) is much more prevalent now in ambulatory units than general anesthesia, "patients indeed are discharge-ready fairly rapidly." Nurses are another key component, she says. "The nursing staff has developed a comfort level and recognized fast tracking a patient doesn’t compromise their safety and the ability to educate the patient and family postop," Twersky says.
These pathways all segway into the concept of the perioperative surgical home where anesthesiologists collaborate with other professionals to provide a patient-centered perioperative surgical care system designed to improve efficiency, be cost effective, enhance value, and focus on safety.
Another change for many patients has been a provision for them to drink up to about four hours before surgery. The drink is supposed to help with gastric emptying and improve sugar control, Cima says. Patients are instructed they can have clear drinks, with no creamer, through the night and up to four hours before the procedure, he says.
The end result of these enhanced recovery protocols, when handled appropriately, is happy patients, say our sources.
"Patient satisfaction is key," Link says. Patients expect to have pain control, no nausea and vomiting, and no complications or readmissions, she says. "Great outcomes do not happen by chance," she says. "Having proven pathways of care which are safe, cost saving, and with great outcomes and satisfied patients are the goal." (For more information on the components of a successful enhanced recovery protocol, see story, below.)
