A multidisciplinary team helps optimize patients for surgery
It has been said that surgery is like a marathon. Shouldn’t it follow, then, that patients be preconditioned accordingly? Unfortunately, that is not necessarily the case. “After closely reviewing the pre-surgical processes and protocols already in place, we found that patients can be better prepared for the ‘marathon’ ahead,” says Akanksha Sharma, MD, director of Overlook Medical Center's Enhanced Recovery After Surgery (ERAS) program. ERAS is a multidisciplinary, evidence-based pathway to wellness that emphasizes the preparation of the surgical patient well in advance of his or her surgery. “We identified steps that could be taken to better support patients before and after surgery. This program was a collaborative effort among health care members – from the staff at the surgeon’s office, the anesthesia team, nursing and administration leadership, to the pre-admission testing department, and the operating room and recovery room staffs, the hospital unit team, the ostomy care team, case management, physical therapy, nutrition, and pharmacy – all with a unique set of goals. That is what makes ERAS special.”
How ERAS Helps
The ERAS process begins two to four weeks prior to surgery, when the patient meets with a nurse to discuss plans for improving endurance, increasing lung capacity, smoking cessation and medication management. The nurse also reviews each patient’s nutritional needs and sets the patient on a schedule for taking protein drinks before surgery (these continue after discharge as well) and carbohydrate-loading drinks the night before and the morning of surgery. Dietary consultations and ostomy classes are coordinated as needed.
Pre-operatively, OR nurses check in with the patient on their preparation for surgery and implement physician orders pertaining to the prevention of blood clots and infection. During surgery, an anesthesiologist uses high-tech devices to deliver local anesthetics near nerves to block pain after surgery and to accurately monitor the patient’s cardiac function to optimally deliver intravenous fluids. Additionally, the anesthesiologist enhances patient recovery by implementing a comprehensive protocol for reducing post-operative nausea and vomiting. Post-operatively, non-narcotic medications are administered intravenously to manage pain. The combination of technology and optimized clinical strategy encourages patient mobility and a progressive diet.
Arming Patients with Knowledge
Education is a key component to the ERAS program. “The optimal time to empower patients with knowledge is well ahead of surgery,” says Dr. Sharma. “We’re starting that process early on, so patients understand how to optimize their health before surgery, identify which support systems they will need after surgery, and have time to ask questions. They become empowered. They are informed and prepared, and it works.”
Adds Bertram Chinn, MD, chief of colon and rectal surgery for Overlook Medical Center, “Overlook has done an exceptional job with ERAS. Not all places use ERAS; those that do, generally use only parts of it. We use it comprehensively. The commitment by our teams – from before admission to after discharge – truly enhances surgery and is second to none.”
Thus far, patient outcomes indicate that the addition of the ERAS program has resulted in a significant decrease in length of hospital stay and readmission rates, a decrease in opioid use, reduced nausea and vomiting, fewer wound complications, and an increase in patient satisfaction. “The data show that planning for surgery is just as important as post-operative care,” says Mary Pat Sullivan, RN, MSN, CNS, chief nursing officer for Overlook Medical Center. “These are not small surgical cases. But by partnering with patients and giving them the opportunity to ready themselves for surgery, we are providing them with powerful tools for success.”
When Arlene Levy found herself in need of surgery last summer, research led her up the parkway 45 miles from her home in southern Middlesex County to the office of Dr. Chinn. The 83-year-old was undaunted by the distance and by the prospect of surgery, especially when she became aware of the hospital’s ERAS program.
“I heard about it and I said, ‘Fine, let’s give it a try,’ and I’m glad I did,” says Arlene. She credits the program’s regimen of protein shakes and medication management leading up to surgery for helping her to maintain her trademark boundless energy. She reports she was gardening and walking and doing all of her usual activities right up to the day of surgery, and she was able to return to those activities just a few weeks later. “I thought ERAS was exceptional,” she says, “and I would advise anyone facing surgery to get on this kind of program. I think every part of the program contributed to me being able to handle surgery better than I would have.”
Harold Donovan Jr. of Clark was just as eager to become part of the ERAS program when he learned about it. Faced with surgery that necessitated the removal of part of his colon, he says he was unsure about what to expect but was open to trying anything that would aid in his recovery. Harold adds that he was especially grateful for all of the education and instructions he received prior to surgery. “It was a wonderful program, and Dr. Chinn was an excellent surgeon; and even he was surprised just how well I did with the surgery. Anything I was told to do, I followed to the letter.”
In fact, Harold is so pleased with how well he is feeling, he has even continued with the program’s protein shakes on occasion, though he admits to making one small change: “I switched from vanilla to chocolate.”