by Paul Govern
At Vanderbilt University Adult Hospital (VUAH) a vanguard of surgical service lines, with key assistance from anesthesiology, has in recent years shown that patients can be helped to recover more quickly from major surgery, leave the hospital earlier and have fewer side effects from their pain management, all without increased rates of unexpected readmission to VUAH or unexpected second operations at VUAH.
In step with reductions in length of stay across these service lines, the cost of care has decreased and, due to improved efficiency, operating margins have benefited.
This cadre of service lines includes colorectal surgery, surgical weight loss, urological surgery, plastic surgery, living donor nephrectomy, surgical oncology, gynecological surgery, abdominal wall reconstruction, spine surgery and orthopaedic surgery.
“We used to fill every bed on the fourth floor of the round wing and part of the third floor with post-operative colorectal patients. Today, we perform more cases and can’t even fill the fourth floor, because patients recover and go home so fast,” said Timothy Geiger, MD, MMHC, director, Colon and Rectal Surgery, chief of the Division of General Surgery and medical director of the Surgery Patient Care Center.
The principles and practices used to achieve these improvements at VUMC are known in the clinical literature as enhanced recovery after surgery (ERAS).
An effort is underway at VUMC to assist all adult surgical service lines in adapting ERAS.
“We want these care practices to become the standard for major surgery. We want ‘enhanced recovery’ to become simply ‘recovery,’” said Warren Sandberg, MD, PhD, chair of the Department of Anesthesiology and chief of staff for Perioperative and Critical Care Services at VUAH.
“Having shown over and over that with this approach patients fare better, and our operating margin is enhanced, the hospital and anesthesiology are committing new resources to help more surgical service lines realize these benefits.”
The improvement program applies to major surgery, defined as surgery involving at least one night’s recovery in the hospital.
Matthew Spann, MD, MMHC, director of Metabolic and Bariatric Surgery, led the adoption of ERAS for his service line.
“Using ERAS protocols for patients undergoing surgical weight loss procedures has allowed us to further decrease an already short length of stay and significantly reduce the opioids required in the post-operative period. The result has been grateful patients who have less nausea, faster return of bowel function and pain that is well controlled. We have had many patients return to other service lines in VUMC for elective procedures due to the experience they had with ERAS for their bariatric procedure,” Spann said.
Leading the hospitalwide effort are Geiger and Matthew McEvoy, MD, vice chair of the Department of Anesthesiology, chief of Perioperative Consult Services and co-director of the High-Risk Surgical Encounter (Hi-RiSE) Clinic. Executive sponsors include VUAH’s Chief Operating Officer, Scott McCarver, and VUMC’s Executive Chief Nursing Officer, Marilyn Dubree, MSN, RN.
Anesthesiology will provide support preoperatively through Vanderbilt Preoperative Evaluation Centers, or VPEC, intraoperatively through the anesthesia care team and postoperatively through its consult service.
“VPEC will need to touch every patient having major surgery, and we’re adding resources to make that happen. We’re also going to double or triple the size of our consult service, which currently sees about 3,000 patients per year,” McEvoy said.
According to McEvoy, for patients followed by Perioperative Consult Services there has been an average 22%, or 1.2-day, reduction in length of stay. And across the services that have already made the change there have been 15 to 20% reductions in hospital costs and greater than 80% reduction in the use of opioids.
“If you look at colorectal surgery, surgical site infections and complications associated with organ injury also went down significantly,” Geiger said.
“It’s not that we’re getting patients home sicker but faster, as critics of this approach sometimes like to think — it’s that patients are actually recovering better.”
The program hinges on patient education and engagement, which begins in the surgeon’s office.
It relies also on non-opioid multimodal post-op pain management, supplemented with opioids strictly on an as-needed basis.
This approach to pain management — involving medications such as acetaminophen (Tylenol), ibuprofen and gabapentin — helps patients avoid sedation, nausea and vomiting, and disruption of normal sleep patterns, and paves the way for quicker return to solid food and earlier ambulation.
So as not to unduly restrict activity after surgery, the program avoids overuse of lines and tubes for draining fluids from patients. Finally, the program requires ongoing evaluation of patient outcomes.
“One of the keys to success is to start with a surgeon within the service line who serves as a champion. You have to have an expert who’s interested in helping to define a best practice model and helping his or her group create a program around that model,” Geiger said.
Nursing also plays a key role.
“We need to have nurse education and participation at every step. It starts in the clinic, so that patients are taught exactly what the expectations will be to get ready for surgery. Then we need to have inpatient nurse champions educating nurses on what the care of the patient should be after surgery,” Geiger said. The program is also assisted by pharmacists, nutritionists and patient education experts.
VUAH will provide process engineering support to service lines, as well as analytics support to help teams track clinical and operational outcomes. Geiger and McEvoy stressed that the program relies on ongoing evaluation of best practices, along with periodic review of patient outcomes on at least a quarterly basis.
“As we expand to more patients, phase two is going to be looking at patient-reported outcomes at 30 days and 90 days, to answer whether we’re doing a better job of returning patients back to their normal lives. That should in turn help make the case to employers to select VUMC for their employee health plans,” Geiger said.
