Vanderbilt University Medical Center’s enhanced recovery after surgery (ERAS) program recently expanded to include the 1,400 patients per year who receive total hip replacement or total knee replacement surgery at Vanderbilt University Hospital or Belle Meade Surgery Center.
ERAS originated in Denmark in the early 1990s and has since been adopted internationally. In 2014 at VUH an initial ERAS clinical pathway was introduced for adult colorectal surgery, and in 2015 at Monroe Carell Jr. Children’s Hospital at Vanderbilt an ERAS pathway was introduced for complex hip surgery. So far, six ERAS clinical pathways have been adopted for major surgical procedures on the adult side and seven have been adopted on the pediatric side.
With ERAS, service lines have reported shorter hospital stays, fewer complications, and reduced opioid usage while maintaining excellent postoperative pain control.
Warren Sandberg, MD, PhD, chair of the Department of Anesthesiology and chief of staff at VUH, serves as executive sponsor of the ERAS program.
“We want consistent and continually improving care practices to become the routine for all surgery. In other words, we want ‘enhanced recovery’ to become simply ‘recovery.’ VUMC teams have shown over and over that with ERAS approaches patients fare better, so the hospital and Anesthesiology are committing new resources to help more surgical service lines realize these benefits,” Sandberg said.
ERAS pathways at VUMC hinge first of all on patient and family education and engagement, which begins in the surgeon’s office.
Intraoperatively, ERAS attempts to reduce physiological stress to the patient and preserve preoperative organ function, often through minimally invasive surgical approaches and aggressive use of regional anesthesia and local anesthetics placed around the nerves of the central nervous system.
“ERAS pathways are achieving remarkable results that are benefiting our patients in the most fundamental ways. I am grateful to Drs. Sandberg, McEvoy and Geiger, along with many others, who are championing these efforts,” said C. Wright Pinson, MBA, MD, Deputy Chief Executive Officer and Chief Health System Officer for VUMC. “The work to create additional pathways is yet another example of the vitality and leadership of our surgical programs.”
For postoperative pain management, ERAS uses the principle that non-opioid medications should be used first — on a scheduled basis — and should be discontinued last, whereas opioids should be used last, taken only as needed, and discontinued first. This approach helps avoid sedation, nausea and vomiting and disruption of normal sleep patterns, shortening the patient’s route back to solid food and ambulation. (For post-op pain management, the motto is “function first, opioids last.”)
Finally, ERAS includes ongoing team evaluation of pathway compliance and patient outcomes, through data dashboards created by Analytics Consultant Brandi Cherry and a team at Enterprise Analytics.
The effort to spread ERAS to more adult service lines is led by ERAS steering committee co-chairs Matthew McEvoy, MD, professor of Anesthesiology, and Timothy Geiger, MD, MMHC, associate professor of Surgery and chief of the Division of General Surgery.
“One of the keys to success,” Geiger said, “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.”
McEvoy adds, “It only works as a partnership, where the key stakeholders get together, decide upon the components of the pathway and how they can be delivered in a high-reliability fashion, then agree who owns which steps of the process — and nursing, pharmacy and the rest of the care team all have very important parts in that.”
Jennifer Jayaram, MSN, ERAS program coordinator on the adult side, boiled down the typical ERAS pathway development process as a review of the current clinical pathway and current outcomes, a review of literature supporting best clinical practice, and discussions and agreement on what may need to change to accomplish better patient outcomes.
“Then several workgroups meet separately to build eStar enhancements like electronic order sets,” Jayaram said, “and to build and validate metric queries to ensure accurate data capture. We expect that the pathway launch date is really just the half-way point in a cycle of continuous improvement.”
Andrew Franklin, MD, MBA, associate professor of Pediatric Anesthesiology, leads the Pediatric Pain Management Service and is the immediate past president of ERAS Pediatrics, a component of the international ERAS Society.
Use of ERAS in the U.S. is apparently far more common in adult surgery, and according to Franklin, Monroe Carell is among only a handful of U.S. pediatric hospitals to have adopted ERAS pathways across multiple service lines.
“As we introduce new pediatric patients to one of our ERAS pathways,” Franklin said, “it seems once a week a parent will say to us, ‘yes, we heard about this aspect of your program — through Instagram, through Twitter, from other parents of your patients — and part of the reason that we’re having our operation done at Monroe Carell is this enhanced recovery approach.’”
Development of the new pathway for total joint replacement was led by orthopedic surgeons Ryan Martin, MD, and Gregory Polkowski II, MD, and anesthesiologists Vikram Bansal, MD, and Rajnish Gupta, MD, with collaboration of staff members from Nursing, Enterprise Analytics, HealthIT and the Project Management Office, as well as from advance practice providers from the departments of Surgery, Anesthesiology and Perioperative Services.
