by Paul Govern
Using an approach known as enhanced recovery after surgery, or ERAS, a group of adult and pediatric surgical service lines at Vanderbilt University Medical Center has in recent years reported shorter hospital stays, fewer complications and reduced opioid usage while maintaining exacting standards for postoperative pain control.
VUMC’s latest ERAS clinical pathway was launched last month by the musculoskeletal oncology service at Vanderbilt University Hospital (VUH). The new pathway is for adult patients receiving surgery to remove extremity soft tissue sarcomas, which are cancerous tumors that can arise in muscles, tendons, fat, blood vessels and other connective tissue.
“Coupled with outcomes analysis and continuous process improvement, our new recovery pathway for soft tissue sarcoma — emphasizing nutritional supplementation, nonopioid analgesia and rapid mobilization — is an important part of our ongoing effort to assure the very best perioperative experience for our patients,” said Joshua Lawrenz, MD, assistant professor of Orthopaedic Surgery, who led development of the new pathway with anesthesiologists Danial Shams, MD, and Kaylyn Sachse, MD.
So far at VUMC, seven ERAS clinical pathways have been adopted for major surgical procedures on the adult side, and another seven have been adopted on the pediatric side.
Warren Sandberg, MD, PhD, chair of the Department of Anesthesiology and chief of staff at VUH, serves as executive sponsor of the ERAS program at VUMC. After adoption this August of an ERAS pathway for total joint replacement, Sandberg said, “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.”
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 and local anesthesia.
For postoperative pain management, ERAS uses the principle that nonopioid 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 sleep, shortening the patient’s route back to solid food and ambulation.
Finally, with assistance from Enterprise Analytics, ERAS includes ongoing team evaluation of pathway compliance and patient outcomes.
Jennifer Jayaram, MSN, assistant in Anesthesiology, coordinates the ERAS program on the adult side at VUMC. The new clinical pathway for soft tissue sarcoma surgery was developed with collaboration from Nursing, Rehabilitation Services, Nursing Education and Professional Development, Patient Education, Enterprise Analytics, Pain Management and Health IT.
