Enhanced Recovery After Surgery (ERAS) is a multimodal approach that focuses on optimizing nutrition, early mobilization, and pain management while minimizing narcotic usage. In colorectal and general surgery, ERAS has led to improved outcomes, reduced length of stay (LOS), and lower hospital costs.*† Less has been published about implementing ERAS in the field of orthopaedic surgery or in geriatric patient populations; however, additional studies such as this one are looking to address the lack of literature in these groups of patients.
Kaiser Westside Medical Center (KWMC), Hillsboro, OR, had a LOS for arthroplasty patients that was significantly longer than that of Kaiser Permanente hospitals in other regions. As more patients joined our health plan, the volume of total joint replacements at the hospital increased, which led to a bottleneck in our arthroplasty service line. A team was assembled to work on implementing ERAS principles in the care of total hip and total knee replacement patients. Until this point, no surgical services at Kaiser Permanente Northwest had implemented ERAS protocols.
Standardizing ERAS principles required a culture shift that included familiarizing staff with core concepts (minimizing opioids, early ambulation, optimized nutrition), as well as educating patients about expectations of early discharge and pain management.
Certain elements of ERAS already were in place for arthroplasty patients, such as mobilization on the day of the operation and a component of multimodal pain management. However, prior to the rollout in October 2017, no clearly defined process for all joint replacement patients had been implemented. Other elements were added to the arthroplasty bundle, including a preoperative carbohydrate drink two hours before arrival (approximately four hours before scheduled operation); avoiding routine use of urinary catheters; short-acting spinal anesthesia; postoperative mobilization within 12 hours; resumption of regular diet within 12 hours; maintenance of euvolemia (minimize intraoperative fluid volume and avoiding hemodilution); and standardized postoperative nausea and vomiting prophylaxis. In addition, the orthopaedic service lacked a consistent method of documentation to identify improvements and gaps. Standardizing ERAS principles required a culture shift that included familiarizing staff with core concepts (minimizing opioids, early ambulation, optimized nutrition), as well as educating patients about expectations of early discharge and pain management.
Putting the quality improvement activity in place
KWMC is a community hospital located west of Portland. It is one of two hospitals owned by Kaiser Permanente Northwest. The service area comprises the Portland metropolitan area (including Vancouver, WA), extending south to Salem and Eugene. KWMC has 126 licensed beds, approximately 675 physicians, and more than 1,000 employees. The hospital opened in 2013 and prioritizes high-reliability organization principles in patient care. It participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Multispecialty Option, abstracting primarily orthopaedics, general surgery, and urology.
The highest volume service is orthopaedic surgery, specifically hip and knee replacement. In 2017, 2,045 total joint operations were performed at KWMC, 391 of which involved patients who were 75 years old or older. In 2018, that number increased 21 percent, bringing the annual volume to 2,496 (521 of these patients were age 75 older), making KWMC the busiest joint replacement center in the state of Oregon.
At KWMC, our total joint patients were the first population in the region for which the ERAS multimodal care pathway was implemented. It was the first step of a larger regional project to rollout ERAS across all surgical specialties. Launching this initiative required executive-level sponsorship and collaboration between physicians, nurses, and operational leaders.
This region-wide initiative provided the executive-level support needed to implement culture changes specific to KWMC arthroplasty patients. We were able to identify appropriate ERAS process measures with the input of departmental leaders and partner with our change champions in each phase of care (orthopaedic clinic, preoperative medicine clinic, preoperative holding area, operating room, postanesthesia care unit, surgical floor, and physical therapy) to facilitate meaningful discussions regarding opportunities and potential barriers. We also were able to leverage our ACS NSQIP data set for our outcome measures. This project required highly collaborative relationships between multidisciplinary workgroups throughout the hospital.
Key steps involved in the planning and development of the ERAS program were as follows:
- Determine goals for the ERAS program: reduce LOS without concomitant increase in readmissions, achieve harm-free surgery (no surgical site infection, wound dehiscence, pneumonia, sepsis, unplanned intubation, venous thromboembolism, acute renal failure or progressive renal insufficiency, urinary tract infection, cerebrovascular accident, myocardial infarction, cardiac arrest, transfusions)
- Identify stakeholders and subject matter experts
- Develop dashboard team responsible for data validity and integrity for both process and outcome measures, using NSQIP data for outcomes measures
- Engage operational and clinical leaders in measuring discrete steps in the process (that is, early ambulation, last liquids, multimodal analgesia, preoperative carbohydrate drink, avoiding use of urinary catheters)
- Identify all patient touch points to ensure consistent ERAS messaging throughout their care process
- Collaborate with outpatient clinic, the preoperative medicine clinic, preoperative total joint class, surgical prep area (preoperative), intraoperative, postanesthesia care unit, hospital ward, as well as physical and occupational therapy
The planned changes largely came from Kaiser Permanente Northern California’s experience with using ERAS for elective colorectal resection and emergency hip fracture repair across 20 medical centers in their region. They published their findings from 8,770 cases, which demonstrated earlier and greater ambulation, improved nutrition, and reduced opioid use, as well as lower readmission and overall complication rates. Colorectal patients saw a decrease of in-hospital mortality, and hip fracture patients saw increased rates of home discharge. This study showed that rapid, large-scale implementation of a multidisciplinary ERAS program was feasible and cost-effective in improving surgical outcomes.‡
We developed the ERAS protocol for arthroplasty patients in September 2017, and implementation of new protocols began in October 2017. ERAS education materials for both staff and patients were distributed. In January 2018, we began implementation of home recovery (also known as same-day discharge, outpatient arthroplasty). We piloted the home recovery protocol among four surgeons, who closely monitored their patient outcomes. In the second and third quarter of 2018, the remaining surgeons adopted this practice after seeing the early adopters’ initial success. In the second quarter of 2018, we also developed an ERAS rounding tool for both staff and patients. Staff education and rounding on ERAS core principles occurred quarterly, with operational leaders taking responsibility for rounding on staff, supported by their partners in hospital quality. Quarterly patient rounding focused on ERAS principles and experience (preoperative carbohydrate beverage, pain management expectations, avoidance of urinary catheters).
The following staff were involved in the program:
- Quality consultant
- Surgeon champion
- Anesthesia lead
- Hospitalist co-management program
- Nursing leadership: preoperative, intraoperative, postoperative, hospital floor
- Nurse educators from perioperative and hospital floor
- NSQIP surgical case reviewer
- Data analytics
- Physical therapy
No additional costs were incurred beyond normal hospital operations to implement and maintain the quality improvement (QI) program, and no additional funding sources were necessary to implement this program.
This was a retrospective study aimed at determining the effects of ERAS on geriatric arthroplasty patients ages 75 and older. Patients were divided into two groups: pre-ERAS and post-ERAS. Each group consisted of 12 months of geriatric arthroplasty patients: October 1, 2016, to September 30, 2017, for pre-ERAS patients, and October 1, 2017, to September 30, 2018, for post-ERAS. There were 276 patients in the post-ERAS (experimental) group and 253 in the pre-ERAS (control) group.
Table 1 shows that, despite having a similar breakdown of comorbidities as measured by American Society of Anesthesiologists class, after implementation of the ERAS protocol, a significantly greater proportion of patients had a LOS of only one day (64.5 percent versus 45.5 percent; p < 0.0001) (see Figure 1). Similarly, after ERAS, fewer patients had a LOS of two days (16.0 percent versus 32.8 percent, p < 0.0001) or three or more days (13.8 percent versus 21 percent, p = 0.03). Few patients older than the age of 75 participated in the home recovery program, and no significant difference was seen in the proportion being discharged home or to a skilled nursing facility (see Figure 2). Similarly, no difference in unplanned returns to the operating room or readmissions was demonstrated.
Table 1. Effects of ERAS on arthroplasty patients ages 75 and older
Figure 1. LOS in total joint patients ages 75 and older before and after ERAS
Figure 2. Discharge disposition in total joint patients 75 years and older before and after ERAS
All data were analyzed using R statistics package version 3.5.3 (R Foundation for Statistical Computing, Vienna, Austria). When comparing the proportions between groups, a t-test for proportions was used with an alpha of 0.05.
The setbacks for implementing this QI activity included the following:
- Delays in dashboard build-out from other high priorities at the regional level
- Staffing in postanesthesia care unit (PACU) for home recovery patients: procured additional full-time equivalents (FTEs) from leadership for PACU nurses
- Identification of home recovery patients: surgeon reluctance to participate because of perceived increased workload from earlier discharge, and, related to that, the potential need for more opioid refills offered another barrier to identifying home recovery patients
- Patient and family preference to stay longer, so it is necessary to educate them on the benefits of earlier discharge, be it same day or postoperative day one
Solutions for overcoming barriers to implementation included the following:
- Educate staff and surgeons about the benefits of ERAS
- New scripting of preoperative patient education class; inform patients that discharge on postoperative day zero is the norm for healthy patients
- Revisions in original QI plan due to limitations encountered during the process
- Manage expectations, changing deadlines
- Focus on patient collaboration to ensure successful change management
- Modify protocol as needed: switched from intravenous to oral acetaminophen (because of cost issues), did not implement postoperative chewing gum protocol (used in Kaiser Northern California)
No money was directly invested in implementing the ERAS pathway for geriatric arthroplasty patients. Health plan leadership allocated 0.25 FTE of our perioperative regional QI consultant, who had the assistance of a project manager and a senior administrator to help achieve this goal. Further studies are under way to estimate direct reductions in cost from reduced LOS.
The success of a large-scale project like ERAS is completely dependent upon data integrity, accountability for meeting deadlines, and interdepartmental communication.
Many variables must be considered prior to implementing a system-wide initiative like ERAS to ensure success. Early on in the process, research best practices to incorporate and identify organizational leaders to obtain buy-in. Assemble a multidisciplinary team including change champions, clinical subject matter experts, data specialists, frontline champions, and both clinical and nonclinical hospital leadership. Additional lessons learned include the following:
- Achieve consensus on measurable objective rooted in best practice
- Establish reasonable deadlines with accountability
- Identify change champions—subject matter experts who are respected and can solicit buy-in from peers and their groups of influence
- Obtain support of executive leadership (both physicians and health plan operations)
- Reach out to other hospitals that have implemented similar programs—solicit recommendations and shortcomings
- Identify unit-based frontline champions for specific metrics
- Standardize message regarding the change to both staff and patients
- Establish clear budget and strategy for data analytics and marketing
The success of a large-scale project like ERAS is completely dependent upon data integrity, accountability for meeting deadlines, and interdepartmental communication. With this in mind, it is recommended that other institutions engage in the following:
- Monitor data through smaller monthly dashboard meetings
- Present leadership reports at quarterly meeting regarding progress on arena-specific action items
- Conduct focused ERAS rounding with staff and patients
- Share the patient voice and ERAS experience
- Solicit and share staff feedback
Clear and consistent communication is required for success. Communication is facilitated through meaningful relationships across the care continuum and by the use of web-based collaborative platforms.
QI program leaders also should consider the following when implementing a system-wide initiative such as ERAS:
- Develop patient education videos on what ERAS is and why it is important for their successful recovery
- Implement a web-based collaborative platform such as Microsoft SharePoint for the team to access current data and resources
- Stay flexible, as priorities may change
- Anticipate delays
- Develop meaningful relationships across multiple departments to facilitate success
Implementing ERAS is a safe multimodal approach when caring for geriatric total hip and knee arthroplasty patients. In our QI initiative, 66 percent of patients had a LOS of zero or one days compared with 46 percent before the intervention. We did not see a difference in the overall complication rate, readmission rate, or reoperation rate.
There are multiple elements to consider before implementing a program such as ERAS to ensure meaningful and lasting change occurs. The role of multidisciplinary teams is crucial, and much of the success of the program hinges on unwavering collaboration. Additionally, maintain clear and consistent communication with accountability to deadlines, which helps prioritize and sustain the patient-centered approach. Lastly, get buy-in at all levels within the hospital, from senior leadership to frontline staff.
*Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477.
†Ljungqvist O, Scott M, Fearon KC. Enhance recovery after surgery: A review. JAMA Surg. 2017;152(3):292-298.
‡Liu VX, Rosas E, Hwang J, et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg. 2017;152(7):e171032.