E EDITORIAL
Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Maxime Cannesson, MD, PhD, and Zeev Kain, MD, MBA
I
n this issue of Anesthesia & Analgesia, investigators from the Department of Anesthesiology at Duke University present 2 articles focusing on the topic of enhanced recovery after surgery (ERAS). The first article by Miller et al.1 shows that implementation of an ERAS protocol in patients undergoing colorectal surgery leads to a decreased length of stay (LOS) in the hospital. The second article by Waldron et al.2 demonstrates that intraoperative fluid management strategies based on the concept of perioperative goal-directed therapy can be facilitated by using a noninvasive and operator-independent cardiac output monitoring system (NICOM, Cheetah Medical, Vancouver, WA). Because intraoperative goal-directed fluid management is considered as one of the key components of ERAS,3,4 this finding is significant since it may facilitate implementation of this approach in routine clinical practice.5,6 These investigators should be congratulated on helping our community to learn what is the value associated with the adoption of ERAS to academic settings in the United States. Kehlet,7 a renowned colorectal surgeon from Copenhagen University Hospital in Denmark, was the first to describe the concept of ERAS in the 1990s. The ERAS protocol consists of about 20 specific clinical practices such as reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, and others. When originally introduced, the ERAS protocol was used specifically for patients undergoing colorectal surgery but subsequently the use of this protocol has expanded to other surgical subspecialties.8,9 To date, ERAS protocols have been embraced in several European and Canadian institutions and have already been tested in multiple large-scale health care systems such as the National Health Services in the United Kingdom for colorectal surgery.5 ERAS has been shown to decrease the incidence of postoperative complications and decrease the LOS in the hospital without the use of new expensive equipment.10 The studies by Miller et al.1 and Waldron et al.2 presented in this
From the Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, California. Accepted for publication January 24, 2014. Funding: Departmental funding. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Maxime Cannesson, MD, PhD, Department of Anesthesiology & Perioperative Care, UC Irvine, 101 S City Drive, Orange, CA 92868. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000177
May 2014 • Volume 118 • Number 5
issue of Anesthesia & Analgesia suggest that similar benefits of ERAS can be reproduced in the United States. Interestingly, with the recent changes occurring in the health care system in the United States, the American Society of Anesthesiologists has endorsed the concept of the Perioperative Surgical Home (PSH) and has recommended including it as part of affordable care organizations and hospitals.11 It is widely recognized that our current perioperative system in the United States is costly, fragmented, and often driven by focus on hospital reimbursement as well as culture and tradition rather than on quality and service.12,13 The health care system in the United States is moving from a fee-for-service model (“pay for volume”) to a bundled payment model (“pay for value”) for common elective procedures, and this may further incentivize organizations to improve quality and service while lowering the costs. Because it has been shown that most perioperative complications are related to a lack of coordination of care and a wide variability in the way care is delivered, a model such as the PSH is much needed.14 The PSH is a practice model that emphasizes superior coordination of care from the minute a decision to operate is made until 30 days after discharge. Within that time period, this practice model calls for the implementation of a series of evidencebased preoperative, intraoperative, and postoperative protocols that will be applied with minimal variability across a single institution. These clinical protocols will vary based on surgical services and will be tailored to the local environment. It is hoped that implementation of the PSH will result in improved outcomes such as reduction in LOS and cost, better quality as assessed by the Surgical Care Improvement Project and National Surgical Quality Improvement Program measures, and improved satisfaction scores. There are minimal data, however, to support this assertion today.15 The current issue of Anesthesia & Analgesia includes a series of articles on both ERAS and the PSH, and one may wonder what is the difference between these 2 practice models? Although both these models have similar goals to improve clinical care and service and reduce cost, they vary in their approach. ERAS, as described previously, is a well-defined clinical protocol that relies on very specific items that are to be used on each implementation. The PSH is a much larger conceptual framework that includes coordination of care from the minute the decision to operate was made until 30 days after discharge. This improvement in coordination of care is likely to require the use of methods such as LEAN Six Sigma methodology and other management engineering methods and www.anesthesia-analgesia.org
901
E Editorial active participation of all stakeholders that are part of the perioperative environment. PSH also calls for the use of many specific protocols for optimization of patients before surgery (e.g., delirium prevention and hemoglobin optimization), intraoperative management (e.g., anesthesia and nursing), and immediate postoperative management (e.g., nausea and vomiting). It also includes protocols for management of patients on the surgical wards (e.g., ambulation) and on discharge home (e.g., rehabilitation). Although ERAS protocols will mostly look the same whether they are implemented in the United Kingdom or in the United States, PSH protocols will vary significantly across institutions, as they will depend on the surgical services and on the local perioperative environment. Indeed, it is very likely that many of the PSH models will include a large number of the clinical items that are part of ERAS as they are relevant to the specific surgical episode and specific hospital. We submit that the future of anesthesiology and perioperative medicine must rely not only on the development of new pharmacological and diagnostic modalities and treatments but also on better and more consistent implementation of evidence-based best practices. Although both ERAS and PSH have the same goals of better outcomes, better service, and lower cost, the route that these 2 methodologies are taking to achieve these goals may be different but complementary. RECUSE NOTE
Dr. Maxime Cannesson is the Section Editor for Technology, Computing, and Simulation for the Journal. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Cannesson was not involved in any way with the editorial process or decision. DISCLOSURES
Name: Maxime Cannesson, MD, PhD. Contribution: This author helped write the manuscript. Attestation: Maxime Cannesson approved the final manuscript. Conflicts of Interest: Maxime Cannesson consulted for Edwards Lifesciences, received research funding from Edwards Lifesciences, consulted for Masimo Corp., and received research funding from Masimo Corp. Name: Zeev Kain, MD, MBA. Contribution: This author helped write the manuscript. Attestation: Zeev Kain approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. REFERENCES 1. Miller T, Thacker JK, White WD, Mantyh C, Miglay J, Jin J, Roche AM, Eisenstein EL, Edwards R, Moon R, Gan TJ. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61 2. Waldron NH, Miller TE, Thacker JK, Manchester AK, White WD, Nardiello J, Elgasim MA, Moon RE, Gan TJ. A Prospective
902 www.anesthesia-analgesia.org
comparison of noninvasive cardiac output monitor versus esophageal doppler monitor for goal-directed fluid therapy in colorectal surgery patients. Anesth Analg 2014;118:966–75 3. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012;31:783–800 4. Feldheiser A, Conroy P, Bonomo T, Cox B, Garces TR, Spies C; Anaesthesia Working Group of the Enhanced Recovery After Surgery (ERAS®) Society; Enhanced Recovery After Surgery Society. Development and feasibility study of an algorithm for intraoperative goaldirected haemodynamic management in noncardiac surgery. J Int Med Res 2012;40:1227–41 5. Knott A, Pathak S, McGrath JS, Kennedy R, Horgan A, Mythen M, Carter F, Francis NK. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open 2012;2: 6. Kuper M, Gold SJ, Callow C, Quraishi T, King S, Mulreany A, Bianchi M, Conway DH. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ 2011;342:d3016 7. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–17 8. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, Kassouf W, Muller S, Baldini G, Carli F, Naesheimh T, Ytrebo L, Revhaug A, Lassen K, Knutsen T, Aarsether E, Wiklund P, Patel HR. Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced Recovery After Surgery (ERAS(®)) society recommendations. Clin Nutr 2013;32:879–87 9. Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH; Enhanced Recovery After Surgery (ERAS) Society, for Perioperative Care; European Society for Clinical Nutrition and Metabolism (ESPEN); International Association for Surgical Metabolism and Nutrition (IASMEN). Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013;37:240–58 10. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434–40 11. Available at: http://www.asahq.org/For-Members/Advocacy/ Washington-Alerts/ASA-Responds-to-Accountable-CareOrganization-Proposed-Rule.aspx. Accessed November 24, 2013 12. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513–6 13. Fry DE, Pine M, Jones BL, Meimban RJ. The impact of ineffective and inefficient care on the excess costs of elective surgical procedures. J Am Coll Surg 2011;212:779–86 14. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol 2013;13:6 15. Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr, Pittet JF; UAB Perioperative Surgical Home Group. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology 2013;119:1261–74
anesthesia & analgesia
Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Maxime Cannesson, MD, PhD, and Zeev Kain, MD, MBA
I
n this issue of Anesthesia & Analgesia, investigators from the Department of Anesthesiology at Duke University present 2 articles focusing on the topic of enhanced recovery after surgery (ERAS). The first article by Miller et al.1 shows that implementation of an ERAS protocol in patients undergoing colorectal surgery leads to a decreased length of stay (LOS) in the hospital. The second article by Waldron et al.2 demonstrates that intraoperative fluid management strategies based on the concept of perioperative goal-directed therapy can be facilitated by using a noninvasive and operator-independent cardiac output monitoring system (NICOM, Cheetah Medical, Vancouver, WA). Because intraoperative goal-directed fluid management is considered as one of the key components of ERAS,3,4 this finding is significant since it may facilitate implementation of this approach in routine clinical practice.5,6 These investigators should be congratulated on helping our community to learn what is the value associated with the adoption of ERAS to academic settings in the United States. Kehlet,7 a renowned colorectal surgeon from Copenhagen University Hospital in Denmark, was the first to describe the concept of ERAS in the 1990s. The ERAS protocol consists of about 20 specific clinical practices such as reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, and others. When originally introduced, the ERAS protocol was used specifically for patients undergoing colorectal surgery but subsequently the use of this protocol has expanded to other surgical subspecialties.8,9 To date, ERAS protocols have been embraced in several European and Canadian institutions and have already been tested in multiple large-scale health care systems such as the National Health Services in the United Kingdom for colorectal surgery.5 ERAS has been shown to decrease the incidence of postoperative complications and decrease the LOS in the hospital without the use of new expensive equipment.10 The studies by Miller et al.1 and Waldron et al.2 presented in this
From the Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, California. Accepted for publication January 24, 2014. Funding: Departmental funding. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Maxime Cannesson, MD, PhD, Department of Anesthesiology & Perioperative Care, UC Irvine, 101 S City Drive, Orange, CA 92868. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000177
May 2014 • Volume 118 • Number 5
issue of Anesthesia & Analgesia suggest that similar benefits of ERAS can be reproduced in the United States. Interestingly, with the recent changes occurring in the health care system in the United States, the American Society of Anesthesiologists has endorsed the concept of the Perioperative Surgical Home (PSH) and has recommended including it as part of affordable care organizations and hospitals.11 It is widely recognized that our current perioperative system in the United States is costly, fragmented, and often driven by focus on hospital reimbursement as well as culture and tradition rather than on quality and service.12,13 The health care system in the United States is moving from a fee-for-service model (“pay for volume”) to a bundled payment model (“pay for value”) for common elective procedures, and this may further incentivize organizations to improve quality and service while lowering the costs. Because it has been shown that most perioperative complications are related to a lack of coordination of care and a wide variability in the way care is delivered, a model such as the PSH is much needed.14 The PSH is a practice model that emphasizes superior coordination of care from the minute a decision to operate is made until 30 days after discharge. Within that time period, this practice model calls for the implementation of a series of evidencebased preoperative, intraoperative, and postoperative protocols that will be applied with minimal variability across a single institution. These clinical protocols will vary based on surgical services and will be tailored to the local environment. It is hoped that implementation of the PSH will result in improved outcomes such as reduction in LOS and cost, better quality as assessed by the Surgical Care Improvement Project and National Surgical Quality Improvement Program measures, and improved satisfaction scores. There are minimal data, however, to support this assertion today.15 The current issue of Anesthesia & Analgesia includes a series of articles on both ERAS and the PSH, and one may wonder what is the difference between these 2 practice models? Although both these models have similar goals to improve clinical care and service and reduce cost, they vary in their approach. ERAS, as described previously, is a well-defined clinical protocol that relies on very specific items that are to be used on each implementation. The PSH is a much larger conceptual framework that includes coordination of care from the minute the decision to operate was made until 30 days after discharge. This improvement in coordination of care is likely to require the use of methods such as LEAN Six Sigma methodology and other management engineering methods and www.anesthesia-analgesia.org
901
E Editorial active participation of all stakeholders that are part of the perioperative environment. PSH also calls for the use of many specific protocols for optimization of patients before surgery (e.g., delirium prevention and hemoglobin optimization), intraoperative management (e.g., anesthesia and nursing), and immediate postoperative management (e.g., nausea and vomiting). It also includes protocols for management of patients on the surgical wards (e.g., ambulation) and on discharge home (e.g., rehabilitation). Although ERAS protocols will mostly look the same whether they are implemented in the United Kingdom or in the United States, PSH protocols will vary significantly across institutions, as they will depend on the surgical services and on the local perioperative environment. Indeed, it is very likely that many of the PSH models will include a large number of the clinical items that are part of ERAS as they are relevant to the specific surgical episode and specific hospital. We submit that the future of anesthesiology and perioperative medicine must rely not only on the development of new pharmacological and diagnostic modalities and treatments but also on better and more consistent implementation of evidence-based best practices. Although both ERAS and PSH have the same goals of better outcomes, better service, and lower cost, the route that these 2 methodologies are taking to achieve these goals may be different but complementary. RECUSE NOTE
Dr. Maxime Cannesson is the Section Editor for Technology, Computing, and Simulation for the Journal. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Cannesson was not involved in any way with the editorial process or decision. DISCLOSURES
Name: Maxime Cannesson, MD, PhD. Contribution: This author helped write the manuscript. Attestation: Maxime Cannesson approved the final manuscript. Conflicts of Interest: Maxime Cannesson consulted for Edwards Lifesciences, received research funding from Edwards Lifesciences, consulted for Masimo Corp., and received research funding from Masimo Corp. Name: Zeev Kain, MD, MBA. Contribution: This author helped write the manuscript. Attestation: Zeev Kain approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. REFERENCES 1. Miller T, Thacker JK, White WD, Mantyh C, Miglay J, Jin J, Roche AM, Eisenstein EL, Edwards R, Moon R, Gan TJ. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61 2. Waldron NH, Miller TE, Thacker JK, Manchester AK, White WD, Nardiello J, Elgasim MA, Moon RE, Gan TJ. A Prospective
902 www.anesthesia-analgesia.org
comparison of noninvasive cardiac output monitor versus esophageal doppler monitor for goal-directed fluid therapy in colorectal surgery patients. Anesth Analg 2014;118:966–75 3. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012;31:783–800 4. Feldheiser A, Conroy P, Bonomo T, Cox B, Garces TR, Spies C; Anaesthesia Working Group of the Enhanced Recovery After Surgery (ERAS®) Society; Enhanced Recovery After Surgery Society. Development and feasibility study of an algorithm for intraoperative goaldirected haemodynamic management in noncardiac surgery. J Int Med Res 2012;40:1227–41 5. Knott A, Pathak S, McGrath JS, Kennedy R, Horgan A, Mythen M, Carter F, Francis NK. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open 2012;2: 6. Kuper M, Gold SJ, Callow C, Quraishi T, King S, Mulreany A, Bianchi M, Conway DH. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ 2011;342:d3016 7. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–17 8. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, Kassouf W, Muller S, Baldini G, Carli F, Naesheimh T, Ytrebo L, Revhaug A, Lassen K, Knutsen T, Aarsether E, Wiklund P, Patel HR. Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced Recovery After Surgery (ERAS(®)) society recommendations. Clin Nutr 2013;32:879–87 9. Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH; Enhanced Recovery After Surgery (ERAS) Society, for Perioperative Care; European Society for Clinical Nutrition and Metabolism (ESPEN); International Association for Surgical Metabolism and Nutrition (IASMEN). Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013;37:240–58 10. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434–40 11. Available at: http://www.asahq.org/For-Members/Advocacy/ Washington-Alerts/ASA-Responds-to-Accountable-CareOrganization-Proposed-Rule.aspx. Accessed November 24, 2013 12. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513–6 13. Fry DE, Pine M, Jones BL, Meimban RJ. The impact of ineffective and inefficient care on the excess costs of elective surgical procedures. J Am Coll Surg 2011;212:779–86 14. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol 2013;13:6 15. Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr, Pittet JF; UAB Perioperative Surgical Home Group. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology 2013;119:1261–74
anesthesia & analgesia
