E Letters to the Editor
ERAS: Enhancing Recovery One Evidence-Based Step at a Time To the Editor
W
e congratulate Miller et al.1 not only for demonstrating that enhanced recovery after surgery (ERAS) pathways work to reduce complications, hospital length of stay (HLOS), and readmissions but also for demonstrating the important role played by anesthesiologists in coordinating care of patients throughout the entire perioperative period. We do, however, have a number of points to highlight. First, rather than “protocol” (Table 6), which implies that all steps must be followed to achieve the stated outcomes, we suggest “pathway” as a far better term. As suggested by the authors, the beneficial clinical or financial impact of any one step in this protocol is not known, and thus, recommending that all of these steps be followed, even if in line with currently published ERAS guidelines2 is flawed. To this point, the demonstrated reduction in catheter-associated urinary tract infection rates is easily explained, not by adherence to the entire protocol, but by the early removal of the Foley catheter.3 Second, we agree that intraoperative fluid management is critical to avoiding fluid overload and its associated complications, and that appropriate perioperative analgesia is an important factor associated with postoperative ileus— the principal factor influencing HLOS after colon surgery. However, we are not convinced that these factors represent the “key” to “laying the groundwork” for early ambulation and/or alimentation. For example, we recently demonstrated that the implementation of a 2-driver pathway including early ambulation (3 times daily) and alimentation (200 mL minimal) on postoperative day 1 after elective small or large bowel surgery was associated with a 28.8% reduction in overall complications and a 17.5% reduction in readmissions.4 Third, value is an increasingly important aspect of health care delivery today, and Miller et al. have convincingly highlighted the effect of length of stay on cost. However, we ask whether the authors included the initial cost of the equipment used in their financial analysis? In other words, a facility or system must take into account the cost avoided by implementation (reduced complications and HLOS) versus the cost of implementation (technology-associated cost [capital and disposables], education and communication plans, information technology, and data analysis) relative to the current availability of technology within the institution as well as the total number of patients benefitting. A facility with many qualifying cases may clearly benefit financially, whereas the one with a small number of qualifying cases may not. Fourth, and regarding simplicity and generalizability, the authors advocate 22 specific and equally weighted interventions. This works when the 3 surgeons who developed the protocol are the only ones required to use it. But what happens when it is implemented across a large number of surgeons in a diverse health care system? What we discovered is that when the structure (context) is complex, the process must be simplified to achieve the desired outcome.4,5 Fifth and perhaps the most critical, although we agree that “enhanced recovery programs should be considered as the new standard of care for patients undergoing elective colorectal resection,” we also suggest that to reach the threshold
256 www.anesthesia-analgesia.org
defining a standard of care, each of the clinical steps must be supported by evidence-based data. Clearly, the Enhanced Recovery Group at Duke has been successfully implementing this 22-step ERAS protocol. However, further study to identify which of these steps clearly impacts outcome, both clinical and financial, is mandatory before the entire protocol (pathway) can be accepted as standard of care. Joshua A. Bloomstone, MD, CSSGB, CLS Perioperative Clinical Consensus Group Banner Health Phoenix, Arizona Department of Anesthesiology and Perioperative Medicine Banner Thunderbird Medical Center Glendale, Arizona Valley Anesthesiology Consultants, Ltd. Phoenix, Arizona [email protected] Terry Loftus, MD, MBA, FACS Surgical Services and Clinical Resources Banner Health Phoenix, Arizona Ryan Hutchison, MBA, BSIE Process Engineering Banner Health Phoenix, Arizona References 1. Miller TE, Thacker JK, White WD, Mantyh C, Migaly J, Jin J, Roche AM, Eisenstein EL, Edwards R, Anstrom KJ, Moon RE, Gan TJ; Enhanced Recovery Study Group. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61 2. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144:961–9 3. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010;31:319–26 4. Loftus T, Stelton S, Efaw BW, Bloomstone J. A system wide care pathway for enhanced recovery after bowel surgery focusing on alimentation and ambulation reduces complications and readmissions. J. Healthcare Quality 2014 [Epub ahead of print] 5. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:Suppl:166–206 DOI: 10.1213/ANE.0000000000000503
In Response We agree with Bloomstone et al.1 that early ambulation and alimentation after surgery are the pivotal changes in care that have occurred over the last 10 years. Enhanced recovery after surgery (ERAS) protocols aim to standardize perioperative care to enable early feeding and mobilization. There are a number of components to our ERAS protocol. However, we do not believe the protocol is complex. In fact, we have found that the 2 components that Bloomstone et al.1 suggest should be fundamental components of an ERAS program—early mobilization and feeding—are some of the most challenging to implement. Changing the postoperative
anesthesia & analgesia
ERAS: Enhancing Recovery One Evidence-Based Step at a Time To the Editor
W
e congratulate Miller et al.1 not only for demonstrating that enhanced recovery after surgery (ERAS) pathways work to reduce complications, hospital length of stay (HLOS), and readmissions but also for demonstrating the important role played by anesthesiologists in coordinating care of patients throughout the entire perioperative period. We do, however, have a number of points to highlight. First, rather than “protocol” (Table 6), which implies that all steps must be followed to achieve the stated outcomes, we suggest “pathway” as a far better term. As suggested by the authors, the beneficial clinical or financial impact of any one step in this protocol is not known, and thus, recommending that all of these steps be followed, even if in line with currently published ERAS guidelines2 is flawed. To this point, the demonstrated reduction in catheter-associated urinary tract infection rates is easily explained, not by adherence to the entire protocol, but by the early removal of the Foley catheter.3 Second, we agree that intraoperative fluid management is critical to avoiding fluid overload and its associated complications, and that appropriate perioperative analgesia is an important factor associated with postoperative ileus— the principal factor influencing HLOS after colon surgery. However, we are not convinced that these factors represent the “key” to “laying the groundwork” for early ambulation and/or alimentation. For example, we recently demonstrated that the implementation of a 2-driver pathway including early ambulation (3 times daily) and alimentation (200 mL minimal) on postoperative day 1 after elective small or large bowel surgery was associated with a 28.8% reduction in overall complications and a 17.5% reduction in readmissions.4 Third, value is an increasingly important aspect of health care delivery today, and Miller et al. have convincingly highlighted the effect of length of stay on cost. However, we ask whether the authors included the initial cost of the equipment used in their financial analysis? In other words, a facility or system must take into account the cost avoided by implementation (reduced complications and HLOS) versus the cost of implementation (technology-associated cost [capital and disposables], education and communication plans, information technology, and data analysis) relative to the current availability of technology within the institution as well as the total number of patients benefitting. A facility with many qualifying cases may clearly benefit financially, whereas the one with a small number of qualifying cases may not. Fourth, and regarding simplicity and generalizability, the authors advocate 22 specific and equally weighted interventions. This works when the 3 surgeons who developed the protocol are the only ones required to use it. But what happens when it is implemented across a large number of surgeons in a diverse health care system? What we discovered is that when the structure (context) is complex, the process must be simplified to achieve the desired outcome.4,5 Fifth and perhaps the most critical, although we agree that “enhanced recovery programs should be considered as the new standard of care for patients undergoing elective colorectal resection,” we also suggest that to reach the threshold
256 www.anesthesia-analgesia.org
defining a standard of care, each of the clinical steps must be supported by evidence-based data. Clearly, the Enhanced Recovery Group at Duke has been successfully implementing this 22-step ERAS protocol. However, further study to identify which of these steps clearly impacts outcome, both clinical and financial, is mandatory before the entire protocol (pathway) can be accepted as standard of care. Joshua A. Bloomstone, MD, CSSGB, CLS Perioperative Clinical Consensus Group Banner Health Phoenix, Arizona Department of Anesthesiology and Perioperative Medicine Banner Thunderbird Medical Center Glendale, Arizona Valley Anesthesiology Consultants, Ltd. Phoenix, Arizona [email protected] Terry Loftus, MD, MBA, FACS Surgical Services and Clinical Resources Banner Health Phoenix, Arizona Ryan Hutchison, MBA, BSIE Process Engineering Banner Health Phoenix, Arizona References 1. Miller TE, Thacker JK, White WD, Mantyh C, Migaly J, Jin J, Roche AM, Eisenstein EL, Edwards R, Anstrom KJ, Moon RE, Gan TJ; Enhanced Recovery Study Group. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61 2. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144:961–9 3. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010;31:319–26 4. Loftus T, Stelton S, Efaw BW, Bloomstone J. A system wide care pathway for enhanced recovery after bowel surgery focusing on alimentation and ambulation reduces complications and readmissions. J. Healthcare Quality 2014 [Epub ahead of print] 5. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:Suppl:166–206 DOI: 10.1213/ANE.0000000000000503
In Response We agree with Bloomstone et al.1 that early ambulation and alimentation after surgery are the pivotal changes in care that have occurred over the last 10 years. Enhanced recovery after surgery (ERAS) protocols aim to standardize perioperative care to enable early feeding and mobilization. There are a number of components to our ERAS protocol. However, we do not believe the protocol is complex. In fact, we have found that the 2 components that Bloomstone et al.1 suggest should be fundamental components of an ERAS program—early mobilization and feeding—are some of the most challenging to implement. Changing the postoperative
anesthesia & analgesia
