Re­vis­ing sur­gi­cal pro­to­cols short­ens stays

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKinney

Dr. To­nia Young-Fadok was al­ways look­ing for in­no­va­tive ways she and her col­leagues at the Mayo Clinic in Phoenix could im­prove the qual­ity of care for their colon and rec­tal surgery pa­tients.

Their pa­tients’ lengths of stay and out­comes were on par with other high­per­form­ing hos­pi­tals, said YoungFadok, who chairs the di­vi­sion of colon and rec­tal surgery. Still, she thought they could do bet­ter.

Then, sev­eral years ago at a con­fer­ence in Ok­la­homa, Young-Fadok had a con­ver­sa­tion that led her to cham­pion rad­i­cal changes to sur­gi­cal prac­tices that had been stan­dard at her hos­pi­tal and most oth­ers for decades. That con­ver­sa­tion was with one of the lead­ers of the En­hanced Re­cov­ery After Surgery (ERAS) So­ci­ety, a Swe­den-based group that pro­motes ev­i­dence-based pro­to­cols to im­prove sur­gi­cal care and speed re­cov­ery.

Young-Fadok said she ini­tially was wary be­cause other sur­gi­cal stream­lin­ing ef­forts had been linked to higher read­mis­sion rates. “But I re­al­ized the ev­i­dence was there,” she said.

Cre­ated in the mid-1990s by a Dan­ish sur­geon, ERAS pro­to­cols aim to make surgery less phys­i­cally de­bil­i­tat­ing for pa­tients so they can leave the hos­pi­tal sooner. En­hanced re­cov­ery has been shown in tri­als to im­prove lengths of stay and out­comes, and curb costs. Many Euro­pean hos­pi­tals now use en­hanced re­cov­ery pro­to­cols. But only a few U.S. hos­pi­tals have im­ple­mented them.

Many key ERAS pro­to­cols turn usual prac­tices on their head. For in­stance, in­stead of fast­ing after mid­night the night be­fore surgery, pa­tients are al­lowed to have a clear drink such as ap­ple juice up to two hours be­fore the pro­ce­dure. They re­ceive far less IV flu­ids and nar­cotics dur­ing and after surgery. They are en­cour­aged to get up and walk around soon after the op­er­a­tion in­stead of ly­ing in bed for sev­eral days. And they are al­lowed solid foods on the day of surgery, pro­vided they tol­er­ate flu­ids first.

The ev­i­dence base for en­hanced re­cov­ery after surgery is strong, but “you have to change cul­ture and that’s not easy,” said Dr. Tong Joo Gan, chair of the depart­ment of anes­the­si­ol­ogy at Stony Brook (N.Y.) Medicine and founder of the new Amer­i­can So­ci­ety for En­hanced Re­cov­ery.

Be­fore join­ing Stony Brook this fall, Gan spent two decades at Duke Univer­sity, where he led the first im­ple­men­ta­tion in the U.S. of en­hanced re­cov­ery after surgery. That ef­fort, fo­cused on col­orec­tal surgery pa­tients, led to a two­day re­duc­tion in av­er­age length of stay, de­creased read­mis­sions, fewer com­pli­ca­tions and av­er­age sav­ings of $2,000 per pa­tient. Although the ev­i­dence is strong­est for col­orec­tal surg­eries, en­hanced re­cov­ery pro­to­cols are rel­e­vant for any ma­jor gen­eral ab­dom­i­nal surgery, Gan added.

Young-Fadok and her team fo­cused on col­orec­tal and gy­ne­co­log­i­cal surg­eries when they launched the en­hanced re­cov­ery pro­gram at Mayo Clinic in Ari­zona in July 2013, after six months of ex­ten­sive plan­ning and ed­u­ca­tion. As an ex­am­ple of her care­ful ground­work, when she met with the chair of anes­the­sia, Young-Fadok printed out guide­lines from the Amer­i­can So­ci­ety of Anes­the­si­ol­o­gists show­ing that clear liq­uids up to two hours be­fore surgery are now al­lowed.

Her team also ar­ranged for post-oper­a­tive pa­tient ed­u­ca­tion to take place sooner given that pa­tients would spend fewer days in the hos­pi­tal. They col­lab­o­rated with the in­for­ma­tion tech­nol­ogy depart­ment to get cus­tom­ized or­der sets in the hos­pi­tal’s elec­tronic health record. They ed­u­cated di­etary staff on the re­vised food rules. They worked with pharmacy staff on a new cock­tail of pre­op­er­a­tive pain med­i­ca­tions. And they made sure nurses knew to get pa­tients up and mov­ing soon after surgery.

The hos­pi­tal saw a 1.2 day re­duc­tion in av­er­age lengths of stay for la­paro­scopic surgery pa­tients and a 2.6 day re­duc­tion for open-surgery pa­tients, said Kripa Krishnan, op­er­a­tions ad­min­is­tra­tor for the depart­ment of surgery. Costs per case fell 7% for la­paro­scopic pro­ce­dures and 16% for open cases. “And we didn’t see any in­crease in read­mis­sions,” said Krishnan, who pre­sented the re­sults at the most re­cent meet­ing of the Amer­i­can Col­lege of Health­care Ex­ec­u­tives.

Pa­tients feel bet­ter, too, Young-Fadok said. They’re not over­loaded with flu­ids, their bowel func­tion comes back sooner and they’re not mis­er­able from so much pain med­i­ca­tion, she added.

The de­gree of up­take among the hos­pi­tal’s at­tend­ing physi­cians has var­ied, Young-Fadok said. Although the en­hanced re­cov­ery plan is the de­fault op­tion in the EHR, some physi­cians over­ride it and stick with old prac­tices. “I have some con­sid­er­ably se­nior at­tend­ings who still say, ‘Let’s not put this pa­tient on en­hanced re­cov­ery, let’s wait on a bowel move­ment,’” she said. “I have to re­mind them that th­ese prac­tices are ev­i­dence-based.”

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