Research highlights benefits from enhanced recovery after surgery program

Colorectal and bariatric surgery patients benefited from an enhanced recovery after surgery (ERAS) program, leaving the hospital sooner and requiring fewer opioids to control pain, according to new research presented at the American Society of Anesthesiologists PRACTICE MANAGEMENT 2018 meeting. The paper, and other research being presented, highlight how physician anesthesiologists are leading the way in improving the entire surgical experience for patients - from the decision to have surgery through discharge, recovery and beyond - to help enhance outcomes and reduce costs.

- ERAS program shortens hospital stay: ERAS programs use a variety of methods to ease the effects of surgery and facilitate early patient recovery. They are an important aspect of the Perioperative Surgical Home (PSH), in which a patient's surgical experience is fully coordinated and treated as a continuum of care. Providence Anesthesiology Associates in Charlotte, North Carolina compared the results of 621 patients undergoing colorectal or bariatric surgery who participated in an ERAS program to historical data prior to the implementation of the ERAS. Colorectal patients in the ERAS group stayed in the hospital 2.05 days compared to 4.5 days for non-ERAS patients. Bariatric patients in the ERAS group stayed .95 days vs. 2.15 for non-ERAS patients. Patients in both ERAS groups used significantly fewer opioids after surgery than those in the non-ERAS groups and had shorter stays in the post-anesthesia care unit (PACU). Costs were reduced by 20 percent per case among the colorectal surgery ERAS patients compared to non-ERAS patients. The ERAS program included the following elements: preoperative patient education beginning in the surgeon's office and more extensively at the preadmission testing clinic, carb loading the night before surgery and three hours before the procedure, administering preoperative Alvimopan to restore bowel function after surgery, and employing pain methods other than opioids including transversus abdominal plane blocks to reduce or eliminate opioids after surgery. "Our results demonstrate the benefits of physician anesthesiologists and surgeons working collaboratively to lower costs and improve our patients' outcomes," said Vicki Morton, DNP, MSN, AGNP-BC, director of clinical and quality outcomes at Providence Anesthesiology Associates.

- Pre-surgical consultation with pain medicine specialist eases anxiety for certain patients: Consultation with a pain medicine specialist before surgery may help chronic pain patients and those with substance abuse problems feel less anxious about their post-surgical pain management, suggests a University of Pittsburgh Medical Center study. The study includes 12 spinal fusion patients who consulted with a physician anesthesiologist pain specialist before surgery. The patients either had a history of substance abuse and were on outpatient addiction maintenance therapy, had a history of high opioid use before surgery, or specifically requested a pain clinic consultation. Each met with the physician anesthesiologist, who consulted with the surgeon and patient to formulate a plan for the most appropriate pain management after surgery. That plan was shared with the patient's primary care or pain medicine specialist. The patients reported they were less stressed about surgery, less anxious during the perioperative period and more satisfied with pain control after surgery. The researchers believe this method may help decrease hospital length of stay which could lower costs, as well as improve patient satisfaction. "Some of these patients refuse to leave the hospital after surgery until they feel they are on the right pain regimen, and therefore stay longer," said Trent Emerick, M.D., M.B.A., director of quality improvement and innovation, Chronic Pain Division, in the Department of Anesthesiology at the University of Pittsburgh Medical Center. "We believe that by working to address these issues before surgery we can decrease costs while improving satisfaction."

- Assessing patients for frailty before surgery could prevent bad outcomes: Evaluating older patients for frailty before they have surgery may improve outcomes and should be part of standard anesthesia presurgical screening, say researchers from Beaumont Health, Royal Oak, Michigan. The researchers suggest using a short questionnaire to screen for frailty, such as Fried's Frailty criteria, since frailty can be an independent predictor of postoperative complications. Patients who are identified as frail prior to surgery should be optimized before undergoing the procedure through nutrition, strength training, improving balance and mobility, counseling and medications, the researchers note. "A healthy 80-year-old is not the same as a healthy 30-year-old, but they often are assessed for surgery in the same way," said Laura Lepczyk, D.O., a clinical anesthesia resident at Beaumont Health. "Further, some 80-year-olds are strong and vibrant and others are weak. A frailty assessment before surgery can help providers determine whether a patient is strong enough for surgery and if not, help determine if the patient's health can be optimized to enable the procedure."

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