Enhanced recovery programs improve oncologic surgical care

The increased focus on helping surgical oncology patients recover from surgery sooner and more completely has implications beyond the operating room.

Enhanced recovery programs (ERPs) promote standardized, multidisciplinary care throughout the perioperative course to improve patient outcomes, rather than focusing on surgical technique. The concept originated in Europe more than 20 years ago and has steadily gained momentum at cancer centers around the world, as the body of evidence has grown to support the ERP approach.

A variety of studies have found that ERPs are associated with reduced time in the intensive care unit, shorter hospital stays, fewer complications, cost savings and reduced opioid use after discharge, among other positive patient outcomes. Care is both more efficient and provides a better overall experience for the patient.

"Oncologic Surgical Care Using an Enhanced Recovery Approach" describes potential components of multimodal, evidence-based perioperative programs designed to improve a surgical oncology patient's functional recovery after surgery. The article is published in AACN Advanced Critical Care.

Co-author Lynne Brophy, MSN, PMGT-BC, APRN-CNS, AOCN, is breast oncology clinical nurse specialist, The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard M. Solove Research Institute, Columbus.

"The growing acceptance of the enhanced recovery approach has created a paradigm shift in our care of surgical oncology patients," she said. "Nurses working in acute and critical care should be aware of the approach and prepared to implement whatever aspects of enhanced recovery are adopted at their institution."

The enhanced recovery approach to cancer surgery begins with prehabilitation to identify a patient's impairments and opportunities to improve their strength, endurance, nutrition and organ function before surgery. Tobacco cessation is a frequent component of preoperative counseling, and alcohol consumption is also assessed. Psychological counseling to reduce anxiety may be a component of an ERP.

In addition to prehabilitation, ERPs include a preoperative evaluation, with a thorough medical history, head-to-toe physical examination, testing and medication management. Frailty assessment may be added as a component of determining surgical risk.

ERPs increasingly include an assessment of social determinants of care or the patient's social vulnerability, offering clinicians the opportunity to tailor care to ensure a better surgical outcome.

During the 24-hour period prior to surgery, ERPs often take a different approach to the traditional nothing-by-mouth guidance; instead administering carbohydrate-loading clear liquids to prepare the body for the stress of surgery.

ERPs also address the patient's time in the operating room and immediate postoperative care in post-anesthesia care units (PACUs).

After a patient leaves the PACU, enhanced recovery efforts go beyond standard postoperative care to include ambulation on the night of surgery, early removal of the urinary catheter and use of gum or early feeding to encourage bowel function return.

Because of the shortened length of stay in the hospital, family and patient education regarding post-discharge care and medication regimens should begin as soon as possible during hospitalization. Follow-up calls after discharge, to check on progress, and telehealth visits can reinforce the information, in addition to post-discharge appointments with providers.

The article is part of a symposium series in the journal's fall 2021 issue about organ-specific solid tumors and surgical oncology. Other articles address:

• Complex oncologic surgeries and implications for critical care nurses
• Oncologic emergencies
• Novel therapies in oncology
• Critically ill patients with advanced cancer
• Geriatric implications of surgical oncology