By Dr. Henrik Kehlet of Denmark, the Pioneer of Enhanced Recovery After Surgery, started the idea of fast-track surgery in the 1990s. The first ERAS® Symposium was hosted in Stockholm in 2003 and has since spread worldwide. Colorectal surgery has traditionally been the primary Enhanced Recovery pathway and hosts the most information in the literature. Recently, many different surgical service lines have adopted Enhanced Recovery pathways with great success. This has led many Enhanced Recovery experts to ask the question- Should ERAS® be the standard of care for all surgery patients? I do believe that all patients deserve the best possible care, and therefore we should be adopting Enhanced Recovery as the standard of care. In this article I will review the top five reasons why.
1. Better patient outcomes
The main reason we do anything in healthcare is for the benefit of patients. There are numerous reports published in medical journals showing patients in Enhanced Recovery Programs do better than patients who receive traditional care. Here are the major outcomes that have been reported as improved with Enhanced Recovery After Surgery Programs:
-Reduced length of stay
-Reduced time to readiness for discharge
-Reduced readmissions
-Reduced post-op ileus
-Reduced peri-operative blood transfusions
-Reduced post-operative nausea
-Reduced opioid consumption intra-op and post-op
2. Increased patient satisfaction
When patients have better outcomes and recover quickly, they tend to be more satisfied with their care than patients with a prolonged complicated recovery. A 2019 literature review by Dr. Li and Dr. Jensen suggests that Colorectal Enhanced Recovery After Surgery patients have equal or higher satisfaction with their care than those receiving historical standard care. The patients on Enhanced Recovery Pathways also reported feeling that they were ready to go home sooner, experienced lower levels of fatigue and shorter time to doing activities than the patients receiving standard care. 1
3. Reduced nurses workload
Nursing workload has been shown to decrease with the implementation of an Enhanced Recovery After Surgery Program. This is hard to objectively evaluate in a research study without a validated tool. Hubner et al examined nursing workload using an objective point system called Projet de Recherche en Nursing (PRN) where 1 point represents 5 minutes of nursing time. Nurses average 48 minutes of timesavings per patient per day after implementation of an Enhanced Recovery Pathway.2 This alleviates some pressure that nurses feel when caring for multiple post-op patients and we will likely see an increase in job satisfaction within this group of nurses.
4. The opioid crisis
America has officially been amidst an opioid crisis since 2017 with over 2 million people addicted to opioids according to the US Department of Health & Human Services. Enhanced Recovery After Surgery Programs have been shown to reduce the amount opioids needed during and after surgery. Some patients go through Enhanced Recovery After Surgery without taking a single opioid. Reducing or eliminating exposure to opioids helps reduce the likeliness of patients ever becoming addicted.
5. The bottom line
One of the biggest obstacles in implementing an Enhanced Recovery After Surgery Program is the perceived cost. Many are skeptical and think an Enhanced Recovery Program will have significant cost. However several hospitals have demonstrated an overall cost savings when using an Enhanced Recovery Program. The Johns Hopkins team’s literature review shows that net savings can range from $159,720 to $634,720 annually.3 Dr. Jung et al showed an annual savings of $250,682 when they implemented an Enhanced Recovery Program for Colorectal patients.4 Dr. Huang demonstrated commonalities between Enhanced Recovery Programs and bundled payments in his 2015 overview. He suggests that utilizing Enhanced Recovery Programs will lead to successful surgical procedure bundled payments. 5
1 Li D, Jensen C. Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols. Clinics in Colon and Rectal Surgery. 2019;32(02):138-144. doi:10.1055/s-0038-1676480.
2 Hübner M, Addor V, Slieker J, et al. The impact of an enhanced recovery pathway on nursing workload: A retrospective cohort study. International Journal of Surgery. 2015;24:45-50. doi:10.1016/j.ijsu.2015.10.025.
3 Stone AB, Grant MC, Roda CP, et al. Implementation Costs of an Enhanced Recovery After Surgery Program in the United States: A Financial Model and Sensitivity Analysis Based on Experiences at a Quaternary Academic Medical Center. Journal of the American College of Surgeons. 2016;222(3):219-225. doi:10.1016/j.jamcollsurg.2015.11.021.
4 Jung AD, Dhar VK, Hoehn RS, et al. Enhanced Recovery after Colorectal Surgery: Can We Afford Not to Use It? Journal of the American College of Surgeons. 2018;226(4):586-593. doi:10.1016/j.jamcollsurg.2017.12.031.
5 Huang J. Bundled Payment and Enhanced Recovery After Surgery. Journal of Medical Practice Management. 2015;30(5):349-353.
Kara Douglas, MSN, APN, CRNA
Director of Enhanced Recovery After Surgery
Baltimore, MD
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