By What is the first thing that comes to most people’s minds when they think of Enhanced Recovery After Surgery Programs? Protocols. I have been asked by people all over the country to help them write a protocol for their particular hospital. Usually I respond with something along the lines of- “Sure, the protocol part of an Enhanced Recovery Program is actually the easy part!” The real challenges are in everything else.
In this post, I will discuss the top 10 steps that I have found imperative to a successful Enhanced Recovery Program. I will give an overview of each section, and delve into more details in later posts. If you are working on an Enhanced Recovery Program for your hospital, I hope you find this helpful!
- Create an Enhanced Recovery Committee
A multidisciplinary Enhanced Recovery Committee is the number one key to a successful program. This ensures buy-in from multiple specialties across the hospital and keeps communication open across the disciplines. The Enhanced Recovery Nurse Coordinator and the surgeon champion lead this committee. Here is a list of people you need on your committee:
- Director of Enhanced Recovery/ Nurse Coordinator
- Surgeon Champions from each specialty involved
- Anesthesia Champion (one from each specialty if needed)
- C-suite representative (CNO, CMO, or CFO)
- Posting/Scheduling
- Pre-Admission Testing
- Pre-op/PACU Nurse Manager
- OR Nurse/ Surgical Team Leads
- Advanced Practitioners on the floor
- Pharmacist
- Physical Therapist
- Occupational Therapist
- Respiratory Therapist
- Nutrition & Dietary
- Ostomy Nurse/ Wound care
- Endocrine
- Epic or other EHR
- Clinical Quality Outcomes Nurse Leader
- Use Data to Set Goals
The second step is utilizing your hospital’s data to create goals for your Enhanced Recovery Program. There are different platforms in which this data can be collected and analyzed. If you are fortunate enough to use an EMR system (such as Epic) daily, monthly, and annual reports can be created for your program.
Other common options include: National Surgical Quality Improvement Program (NSQIP), Improving Surgical Care and Recovery (ISCR), and ERAS® Interactive Audit System (EIAS) The committee should decide on clear goals, for example: Reduce Length of Stay by at least 24 hours within one year.
Here are some common data points you should consider for goal setting:
- Length of Stay (I like using hours instead of days to be more precise)
- 30 day Readmission rate
- 30 day Mortality rate
- 30 day UTI rate
- Superficial SSI rate
- Deep SSI rate
- Organ/Space SSI rate
- Vein thrombosis requiring therapy rate
- Pulmonary Embolism rate
- Average amount of opioids administered intra-operatively
- Average amount of opioids administered post-operatively
- Average pain scores
- Pathway Creation
There is no need to reinvent the wheel with your Enhanced Recovery Pathway. There are plenty of pathways already in use at different hospitals that you can easily adopt to fit your needs. The main sections of any Enhanced Recovery Pathway include:
- Preadmission
- Pre-op
- Intra-op
- Post-op
- Post-Discharge
Developing both an order set and a checklist for each section is a great way to standardize your pathway. The checklists will also prove helpful for auditing your pathway.
If you want to see examples of guidelines, here are some good places to start:
The Practice Guidelines from American Society of Colon and Rectal Surgery and Society of American Gastrointestinal and Endoscopic Surgeons here.
The ERAS® Society list of guidelines can be found here.
- Reviews and Approvals by Hospital Committees
Once your Enhanced Recovery Committee has agreed on a standardized pathway, it needs to go through your hospital’s process to be approved for use. Become familiar with your facility’s process to help with efficiency and reduce possible roadblocks. Here is an example of what the process could look like:
- Enhanced Recovery Committee creates a pathway
- Present the pathway to Pharmacy and Therapeutics (P&T) Committee. This step is especially critical if you need to introduce a new medication to the facility’s formulary.
- Present the pathway to the Nursing Clinical Practice Review Committee to ensure all of the expectations of nurses are within your facility’s scope of practice. They will also identify any changes to workflow and education that may be required.
- Present the pathway to the Orderset Committee. This committee will take your paper version of orders and turn it into an EMR orderset. They will also ensure that the orders are written per Joint Commission standards.
- Present any educational materials to the Education Committee. Most facilities require their patient education materials have a maximum reading level that you should become familiar with prior to this meeting.
- Equipment and Medications
Most facilities need to adjust their purchasing of equipment and medications when they start an Enhanced Recovery Program. This can lead to the biggest pushback you will encounter. Sometimes, doing a trial of different products prior to the launch date will prove helpful. Creating a vendor contact list and working with the Purchasing Department early in the process will limit delays in the start of your Enhanced Recovery Program.
Here are some examples of items that may require purchasing adjustments:
- Complex Carbohydrate Pre-Surgery Drink
- Immunonutrition Supplements
- Chlorhexidine wash (for patients to use the evening before surgery)
- Incentive Spirometers
- Bair huggers or other pre-op warming device
- IV pumps
- Ultrasound machines for Regional Anesthesia
- Good quality echogenic needles for Regional Anesthesia
- Medications such as: Ketamine, Lidocaine, Dexmedetomidine, Exparel, Sugammadex
- Training
Providing staff training within the weeks prior to the launch date is preferable over training months in advance. These training sessions can be provided at Department meetings, or at change of shift meetings. Planning more than one training session per department will help ensure you have reached the majority of staff.
Here is a sample list of who may need training in your facility:
- Surgeons and Residents
- Surgeon’s office staff
- Anesthesia Department
- Pre-Admission Testing Center staff
- Pre-op nurses
- PACU nurses
- OR nurses
- Advanced Practitioners
- Launch Date
It is very easy to get excited about your Enhanced Recovery Program and want to implement aspects of the program as soon as possible. I advise against falling into this trap. Having a firm program launch date will prove to be beneficial. Your data will be skewed if you have a rolling start, rather than a firm date. Staff will appreciate having a launch date as well.
Confusion tends to come with rolling starts mainly because the staff are not sure what is expected out of them. When everyone is on the same page for the launch day, everyone has been educated and is aware of the expectations. Some hospitals make a big deal out of it and have a “go live” party offering free lunch or ice cream to the staff, which adds a nice touch.
- Regular Meetings
Monthly Enhanced Recovery Committee meetings are useful for the duration of the program. When you are in the planning stage and early implementation most groups find it most productive to have a weekly or bi-weekly meeting of key stakeholders.
- Audit
Utilizing your data platform to audit your Enhanced Recovery Pathway is arguably the most important and most difficult of these 10 steps. You will continuously collect data on all measures mentioned in #2, as well as any other data points you wish to monitor. You will be able to analyze outcomes as well as compliance to your pathway. This data should be reviewed at the monthly meetings. Celebrating accomplishments with providers is a great way to provide positive reinforcement.
This could be as simple as hanging a certificate on a nursing unit wall congratulating them for having 100% compliance for a task on the pathway. On the contrary, when pitfalls are found in the audits, it is always recommended to take action quickly to increase the benefit of the pathway. Usually, this is simply re-educating the staff on a portion of the pathway.
- Revision
Now that your Enhanced Recovery Program has been in place long enough to analyze the outcomes and compliance, it is time to determine what is working well and where there is room for improvement. Every hospital is going to need to tweak their program once it is in place. Planning an annual review and revise session 1 year from the launch date is best so all of the team members have this expectation from the beginning.
Kara Douglas, MSN, APN, CRNA
Director of Enhanced Recovery After Surgery
Baltimore, MD
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