Eliminating preventable harm is now a top priority for health care organizations across the country. At Johns Hopkins, a team of surgeons, nurses and anesthesiologists developed a new approach that has already improved multiple aspects of surgical care, including patient outcomes, value and experience. Notably, in colorectal surgery, it has reduced hospital stays by 50 to 60 percent.
In early 2014, the team began implementing this new, integrated approach known as the enhanced recovery after surgery (ERAS) pathway. Led by former Johns Hopkins surgeon Elizabeth Wick and anesthesiologist Christopher Wu, ERAS spans the full arc of patient care, including preoperative, intraoperative, postoperative and post-discharge phases, as well as a standard perioperative anesthetic plan.¹
“For so long, we had focused mainly on postsurgical infections,” says Wick. “We really needed to step back and take a more comprehensive view of everything that can happen to a surgical patient—especially all of the things that can go wrong—and come up with a pathway that aims to prevent those potential harms.”
Novel Pathway Spurs Major Improvements
To address all elements of preventable harm in colorectal surgery, Wick and her colleagues reviewed national guidelines and level 1 evidence supporting enhanced recovery, prevention of surgical site infection (SSI), venous thromboembolism (VTE), urinary tract infection (UTI), and patient- and family-centered care. ERAS targets these areas through a multidisciplinary framework that seeks to standardize and unify patient care at all levels and time points within the patient care continuum.
For example, a critical aspect of the pathway is the engagement of patients and family members through education and shared responsibility for recovery. Other key features include reduced fasting time prior to and following surgery, reduced use of intravenous fluids, the use of multimodal pain medication, and an early ambulation protocol to get patients out of bed and moving as soon as possible following surgery.
Remarkably, ERAS has had a fundamental and rapid impact on patient care. In a published analysis of 640 patients who underwent elective colorectal surgery (330 patients during the study period and 310 during the baseline period), the Johns Hopkins team found that the pathway reduced hospital stays by 50 to 60 percent.1 Hospital stays associated with the ERAS pathway (3.5 days) track well below the national average, which is five to six days. In addition, the use of narcotic pain medications was dramatically decreased, and the patients’ perception of their pain management postoperatively also improved. There was also a significant reduction in postsurgical complications, including SSI, VTE and UTI. Moreover, based on analyses of patient experience and health care cost, ERAS enhances patient satisfaction and decreases cost, promoting high-quality care.
Importantly, the team’s approach may offer unique benefits to cancer patients, particularly with respect to pain management and risk of relapse. Research in animal models suggests that preserving perioperative immune function may prevent cancer recurrence. The Johns Hopkins colorectal ERAS pathway is unique because it deliberately avoids agents and/or techniques that may be immunosuppressive, and therefore it is tailored to preserve perioperative immune function, which typically is decreased during surgery.²
A Model for Other Surgical Specialties
Based on the initial success of ERAS in colorectal surgery, Wick and her team have collaborated with providers across the Johns Hopkins’ hospitals to apply the model to other areas of surgical care, including hepatectomy,³ cystectomy and gynecologic oncology. Notably, the pathway has yielded major improvements in these contexts too.
“This is one of the best innovations in perioperative care in the past 20 years,” says Wick. “Patients get back to normal much quicker, and with many fewer complications.”
1 Wick EC et al. Organizational culture changes result in improvement in patient-centered outcomes: Implementation of an integrated recovery pathway for surgical patients. Journal of the American College of Surgeons September 2015 221(3):669-77
2 Wu CL et al. Initiating an enhanced recovery pathway program: An anesthesiology department’s perspective. The Joint Commission Journal on Quality and Patient Safety October 2015 41(10): 447-56.
3 Page AJ et al. Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection. British Journal of Surgery April 2016 103(5):564-71.
An illustration shows the six steps related to the Enhanced Recovery After Surgery (ERAS) Pathway, from outpatient clinic to discharge.