A review of the Kaiser Permanente Enhanced Recovery After Surgery Program (ERAS) was recently published in the Journal of the American Medical Association. The program has resulted in a one-third reduction in postoperative complication rates, a 21% reduction in opioid prescribing rates, a decrease in hospital mortality, and an increase in home discharge rates among patients who underwent colorectal or hip fracture surgery.
The goals of the program are to improve pain management, mobility, nutrition, and patient engagement. Pain management is mediated with limited opioid treatment and preference given to other pain management techniques such as acetaminophen, nonsteroidal anti-inflammatory medication, intravenous lidocaine, and peripheral nerve blocks. Movement is encouraged within 12 hours of surgery with patients having a movement goal of 21 feet within 3 days after surgery. Presurgical fasting is reduced with the consumption of a high carbohydrate beverage within 2 to 4 hours before surgery. Postsurgery nutrition is provided within 12 hours. Patient engagement is fostered through an information video series and an illustrated calendar that details patient expectations from the night before surgery all the way through discharge.
The effectiveness of the program was evaluated in 3768 patients recovering from colorectal surgery and 5002 patients recovering from hip fracture repair. The rate of early movement in ERAS patients increased by 34% and the incorporation of early nutrition increased by 26%. Opioid usage and length of hospital stay also decreased with a one-third reduction in postsurgery complication rates.
“In my 24 years as a surgeon, this has been the biggest change in our clinical practice,” said Efren Rosas, MD, surgeon champion for Kaiser Permanente’s ERAS program, and a co-investigator on the study. “For decades, surgeries were guided by commonly held principles including no food after midnight the night before surgery, strong opioids for pain management and bed rest for recovery. The elements of an ERAS program — alternative medications for pain control, avoiding prolonged fasting, and encouraging walking — have been shown to reduce complications such as blood clots, muscle atrophy, nausea, confusion, delirium, and infection.”
1. Liu VX, Rosas E, Hwang J, et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system [published online May 10, 2017]. JAMA. doi: 10.1001/jamasurg.2017.1032