Safer, Quicker Discharge With Protocols for Enhanced Recovery After Surgery

NEW ORLEANS, LA—Enhanced recovery after surgery (ERAS) protocols can lead to the safe discharge of patients from the hospital as soon as 3 days after cardiac surgery without increasing the risk of readmission, morbidity, or mortality, according to two studies presented at the 2020 meeting of the Society of Thoracic Surgeons (STS).

This “clears the path for us starting an ERAS protocol, and it does answer some pertinent questions from both the patient and our administration,” lead investigator S. Chris Malaisrie, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), said during a press conference highlighting his study results. “‘If I get sent home too early, will I have any problems if I’m home?’ That can be safely answered no. . . . ‘Are we going to have an unintended consequence of readmission because you send patients home?’ The answer to that is also no.”

During a press conference, Daniel T. Engelman, MD (Baystate Medical Center, Springfield, MA), who serves as president of the ERAS Cardiac Society, said that “some of the worries that patients and people have had in the past about enhanced recovery programs is that maybe it’s all about getting patient out of the hospital earlier. It’s actually not. It's not earlier. It's actually following evidence-based standardized best practice in order to get patients out at the right time.”

ERAS comprises preoperative education, early ambulation, perioperative medication and analgesia planning, and diet and bowel control, but the specific details of these protocols can differ by institution. While it has been recognized and used by most surgical fields over the past two decades, cardiac surgeons only formally embraced ERAS in 2018.

In Malaisrie’s study, the researchers looked at 5,987 patients who underwent cardiac surgery at their institution between 2004 and 2017, comparing those who were sent home within 3 days of their operation versus those who stayed in the hospital longer. Median length of stay was 6 days, and only 2.2% stayed in the hospital 3 days or fewer. The latter group tended to be younger, more often male, and at very low risk.

After propensity matching, no patients in either group died at 30 days (P = 0.56). Also, while 26 patients in the later discharge group (n = 357) had a major in-hospital complication, none who went home early (n = 121) reported any events including stroke, renal failure, prolonged ventilation, reoperation for bleeding, or deep sternal wound infection (P = 0.001). A similar proportion of patients in the accelerated and later discharge groups were readmitted within 30 days (8% vs 6%) or received permanent pacemakers (0 vs 1%), but postoperative A-fib was reported in far fewer patients who went home early (2% vs 19%; P < 0.001).

“We remind people that this is just an association, and you can't demonstrate any causality between discharge and postoperative A-fib,” Malaisrie said.

Direct Cost Savings With ERAS

In a second presentation, Anthony Tran, MD (Hartford Healthcare Heart & Vascular Institute, CT), shared findings from before and after his institution enacted an ERAS protocol in January 2018. He described their regimen a “home-recipe type” consisting of new protocols in several categories including “postoperative diet and bowel regimen, patient activity, and perioperative medications and analgesia.”

Specifically, their pain-medication plan relied heavily on nonopioid drugs. The protocol relied on anti-inflammatory agents early but transitioned to ibuprofen or acetaminophen. Dilaudid was prescribed only as needed and started with the minimal dosage. Mild or moderate pain was not treated with narcotics. 

Looking at nonemergent, isolated CABG patients only, Tran and colleagues included 158 treated in 2017 prior to adopting the ERAS protocol and 162 treated afterwards in 2018. Importantly, the same surgeons and staff were involved over the entire study period, Tran said, and there was “limited selection bias” as all eligible consecutive patients were included.

They found a significant reduction in the occurrence of postoperative A-fib after ERAS despite a similar preoperative prevalence of A-fib in both groups (32.9% vs 22.8%; P = 0.044). Additionally, patients in the ERAS cohort were typically discharged 24 hours sooner than their non-ERAS counterparts (median 5 vs 4 days; P < 0.001). There were no differences between the groups with regard to secondary outcomes, except that post-ERAS patients stayed in the ICU for less time (median 31.2 vs 24.7 hours; P = 0.005).

“Interestingly, we did not find a decreased rate of anticoagulation used on discharge even with the reduction of atrial fibrillation postoperatively, although this study was not powered for that particular outcome,” Tran noted.

With an average cost of $20,000 for CABG in the United States, including a $13,000 direct cost to the hospital, Tran estimated a savings associated with ERAS of “about half a million dollars” per hospital using their annual volume of 384 cases.

Looking at opioid reduction more specifically in their experience, he said that “patients tolerated this change with no decrease in satisfaction or reported rise in pain scale ratings. As well, we did not find an increase in incidence of acute kidney injury or renal failure with the use of low-dose ketorolac.”

Following the presentation, audience member James Brevig, MD (Providence Medical Group, Everett, WA), said his institution also recently implemented an ERAS program. “One thing that really strikes me with your presentation is that it is a lot more than ERAS,” he said. “You’ve really relooked at your whole post-op care. I'm interested in what you think was responsible for most of the improvement because you changed so many things in addition to ERAS. Some of them presumably worked really well, but some of them perhaps didn't. Do you have a sense of what actually made the most difference for your patients?”

Tran replied that “there’s no magic” in ERAS. “One of the key things we found in our protocol was that we limited opportunity for deviation,” he said. “A lot of our protocol was implemented into ERAS as a hard stop—must be done, is required. If there were any changes, that would have to be documented as to why has it deviated from the protocol. . . . Overall by limiting opportunities for deviation in the protocol is one of the strong factors for ERAS in general.”

Multidisciplinary Approach, Standardized Protocols

During the press conference, Engelman explained that ERAS generally means “following a standardized bundle of protocols” that begin in the preoperative phase, carry through during surgery with reduced opioids, and end with regimented postoperative care designed to ease the patient’s transition to home. “It turns out that despite how much work we spend at meetings just like this discussing how we operate on patients and the techniques we use in the operating room, 80% of the preventable morbidity and mortality following cardiac surgery actually occurs outside of the operating room,” Engelman said.

Using a multidisciplinary approach, “we found that we can actually significantly reduce the morbidity and mortality associated with surgery and not have readmissions,” he continued. Engelman said that cardiac surgery was one of the last to adopt ERAS protocols because these operations are among the most complex and multidisciplinary.

“But now we fully embrace it, and I would say that most major programs in North America are in some stage of adopting an ERAS protocol,” he asserted.

Asked by TCTMD if there were any patients in whom an ERAS protocol would be ill advised, Malaisrie said he would tend to exclude emergent patients. However, Engelman told TCTMD that while emergent patients won’t be able to engage with preoperative ERAS, “every single patient postoperatively is an ERAS candidate and will benefit from enhanced recovery. It’s low-hanging fruit we're talking about—simple things that people can't argue [with] such as reducing the amount of opioids and using multimodal analgesia, getting them out of bed earlier, getting them back to preoperative state and early exercise.”

Robbin Cohen, MD (University of Southern California, Los Angeles), who moderated the press conference, said his institution was able to cut its opioid use in half by implementing an ERAS protocol. “These strategies are really effective in not only getting the patients out of the hospital earlier but getting them out in better shape,” he said.

“This whole opioid thing actually is enormous,” Engelman agreed. “The benefits to the patients as well as society for getting patients out of the hospital on either very low dose opioids or no opioids at all are tremendous, and we are aggressively pursuing new technological innovations to allow us to get a better sense for in real time how many opioids we're prescribing rapidly, decelerating those opioids, and then sending those patients home on very, very limited doses and bringing them back if they have pain.”

He estimated that about 12% of patients who are sent home on large doses of opioids become dependent. “It is directly related to the amount of opioid the patient received in the operating room, post-operatively, and upon discharge,” Engelman said.