Enhanced Recovery Pathways Reduce Surgical Complications and Shorten Length of Stay

It takes sustained effort from a large group of healthcare providers across a range of disciplines to generate lasting improvement in surgical outcomes. 

NorthStar Anesthesia—an anesthesia-services management company with 180 locations in 20 states—is leading just such an effort at the Detroit Medical Center (DMC), a multi-campus academic medical center and integrated delivery network owned by Tenet Healthcare.

Northstar began overseeing anesthesia services on July 1, 2015, at four acute-care hospitals, a cardiovascular institute and two ambulatory surgery centers operated by DMC.

The goal is to implement enhanced recovery pathways, or ERPs, a structured and coordinated approach to managing surgical care that can help reduce post-surgery complications and inpatient length of stay and enhance cardiopulmonary function and patients’ satisfaction with their care experience.

Improving outcomes and costs is important as DMC adapts to new value-based reimbursement models that pay for services based on outcomes rather than on the volume of those services. For example, Medicare no longer reimburses hospitals for the costs associated with treating avoidable surgical complications, such as certain surgical-site infections, and also has implemented numerous programs to encourage coordination among providers and care sites.

Challenges

While ERPs address quality and cost issues, they’re not  easy to implement because they involve several dozen separate patient-care protocols—starting when surgery is scheduled and continuing through discharge—and many different healthcare providers.

“There’s an average of eight different pockets a surgical patient goes through,” including the surgeon’s office, pre-admission testing, pre-operative area, operative area, post-anesthesia care unit, intensive care unit, inpatient floor and discharge planning, says Vinay Pallekonda, M.D., an anesthesiologist, assistant professor at Wayne State University and regional medical director for NorthStar Anesthesia.

Caregivers working in one pocket typically are unaware of what their peers in other pockets are doing.

“The cornerstone of ERP is you have to get multi-disciplinary team buy in; you have to get them on the same page,” Pallekonda says. If you don’t spend the time upfront on team-building, the end result likely would be a pilot project and a peer-reviewed journal article but not lasting change, he adds.

Many ERP protocols involve modifying such anesthesia practices as requiring patients to fast before surgery and use of narcotics and IV fluids during surgery. 

Fasting leads to dehydration and low blood pressure, and anesthetic agents depress blood pressure even further. To counteract this, the anesthesiology team members give patients IV fluids during surgery, but they typically rely on their professional “gut feeling” to decide how much fluid to give, Pallekonda explains. And narcotics, which reduce pain, can cause nausea, vomiting and excessive drowsiness.

Kathy Sabat-Baber, a registered nurse, clinical-improvement specialist, DMC employee and a leader on the ERP project, sums up the possible impact of these practices: “The patients come out of surgery, and there’s a lot of pain or they’re nauseous or dizzy from the drugs or they feel bloated and their legs are swollen because they got so much fluid in the operating room. They don’t want to get out of bed. They don’t want to eat. They don’t want to do anything.”

Solution

That is why the ERP program begins with patients. Patients prepare their bodies for surgery by exercising regularly, practicing deep breathing with an incentive spirometer and, as surgery day approaches, drinking high-carbohydrate shakes. In contrast to traditional fasting practices, patients drink clear liquids until two hours before surgery.

Different practices occur in the operating room as well. Anesthesia services use a multimodal approach for pain management, including regional nerve blocks to reduce the need for narcotics, and administer IV fluids according to evidence-based protocols.

Surgeons order so-called “power plans,” which include all of the clinical order sets, at the same time as they schedule a surgery. All caregivers have access to the entire power plan, not just their piece of it.

“Everybody knows what’s going on. It’s not this disjointed method of taking care of the patient,” Sabat-Baber says.

To rollout ERP, DMC and Northstar are developing educational materials and power plans. They also plan to computerize anesthesia work processes, which are paper-based, and install specialized software designed to coordinate work processes across the surgical-care continuum. 

Results

The planning process already has led to improved surgical quality. One example is the use of prophylactic antibiotics. During a planning meeting, anesthesiologists and CRNAs who were in attendance realized that they were not re-dosing a common antibiotic quickly enough. After NorthStar employees changed their approach to that antibiotic, DMC’s surgical-site infection rate dropped. 

Commitment to ERP has increased as well. Eight DMC and NorthStar employees attended the first regularly scheduled planning meeting. Within two months, 50 people were attending the planning meetings.

In 2015, the 73-hospital Michigan Surgical Quality Collaborative recognized the ERP work by giving a quality-leadership award to DMC Harper University Hospital, where DMC's ERP efforts began.

Pallekonda says, “I think this could be the first time that anesthesiologists are driving the bus on enhanced recovery pathways,” he says, explaining that surgeons usually spearhead ERP efforts.