5 Things to Look for When Scaling ERAS Programs

Data has shown that Enhanced Recovery After Surgery (ERAS) protocols can contribute to a shorter length of hospital stay by 30-50% and achieve similar results for complications, ED visits, and readmissions. These improved outcomes in turn can help alleviate clinicians' burden, which is vital given the current challenges healthcare systems and hospitals are facing.

Increased ERAS compliance is also directly correlated with decreased cost of care as well as the reduction in the ‘economic burden of disease’ on patients. Considering these significant improvements, ERAS is now regarded as an “important example of value-based care applied to surgery.”

It is therefore not surprising to see the increased adoption of ERAS programs in leading health systems, especially as ERAS in certain specialties surpasses the clinical research stage. 

As Dr. Kevin Elias, President of the ERAS USA Society and Gynecology ERAS Leader at Brigham & Women's Hospital recently shared, “I would say three years ago, you saw a big shift towards most people either implementing [ERAS] for the first time or maybe have one pathway. So seeing expansion across multiple pathways is definitely a progression.”

Organizations are now looking to the next step - scaling and expanding ERAS across multiple service lines and amplifying the results while standardizing care. For instance, Dr. Elias shares how when Brigham introduced ERAS almost a decade ago, their initial focus was colorectal surgery. It was then implemented in gynecologic oncology and urology. “After we had those three specialties up for a couple of years, there came a lot of interest across the hospital and expanding to other surgical disciplines, because it was clear that there had been a marked improvement in outcomes for those service lines”, shared Dr. Elias. “We started getting questions from thoracic surgery, neurosurgery, surgical oncology about how we could generalize that across the hospital. Now we have 20 different ERAS service lines going at the hospital. And for most of our specialties, it's considered the default plan of care.”

Here are 5 things organizations need to consider when scaling ERAS programs. 

1. Identifying the Right Service Lines 

For many healthcare systems and hospitals that have successfully scaled ERAS programs across multiple pathways/service lines, identifying which service line to scale to after initial success is a critical decision. 

A pathway that can demonstrate high ROI quickly for the organization (both clinical outcomes and costs), has more clinical champions, and has an abundance of literature are three key considerations when picking the first pathway. And these considerations, among others, continue to hold sway when it comes to being strategic about expansion. 

For instance, for Baylor Scott & White Health, Charlette Hart, Director Surgery Administration shares that “We were trying to figure out how we were going to expand. We looked at where the literature is the strongest, where we have the biggest buy-in, where we have the biggest impact to make improvement or change in outcomes or in financial or those types of issues.”

Clinician buy-in

Gina McConnell, ERAS Cardiac Nurse Coordinator at WakeMed, reiterates the need for clinical buy-in for each of the service lines. “It goes back to a couple of things. One, you're getting the buy-in of each individual team again. Each population you develop, it's a completely different set of experts. Getting the buy-in - you're repeating the same process. It gets a little easier though because after the first one, you have a template. And you speak to your team ahead of time, you make sure you outline the expectations and how this is going to work.”

Bridging gaps in care

For Novant Health, expansion and the choice of the service line is very thought-out. A big part of that is observing clinical teams at work, and identifying the gaps that can be tackled with ERAS. Vicki Morton, Director of Clinical & Quality Outcomes for Providence Anesthesiology Associates and ERAS Program Leader at Novant Health, shares how she observes how patients are doing, processes followed by surgeons, and based on that identifying a service line to focus on, “then going to the surgeon who I think might be the champion and having a conversation.” 

Sometimes the surgeons were even unaware of what ERAS could do for that surgical population, especially in the early years. Outlining what ERAS means for the patients and what it can do for their patient population ultimately results in a clinician buy-in. “Many times you don't even know you have a champion until you go to talk to them,” shares Vicki. “We could see the data, we know what the outcomes are right now, and where the challenges are and those are the places we're going to go to and then we're going to find our champion.” 

Data-led insights

Having the data to be able to identify the impact ERAS pathways can have on a service line is incredibly helpful. Vicki shares how at Novant, “As a new service line is starting to develop or we're starting to develop that protocol, we're already collecting that data of the non-ERAS because that helps us to see where are the challenges, what's working, what's not working, and how we then are going to gear our pathway.”

For Dr. Heather McFarland, Vice Chair Operations and Director at Anesthesia Value Network, University Hospitals (UH), “Knowing that we had gotten through six months of gathering data, seeing what we were doing right, seeing what we were doing wrong, where we could tweak things at our academic center was very helpful for us” when it came to identifying the right time to scale up to other service lines. “Finding that balance of what people are going to be doing may have some variation, but as long as you are able to educate and obviously audit and measure the outcomes of that, then you're going to be okay.”

Multi-hospital presence

When it comes to a major healthcare system such as WakeMed, “the more we could bring the culture of ERAS to as many hospitals as we could, the better,” shares Gina. “We also looked at the footprint of where those procedures are being performed and if it's a procedure that's only performed at 3 of our hospitals instead of 10 of our hospitals, then we might pull that one later, and [instead] go to one that has a wider expanse. Because we want to make sure that we're bringing that culture as much as we can to as many places as we can.”

The criteria to decide to expand differs across organizations and, as Vicki reiterates, “I don't think that there's any one way to do it better than the other. It's whatever your system is set up to do and whoever's overseeing it and working on the program itself and what works best for you guys.”

2. Building a Multi-disciplinary ERAS Team

As ERAS leaders would attest, an ERAS committee is critical to ensuring uniformity in protocol implementation of the vast number of elements in an ERAS pathway. A multidisciplinary committee - which includes surgeons, anaesthesiologists, nurses, pharmacists, physical and occupational therapists, and dieticians/nutritionists - can ensure that care teams across all phases of care can collaborate, communicate and set up protocols; share insights from the program and reiterate or adjust workflow efficiencies as needed; ensure standardized deployment of protocols, and more. 

A multidisciplinary committee is even more important when ERAS programs are scaled across multiple service lines, and sometimes across hospitals. Vicki shares, “Having a strong multidisciplinary team is an absolute must … We have an overall ERAS steering committee that we address and discuss things within all institutions and all service lines. Each of our facilities has their own ERAS committee and so some of them, like our main steering committee, we meet every month, some of the hospital committees we may meet every other month.”

For Dr. McFarland, using fractal-based quality management infrastructure with community teams was essential to UH’s scale-up plan. “We use a fractal management system for most of our quality initiatives and implementations here at UH … Thinking about how we scale, it is based upon that fractal and helping with that. You have your horizontal and your vertical learning, but then you have your community teams and for us, it was about having our academic center being able to look at our outcomes, making sure we had the nuances of what ERAS was and then we had our community teams in place. We did not want to scale out until our community teams were in place. For us, that was key.”

Also, as the ERAS program continues to evolve and expand, it is crucial that so do the ERAS committees to ensure system-wide optimization. This means having open sources of communication. For instance, at Baylor, they have an internal intranet set and the ERAS team has its website where internal members can stay updated about the programs. “It's a huge geographic footprint, so definitely communication is key'', shares Charlette.

3. Standardizing Protocols Across Service Lines

An ERAS program’s success relies heavily on the standardized implementation of protocols, as much as possible, as it helps improve the delivery and consistency of care by minimizing errors, enhancing clinical outcomes, and optimizing the overall use of resources. However, when scaling an ERAS program across service lines, organizations might have to consider the scope of variability.

Scoping the extent of variability

As Vicki shares, “Every protocol has the main components and then builds around that. Multimodal for cardiac is going to look a little different than multimodal for C-section patients or gynecology patients. We use a lot of the same multimodals in some service lines, but sometimes there's just not the evidence and findings that show some medications we use in one are not beneficial in another. So there is going to be that variability a little bit. But again, going back to the literature, your champions, your experts to talk about that and coming up with the best plan that's going to work for your institution is what needs to be done.”

Identifying common metrics

Charlette mentions finding the common metrics that you are looking to measure across service lines when scaling, and then maybe identifying those that are service-line specific. “We try to keep it [protocols] as consistent as we possibly can, but there is variability between the programs. When we very first started our programs, we decided we were going to make a giant ‘source of truth’ document. It's a huge base of metrics and a lot of those metrics are common across multiple service lines, but some of them are custom depending on the exact service line. Majority of the time, whenever we start a new service line, we go to that database and we see, "Okay, here's the metrics that we've looked at before, which metrics do we want to look at for this surgery line?" And we try to keep it consistent within that database, but there are times where we have to customize - cardiac is different from spine, which is different from hip fracture.”

Gina echoes the sentiment, sharing, “The source of truth is the main components of ERAS that you have to include in your program… The variability from population to population is absolutely necessary. Cardiac is completely different from a hernia. We have to respect that and allow those teams to be the experts within their teams. But the ‘source of truth’ is you have to at least have these major components of ERAS included.”

Reducing variability within each pathway

However, once these considerations have been taken into account and protocols set, further variation should be avoided within a pathway. Vicki shares, “Once that pathway is built and everybody's educated and everybody's agreed to it, then there should be very little variability within that pathway … It's either they're doing it or not, with the understanding that sometimes you do have to deviate a little bit due to patient care or some patient issues or allergies, etc. But there should not be a ton of variability within that one pathway.” 

For instance, as Charlette shares, “If you don't allow a patient to have clear liquids prior to surgery, but then you want to do goal-directed fluid therapy, you get yourself in trouble. You have to try to do as much of it consistently as you can all the time.”

The consideration is best summarized by Charlette – “Ultimately, you want to make sure that you're hitting all your big quality markers. You want to make sure you're improving care. There has to be a little variability, but as much as you possibly can to standardize is probably going to help you to implement it and do a better job.”

4. Consistent evaluation of processes and data

As organizations scale ERAS programs across service lines, it is pertinent to consistently reevaluate, and update if needed, existing processes for these pathways.

Reviewing protocols

Gina shares how Wakemed recently had a “complete turnover in our GYN population of not just nurses, but a lot of folks. We also noticed that the order sets we had built had some gaps, and had some opportunities. So, we rebuilt those. We're always looking at order sets and continuously improving them, but these were a little bit more of an overhaul. Our lead surgeon  declared that we were relaunching GYN and it was just sending out every provider, every champion, every person the new order set. The pathway didn't change, but it was about drawing attention to it because our compliance was so low and we needed to do something. That's how we approached that.”

Updating perioperative processes

At Baylor, Charlette mentions, the goal when they first started ERAS was to look at the continuum from the inpatient side. “We’re always thinking of ‘how do you improve things?’ We improved by making it easier to order ERAS. We expanded to more surgery lines and now we're looking at how we further expand, how we're providing our care into optimization post-discharge. Right now we're working on standardizing the pre-op clearance … We're also working on some of the strong for-surgery metrics, implementing those and making sure that we are looking at, e.g. hemoglobin or blood sugars before they come in. We're working on some of those optimization tactics. That's probably our biggest change that we've made recently - really expanding from just our intraop through that extra post-discharge and before they come in.”

Consistent data collection

Collecting data consistently, having standardized dashboards, and leveraging it to identify any trends or anomalies that can be identified and acted upon is key for optimizing ERAS programs, especially when it comes to multiple service lines. As Dr. Elias shares, “It's important to have that data, at least a few of those core elements that you want to impact. And [analyze them] pretty frequently rather than quarterly or yearly - that's not often enough if you're trying to be reactive to staying on the protocol.”

Updated education

Scaling and optimizing ERAS pathways also requires ensuring all stakeholders are aligned on the ERAS education, protocols, outcomes, and improvements. 

For instance, Baylor Scott & White holds an annual ERAS symposium – a continuing education event – now in its sixth year. Charlotte shares that they “try to get our internal folks there as best as we can. … We have several different speakers that come, some internal, some external, and we focus on a lot of education. Spreading the ‘why’ and making sure that everyone understands why we're doing what we're doing and just helping get that education helps to improve your buy-in and get everyone to be on the same page.”

5. Collaborating with Care Teams

The transdisciplinary collaboration helps ensure that holistic expertise and knowledge go into setting up an ERAS pathway in a new service line as well as fostering a long-term commitment and learning of best practices across the different frontline teams to truly lead a successful ERAS program.

Open communications

Consistent communication between the ERAS team members is key to ensuring that data is being leveraged to improve the delivery of ERAS pathways and consequent care. “If you're with one group, then you're probably going to have one data coordinator for that group. But as you start expanding, you're going to need support for abstracting imagined data across the different groups, and then some sort of hospital coordination of those individuals. Making sure that whoever is managing the data is in close contact with the frontline providers is key, “ Dr. Elias emphasizes.

“You want your data people to actually be meeting in person regularly with your frontline providers and going through the data together, both to make sure it's accurate but also to make sure that it's acted upon. You don't want these reports to just get filed in someone's inbox and never read.”

Leveraging clinical expertise

When building new pathways, leveraging the expertise of clinical and front-line care teams is helpful, especially when working through potential variations in protocols. “It is an ongoing challenge”, shares Gina. “I tell our surgeon leads and our anesthesia leads this all the time that we're not taking the expertise away. We know you guys are the experts, we value and completely respect that, but I need you to meet us at the table based on literature and evidence-based practice of what we should be doing. I call it the ‘nudge factor’.”

Sorting through variations

Ultimately, it is about acknowledging that care teams are focused on doing the best for their patients and their concern about any potential negative impact of new protocols in a new ERAS pathway. Charlette suggests “Showing them [care teams] the literature, making it easy to do the right thing, and then also having compassion for them and knowing that they're trying to provide the best care that they can. You have to partner with them and get them to come on your side and understand we're all trying to get to the same place.”

Similarly at Novant, “When we're building pathways, we have our surgeon champions who are part of that. And let's say, e.g. cardiac surgery - all of our surgeons were at the table. They all had input, we all looked at the literature together and came up with a pathway, and they agreed on it,” shared Vicki. “Now if we have another cardiac surgeon come in, then typically I will sit down with them, go through the pathway, talk about it, the support behind it, and why we're doing what we're doing. If they want to participate, then they're agreeing and they know the information upfront. They know what's expected of them. If we start to see variability or non-compliance, then it's another discussion. … Those transparent discussions are often very helpful for us to see how we can help you to be better at this and for your patients to do better.”

In Summary

ERAS implementations across multiple service lines have shown to have an incremental impact on an organization's clinical and operational efficiencies. Strategic selection of service lines, seamless alignment of all key stakeholders within and across pathways, and standardization of protocols that are consistently evaluated are effective components to ensure the success of optimization and scaling efforts. 

For more insights on scaling ERAS programs, watch the on-demand webinar featuring Gina, Vicki, and Charlette. If you’d like to learn how Digital Care Journeys are being used by leading health systems like Atrium Health to optimize multiple ERAS pathways or by UAB Medicine to reduce costs upwards of $8100 per surgical encounter, watch this session with Dr. Joshua Liu.