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December 19, 2024
Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway, designed to achieve early recovery for patients undergoing major surgery by minimizing the stress of surgery and supporting patients to recover quickly.
Our ERAS Spotlight series features interviews with clinical leaders who are on the front lines striving to reduce variation of care, standardize care, and deliver high reliability health care.
We spoke with Brie Reed, ERAS Clinical Nurse Coordinator, Total Joint and Spinal Fusion, at the University of Kansas Health System (TUKHS), a world-class academic medical center and destination for complex care and diagnosis. Providing a wide range of services, the health system includes hospital and clinic locations in Kansas City, Great Bend and Topeka, Kansas. With more than 100 hospital and clinic locations, 14,000+ employees, 1003 staffed beds, 1000+ physicians and 101,992 surgical procedures performed in 2022 at the Kansas City Hospital, the U.S. News & World Report ranks The University of Kansas Hospital as the best in Kansas City and in Kansas. The hospital is the first in Kansas to earn Magnet® designation for nursing excellence and one of few to earn it 4 consecutive times. Brie shares her experiences and insights on deploying, scaling, and maintaining an ERAS program across multiple surgical pathways to drive system-wide care standardization, continuous improvement, and patient care excellence.
When did you launch your ERAS program and which ERAS surgical pathways have you deployed?
Our ERAS programs were launched at various intervals over the past few years. At TUKHS, we have chosen to launch our programs by service line/surgical procedures. Overall, we have surgical pathways for Surgical Oncology/Colorectal, Gynecology, Total Joint (Knees and Hips), Spinal Fusion, and C-Section, with Bariatrics being our next to go live. I am currently the coordinator for Total Joint, Spinal Fusion, and Bariatrics once it goes live.
How did you secure organizational buy-in to deploy ERAS?
We secured organizational buy-in by demonstrating the financial impact that ERAS programs have on readmission, surgical site infection, and return to OR rates. We secured the buy-in for the individual service lines in a similar manner; the physician leaders recognizing areas for improvement, whether that be based on a gap in practice standardization or suboptimal outcomes, then requesting a consultation for a pathway to be formed for them.
In my opinion, taking this approach has resulted in better compliance and a higher value being placed on our pathways as the front line providers – the surgeons – truly believe in the value and goals of ERAS. In the past I have worked at other facilities that put into place a more generic ERAS protocol that was all encompassing for all surgical procedures, and it seemed to lack the provider buy-in, and it didn’t take into account the variance in patient population based on the kind of surgical procedure the patient was coming in for.
Do you have an ERAS committee? How did you establish your committee, who is part of your committee and what roles do they play in supporting the sustainment and optimization of your ERAS program?
Yes, each of our ERAS programs have their own committee. These committees were formed by bringing all the key players and leaders to the table. They include our physician lead for each program (though all surgeons involved are invited, and typically more attend), our Anesthesia liaison (physician), our in room provider lead (CRNA), nursing leadership from the various units (pre/post, OR, inpatient), nursing educators from the various units (pre/post, OR, inpatient), dietary leadership, rehab services leadership, pharmacy leadership, infection prevention nurse (we discuss any reportable SSIs at these meetings), and the assigned ERAS coordinator, who leads the meeting.
Having a multidisciplinary team allows us to constantly evaluate the program from various angles and to have a well-rounded discussion of where we are succeeding and where we could focus some improvement measures. It also provides a forum where all the key players and stakeholders can have a voice with the rest of the team.
How do you measure the success of your ERAS program? Are there specific metrics/data that you collect, track, and analyze?
For all our programs, we monitor compliance with our ERAS metrics – pre-warming, antibiotic timing, intra-operative normothermia, diet advanced as tolerated POD #1, foley removed POD #1, daily mobility. Additionally, for the service lines that I coordinate, I also track actual length of stay, discharge disposition, 30- and 90-day readmissions, and 30- and 90-day unplanned return to the OR.
Something unique to how I view readmissions is that I look at and count ED visits and outpatient ultrasounds – to evaluate how often we are sending patients to assess for a DVT. I’ve found that by adding in these categories you can begin to track trends that are often the result of a lack of education, typically regarding pain control and management, wound care, and/or signs and symptoms to report to the provider.
The maintenance and ongoing sustainment of an ERAS program can be daunting. How have you overcome this challenge?
I think we are really lucky to have providers on these teams that are always striving to improve and to provide the most up to date, evidence-based care. I think a large part of ERAS, and healthcare in general, is understanding that there is always somewhere you can improve and never settling once you reach a goal; keep setting new ones.
What are the biggest barriers holding back the rollout of Enhanced Recovery After Surgery (ERAS) Programs, either in your own organization or in the industry?
I would say manpower is a contributing factor, and just generally having a plan on roll out. As I mentioned above, I’ve worked with ERAS in three different health systems now and they have all rolled out programs differently; one used the same protocols but rolled them out service line by service line with little buy in, one rolled it out as a generic process for all elective surgeries/service lines, and TUKHS has rolled it out by surgeon interest.
The quality and data tracking aspect can also be daunting and hard to find manpower for, and I think it’s challenging to recognize you have a need for an ERAS pathway if you don’t have transparent data showing you, down to the patient-specific level, that there are deficiencies that could be improved.
For others that are responsible for managing ERAS Programs, what resources or tools would you recommend?
I would definitely recommend checking the ERAS societal guidelines as well as the societal guidelines for the respective programs you are managing. Looking at publicized programs at other hospitals, or just networking with ERAS managers from other facilities has also been really helpful to us at the University of Kansas Health System.
Is there one piece of advice that you would like to share with others who are starting or scaling an ERAS Program?
Yes, be certain to get the buy-in of the people it will affect before starting. If people understand the value of something, it will make them more likely to strive for the success of the program.
The second is to appreciate the pivotal role that pre-operative patient education can play in ERAS programs. In a few of my previous roles, one thing patients often said helped them the most to reach goals and prepare for their peri-operative experience was attending a pre-operative class. Although I am admittedly a big proponent for patient education, I do truly believe it, when done right, can have one of the biggest impacts on patient outcomes, especially when part of an ERAS pathway.
Brie Reed, MSN RN CPN, is an ERAS Clinical Nurse Coordinator, Total Joint and Spinal Fusion, at the University of Kansas Health System. Brie specializes in Orthopedic nursing and program management and has an interest in ERAS and quality outcomes. Brie received her Bachelor’s and Master’s in Nursing from the University of Central Missouri, and is currently pursuing her Doctorate at the University of Missouri – Columbia. In her spare time, Brie enjoys spending time with her three sons, hiking, driving down back country roads, and attending the occasional country concert. Connect with Brie on LinkedIn.
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