Thought Leadership

ERAS Spotlight: Q&A with Kim Duggan – Senior Director, ERAS Specialist, Pacira BioSciences, Inc. / former Perioperative Surgical Home & ERAS Manager, New Hanover Regional Medical Center

August 15, 2023
By
Tracy Staniland

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 recently interviewed Kim Duggan, Senior Director, ERAS Specialist, Pacira BioSciences, Inc. and former Perioperative Surgical Home & ERAS Manager, New Hanover Regional Medical Center (NHRMC), Wilmington, NC about her ERAS journey. Pacira BioSciences is a global pharmaceutical company and a leading provider of non-opioid pain management and regenerative health solutions dedicated to advancing and improving patient outcomes. Kim shares her insights and experiences deploying, scaling, and optimizing ERAS across multiple service lines including the importance of creating multidisciplinary committees, consistent communication, and tips for inspiring others.  

In your opinion, how do Enhanced Recovery After Surgery protocols challenge the traditional tenets of surgical care? 

ERAS is a paradigm shift from traditional surgical throughput. What was once considered “best practice” is now archaic. With the improvements in surgical technique, technology, and education, it only stands to reason that HOW we put our patients through surgery must also improve. ERAS does exactly that. It is now best-practice and meets the quadruple aim of healthcare. 

When did you first launch your ERAS program and which ERAS surgical pathways did you deploy? 

During my tenure at NHRMC, the hospital's anesthesia team had tried to implement an ERAS program for two years without success. They just couldn’t get traction. Then in 2015, I was asked by our lead anesthesiologist to help scale. Of course, we began with Colorectal (who doesn’t?)  and saw such great success we rapidly expanded to other service lines. By the time I left the health organization in 2022, we had expanded ERAS across 17 service lines and had shifted ERAS pathways to our ASC for 4 service lines.  Ultimately, a $12-$15M cost savings program for the organization. 

Often ERAS programs start off highly successful, but with a lack of on-going commitment, compliance with the ERAS protocols can wane. What approaches do you take to sustain compliance and success of your ERAS program? 

Without question, the number one resource necessary is a dedicated ERAS coordinator. To be boots on the ground, provide daily clinical oversight, and the point of care contact resource. They are essential to the success of the program. Their role will entail capturing and reporting key data metrics. Regularly reviewing data demonstrates lapses and can easily identify wherein the phase of care there are gaps. Having that trusted navigator leading the charge, monitoring compliance, and sharing outcomes with all stakeholders maintains momentum and sustains the program. 

How does ERAS improve the patient experience? 

A key component of ERAS is patient education. Empowering the patient with ERAS methodology, providing discharge criteria, and setting expectations gives the patient skin in the game to advocate for their best outcome. Patients will meet expectations 100%, if provided necessary instructions.  

When you initially launched ERAS, what was the biggest challenge that you encountered and how did you overcome this challenge? 

I had two surgeons wanting to opt out of the ERAS process because they were very close to retirement and didn’t want to change practice at that stage of their careers (I certainly understood). Knowing this I wanted to make sure I was capturing accurate/clean data as theirs would skew mine. So, I worked with our EMR team (EPIC) and the hospital’s scheduling/posting department to build warning logic based on procedure using CPT codes, as well as the ordering surgeon. When the case was being posted from the surgeon’s office, the request would fire warning logic to the hospital asking, “this procedure meets criteria for ERAS, is this an ERAS case Yes / No”?  If yes was selected, the letter E would populate to the storyboard notifying all phases of care to follow the protocol and it allowed for the nonparticipating surgeons to seamlessly opt out.  

On a side note, by design, the EPIC warning logic allowed for harvesting data and running reports on those ERAS patients who had the identifier E. Additionally, excluded trauma patients from the pool being admitted via the Emergency Room (their data would distort my ERAS data as outliers). 

After the initial launch of ERAS in your first pathway, how did you know that the timing was right to scale ERAS across multiple service lines?

LOL! I knew immediately, but my C-suite requested it within 3 months of launching. A situation arose, Our PACU was on hold due to no available beds. This backed up the OR, as patients had to be recovered in the surgical suites. Surgeons were angry. Patients were unhappy. Dead standstill. Cases cancelled. Lost revenue. Administrators were called to the OR by the angry surgeons and were told to “fix it”. The question became, what is the one program we had to improve the situation. ERAS instantly became a priority, and I was given the green light with resources to rapidly expand the program.  

Once you implemented your ERAS program did you see a reduction in length of stay and readmissions?  

Yes! With colorectal surgery, the very first case, we went from an 8-10 LOS to 2 days! It was remarkable! I was concerned it was a fluke, so we ran the process again and got the same results!  This made available an additional 2500 hospital beds, offsetting our capacity issues. Readmissions dropped by 57%, to which we were paying millions in Medicare readmission penalties; after launching ERAS, we did not experience financial penalties any longer due to readmissions.

How frequently do you meet with key stakeholders from management, finance, and your multidisciplinary ERAS team to review the status of your program, outcomes, patient compliance, etc.? 

We formally met quarterly but having a navigator’s physical presence everyday allowed for real time continuous improvements, sharing of successes, obtaining immediate feedback from all stakeholders, and served as ongoing communication. 

What are some approaches health systems can take to incorporate Enhanced Recovery After Surgery (ERAS) Pathways into their clinical practice to help them meet the Quadruple Aim of Healthcare? 

After 25 years of surgical experience, I left NHRMC. I now work for Pacira Biosciences as Sr. Director, ERAS Specialist, where I help hospitals all over the US develop comprehensive ERAS, repair fragmented programs, or assist with ASC ERAS. The following are my recommendations: 

  1. Create momentum by aligning all stakeholders to include surgeons, anesthesia, administration, nursing, nutrition, pharmacy, PT, case management, scheduling, etc.
  2. Have administrative support as a Program of Priority (opens doors and provides resources).
  3. Have a “boots on the ground” Navigator for clinical oversight and point of care contact for patients and staff.
  4. Set the ERAS foundation with a phase of care approach.
  5. Create a point of entry ERAS notification. 
  6. Draft detailed protocols and make them an electronic living document easily accessible to all stakeholders.
  7. Apply all ERAS components within the appropriate phase of care into the protocol.
  8. Start with one service line and expand from there, disseminating processes to other markets. 
  9. Standardize multimodal medications, regional blocks (procedure specific), and patient education.
  10. Minimize opioid consumption via a solid anesthesia regional block program.
  11. Schedule administration of multimodal medications and instructed continued use even after discharge.
  12. Create 3 ERAS order sets: Day of surgery - preop multimodal medications specific to the service line, PACU to include tiered approach to pain control with opioid minimization strategy, and postop ERAS floor admission order set; this will establish the surgeons clinical pathway.
  13. Share and tout success. Listen and apply staff feedback. Communicate patient feedback.
  14. Avoid working in silos. ERAS is a team approach.
  15. Monitor compliance via data collection.  

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? 

The greatest pain point I see across the country is the lack of ERAS understanding by health professionals. Just this past March, there was a well written paper published in the Journal of PeriAnesthesia Nursing discussing the lack of understanding health professionals’ have regarding Enhanced Recovery After Surgery. Although well intended, many ERAS leads do not know the comprehensive ERAS components, what is entailed in a phase of care approach, or how to disseminate service lines across all markets (large health networks).

Without a solid foundation, poorly designed ERAS programs across all surgical fields are unable to realize the abundant downstream rewards comprehensive ERAS provides. Hospital Administrators want to see programs of quality, such as ERAS translate to cost savings and meet the quadruple aim. Improving care quality, enhancing the patient experience, improving provider satisfaction, and reducing total cost of care cannot be achieved if the team doesn’t have a solid understanding of the program or the rationale, so set the foundation from the beginning.

Furthermore, ERAS requires a whole team approach and cannot be limited to just physician leads. For success, it must be collaborative. If staff are excluded and directed to deliver ERAS methodology without having a voice with the process, they feel it’s just another task they are mandated to perform. This builds resentment, leading to silos, and a fragmented program. Frustration sets in and the program will wax/wane and ultimately fail. I see it everyday across the country.  

The solution is to absolutely include all stakeholders. Staff want their work contributions to be meaningful and bring value to the patient, not just another required task. A successful ERAS program is collaborative throughout the entire perioperative continuum of care. Certainly, program protocols are drafted by physician providers and ERAS is physician led. Nonetheless, staff inclusion, communication, responsive feedback, ongoing program education, and setting the ERAS foundation creates unity, momentum and sets the program up for success. 

Is there one piece of advice that you would like to share with others who are starting or scaling an ERAS Program? 

If I may, two pieces of advice. First, to gain buy-in and create momentum, align your stakeholders. Include everyone and launch with WHAT is ERAS and WHY it is important. Provide ongoing ERAS education for new grads, new hires, and create an annual compliance module. This will keep ERAS front-of-mind for sustainability.  

Second, regarding diabetic carbohydrate loading, I had to course correct following an adverse event, so I recommend consulting Endocrinology regarding this practice; follow their recommendations and make it a standard of care hospital policy across all service lines and markets.  


A close-up of a person smilingDescription automatically generated

Kim Duggan, MHA, BSN, RN-C, is the Senior Director, ERAS Specialist at Pacira Biosciences, Inc. where she evaluates and provides discussion for comprehensive ERAS strategies for health organizations throughout the US. With more than 25 years surgical experience, Kim is a national subject matter expert for designing and implementing Enhanced Recovery After Surgery (ERAS). She has over two decades of perioperative experience with New Hanover Regional Medical Center, where she worked with key stakeholders to build a comprehensive Perioperative Surgical Home (PSH) and ERAS program. Before leaving New Hanover, the PSH/ERAS program had expanded to 17 service lines and was a $12 - $15 million dollar savings for the organization. Kim is well published.  She has authored two ERAS implementation manuals and is a contributing author with the American Society of Anesthesia (ASA) PSH Implementation Guidebook, as well as patient education material, journal articles, and whitepapers. In her spare time, Kim enjoys “glamping”, mountain hiking, and whitewater rafting. Connect with Kim on LinkedIn

ERAS Spotlight: Q&A with Kim Duggan – Senior Director, ERAS Specialist, Pacira BioSciences, Inc. / former Perioperative Surgical Home & ERAS Manager, New Hanover Regional Medical Center

Posted by:
Tracy Staniland
on
August 15, 2023

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 recently interviewed Kim Duggan, Senior Director, ERAS Specialist, Pacira BioSciences, Inc. and former Perioperative Surgical Home & ERAS Manager, New Hanover Regional Medical Center (NHRMC), Wilmington, NC about her ERAS journey. Pacira BioSciences is a global pharmaceutical company and a leading provider of non-opioid pain management and regenerative health solutions dedicated to advancing and improving patient outcomes. Kim shares her insights and experiences deploying, scaling, and optimizing ERAS across multiple service lines including the importance of creating multidisciplinary committees, consistent communication, and tips for inspiring others.  

In your opinion, how do Enhanced Recovery After Surgery protocols challenge the traditional tenets of surgical care? 

ERAS is a paradigm shift from traditional surgical throughput. What was once considered “best practice” is now archaic. With the improvements in surgical technique, technology, and education, it only stands to reason that HOW we put our patients through surgery must also improve. ERAS does exactly that. It is now best-practice and meets the quadruple aim of healthcare. 

When did you first launch your ERAS program and which ERAS surgical pathways did you deploy? 

During my tenure at NHRMC, the hospital's anesthesia team had tried to implement an ERAS program for two years without success. They just couldn’t get traction. Then in 2015, I was asked by our lead anesthesiologist to help scale. Of course, we began with Colorectal (who doesn’t?)  and saw such great success we rapidly expanded to other service lines. By the time I left the health organization in 2022, we had expanded ERAS across 17 service lines and had shifted ERAS pathways to our ASC for 4 service lines.  Ultimately, a $12-$15M cost savings program for the organization. 

Often ERAS programs start off highly successful, but with a lack of on-going commitment, compliance with the ERAS protocols can wane. What approaches do you take to sustain compliance and success of your ERAS program? 

Without question, the number one resource necessary is a dedicated ERAS coordinator. To be boots on the ground, provide daily clinical oversight, and the point of care contact resource. They are essential to the success of the program. Their role will entail capturing and reporting key data metrics. Regularly reviewing data demonstrates lapses and can easily identify wherein the phase of care there are gaps. Having that trusted navigator leading the charge, monitoring compliance, and sharing outcomes with all stakeholders maintains momentum and sustains the program. 

How does ERAS improve the patient experience? 

A key component of ERAS is patient education. Empowering the patient with ERAS methodology, providing discharge criteria, and setting expectations gives the patient skin in the game to advocate for their best outcome. Patients will meet expectations 100%, if provided necessary instructions.  

When you initially launched ERAS, what was the biggest challenge that you encountered and how did you overcome this challenge? 

I had two surgeons wanting to opt out of the ERAS process because they were very close to retirement and didn’t want to change practice at that stage of their careers (I certainly understood). Knowing this I wanted to make sure I was capturing accurate/clean data as theirs would skew mine. So, I worked with our EMR team (EPIC) and the hospital’s scheduling/posting department to build warning logic based on procedure using CPT codes, as well as the ordering surgeon. When the case was being posted from the surgeon’s office, the request would fire warning logic to the hospital asking, “this procedure meets criteria for ERAS, is this an ERAS case Yes / No”?  If yes was selected, the letter E would populate to the storyboard notifying all phases of care to follow the protocol and it allowed for the nonparticipating surgeons to seamlessly opt out.  

On a side note, by design, the EPIC warning logic allowed for harvesting data and running reports on those ERAS patients who had the identifier E. Additionally, excluded trauma patients from the pool being admitted via the Emergency Room (their data would distort my ERAS data as outliers). 

After the initial launch of ERAS in your first pathway, how did you know that the timing was right to scale ERAS across multiple service lines?

LOL! I knew immediately, but my C-suite requested it within 3 months of launching. A situation arose, Our PACU was on hold due to no available beds. This backed up the OR, as patients had to be recovered in the surgical suites. Surgeons were angry. Patients were unhappy. Dead standstill. Cases cancelled. Lost revenue. Administrators were called to the OR by the angry surgeons and were told to “fix it”. The question became, what is the one program we had to improve the situation. ERAS instantly became a priority, and I was given the green light with resources to rapidly expand the program.  

Once you implemented your ERAS program did you see a reduction in length of stay and readmissions?  

Yes! With colorectal surgery, the very first case, we went from an 8-10 LOS to 2 days! It was remarkable! I was concerned it was a fluke, so we ran the process again and got the same results!  This made available an additional 2500 hospital beds, offsetting our capacity issues. Readmissions dropped by 57%, to which we were paying millions in Medicare readmission penalties; after launching ERAS, we did not experience financial penalties any longer due to readmissions.

How frequently do you meet with key stakeholders from management, finance, and your multidisciplinary ERAS team to review the status of your program, outcomes, patient compliance, etc.? 

We formally met quarterly but having a navigator’s physical presence everyday allowed for real time continuous improvements, sharing of successes, obtaining immediate feedback from all stakeholders, and served as ongoing communication. 

What are some approaches health systems can take to incorporate Enhanced Recovery After Surgery (ERAS) Pathways into their clinical practice to help them meet the Quadruple Aim of Healthcare? 

After 25 years of surgical experience, I left NHRMC. I now work for Pacira Biosciences as Sr. Director, ERAS Specialist, where I help hospitals all over the US develop comprehensive ERAS, repair fragmented programs, or assist with ASC ERAS. The following are my recommendations: 

  1. Create momentum by aligning all stakeholders to include surgeons, anesthesia, administration, nursing, nutrition, pharmacy, PT, case management, scheduling, etc.
  2. Have administrative support as a Program of Priority (opens doors and provides resources).
  3. Have a “boots on the ground” Navigator for clinical oversight and point of care contact for patients and staff.
  4. Set the ERAS foundation with a phase of care approach.
  5. Create a point of entry ERAS notification. 
  6. Draft detailed protocols and make them an electronic living document easily accessible to all stakeholders.
  7. Apply all ERAS components within the appropriate phase of care into the protocol.
  8. Start with one service line and expand from there, disseminating processes to other markets. 
  9. Standardize multimodal medications, regional blocks (procedure specific), and patient education.
  10. Minimize opioid consumption via a solid anesthesia regional block program.
  11. Schedule administration of multimodal medications and instructed continued use even after discharge.
  12. Create 3 ERAS order sets: Day of surgery - preop multimodal medications specific to the service line, PACU to include tiered approach to pain control with opioid minimization strategy, and postop ERAS floor admission order set; this will establish the surgeons clinical pathway.
  13. Share and tout success. Listen and apply staff feedback. Communicate patient feedback.
  14. Avoid working in silos. ERAS is a team approach.
  15. Monitor compliance via data collection.  

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? 

The greatest pain point I see across the country is the lack of ERAS understanding by health professionals. Just this past March, there was a well written paper published in the Journal of PeriAnesthesia Nursing discussing the lack of understanding health professionals’ have regarding Enhanced Recovery After Surgery. Although well intended, many ERAS leads do not know the comprehensive ERAS components, what is entailed in a phase of care approach, or how to disseminate service lines across all markets (large health networks).

Without a solid foundation, poorly designed ERAS programs across all surgical fields are unable to realize the abundant downstream rewards comprehensive ERAS provides. Hospital Administrators want to see programs of quality, such as ERAS translate to cost savings and meet the quadruple aim. Improving care quality, enhancing the patient experience, improving provider satisfaction, and reducing total cost of care cannot be achieved if the team doesn’t have a solid understanding of the program or the rationale, so set the foundation from the beginning.

Furthermore, ERAS requires a whole team approach and cannot be limited to just physician leads. For success, it must be collaborative. If staff are excluded and directed to deliver ERAS methodology without having a voice with the process, they feel it’s just another task they are mandated to perform. This builds resentment, leading to silos, and a fragmented program. Frustration sets in and the program will wax/wane and ultimately fail. I see it everyday across the country.  

The solution is to absolutely include all stakeholders. Staff want their work contributions to be meaningful and bring value to the patient, not just another required task. A successful ERAS program is collaborative throughout the entire perioperative continuum of care. Certainly, program protocols are drafted by physician providers and ERAS is physician led. Nonetheless, staff inclusion, communication, responsive feedback, ongoing program education, and setting the ERAS foundation creates unity, momentum and sets the program up for success. 

Is there one piece of advice that you would like to share with others who are starting or scaling an ERAS Program? 

If I may, two pieces of advice. First, to gain buy-in and create momentum, align your stakeholders. Include everyone and launch with WHAT is ERAS and WHY it is important. Provide ongoing ERAS education for new grads, new hires, and create an annual compliance module. This will keep ERAS front-of-mind for sustainability.  

Second, regarding diabetic carbohydrate loading, I had to course correct following an adverse event, so I recommend consulting Endocrinology regarding this practice; follow their recommendations and make it a standard of care hospital policy across all service lines and markets.  


A close-up of a person smilingDescription automatically generated

Kim Duggan, MHA, BSN, RN-C, is the Senior Director, ERAS Specialist at Pacira Biosciences, Inc. where she evaluates and provides discussion for comprehensive ERAS strategies for health organizations throughout the US. With more than 25 years surgical experience, Kim is a national subject matter expert for designing and implementing Enhanced Recovery After Surgery (ERAS). She has over two decades of perioperative experience with New Hanover Regional Medical Center, where she worked with key stakeholders to build a comprehensive Perioperative Surgical Home (PSH) and ERAS program. Before leaving New Hanover, the PSH/ERAS program had expanded to 17 service lines and was a $12 - $15 million dollar savings for the organization. Kim is well published.  She has authored two ERAS implementation manuals and is a contributing author with the American Society of Anesthesia (ASA) PSH Implementation Guidebook, as well as patient education material, journal articles, and whitepapers. In her spare time, Kim enjoys “glamping”, mountain hiking, and whitewater rafting. Connect with Kim on LinkedIn

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