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December 19, 2024
As most clinicians and health organizations can attest, incorporating and implementing new evidence-based practice changes almost always involves overcoming systemic challenges and obstacles, and the same holds true for Enhanced Recovery After Surgery (ERAS) programs.
ERAS, an internationally recognized care standard, has been demonstrated to improve patient outcomes, including enhanced patient experience, faster recovery, shorter hospital stays, reduced risk of complications, and lower healthcare costs. The ERAS concept of perioperative care strives to bring together all involved in the surgical care journey process – including the patient – to achieve these outcomes. However, the primary obstacles to ERAS adoption have been resistance to change, lack of time and resources, and inadequate communication and coordination among departments.
This is where ERAS committees come in, helping identify and implement evidence-based clinical pathways, monitor and optimize the program, and be the channel of communication between the frontline care teams and the executive and leadership teams throughout the process. The goal of these committees is to continue working towards continuous enhancement of ERAS programs while ensuring that the healthcare organization is meeting the highest standards of perioperative care for its patients.
Getting started
A lack of uniformity in the implementation of the different elements of an ERAS pathway is often a barrier to ensuring the success of the program. The ERAS committee is important because it provides a forum for all of the stakeholders to communicate, collaborate, and develop strategies to improve patient care. The committee is responsible for monitoring and making adjustments to improve patient outcomes by having all stakeholders involved in the development of protocols and strategies. This is best addressed by building a multidisciplinary ERAS committee, which includes surgeons, anaesthesiologists, nurses, pharmacists, physical and occupational therapists, and dieticians/nutritionists – a team that works well with each other, is present across each phase of care, and believes in the value of ERAS.
Multidisciplinary teams
With representatives from all teams involved in the care of the patient, a multidisciplinary committee needs to have a clear mission, roles and responsibilities for all members, and a clear plan for how the committee will work together.
Vicki Morton, Director of Clinical & Quality Outcomes for Providence Anesthesiology Associates and ERAS Program Leader at Novant Health, shares, “Having a strong multidisciplinary team is an absolute must. Looking at your data continuously is a must … In every service line, we make a point of identifying a nurse champion, an APP champion, a surgeon champion and we have our set anesthesia champions. But you have to have strong people around you to help sustain a program.” The transdisciplinary collaboration is key not just to ensure that there is a vast level of expertise and knowledge that goes in when setting up ERAS pathways and guidelines, but also to foster a long-term commitment across the different frontline teams to truly lead a successful ERAS program.
Each of these stakeholders in an ERAS committee helps sustain the program through their various roles. This includes updating ERAS order sets, reviewing quality metrics on a regular basis, providing patient education as well as educating bedside staff, and communicating the metrics to clinical and organizational leadership.
Ensuring consensus within teams
For organizations just getting started with their ERAS programs, the ERAS committee can be smaller in size, but the key is to ensure that there is complete buy-in from all members in the committee. Dr. Kevin Elias, President of ERAS® USA and Gynecology ERAS Leader at Brigham & Women’s Hospital shares, “At this point, procedure guidelines for pretty much any specialty have been published by the ERAS® society, It really doesn't take a lot of building from scratch. It's often the surgeon and the anesthesiologist and nursing sitting down with the guidelines, looking over them and saying, ‘Well, what can we do here at our hospital? What makes sense for us? What are we already doing? If we're not doing it, why?’”
Which is why Dr. Elias suggests, “You start with a small group of people who actually want to spend some time doing this … It does require consensus, and it's one of the most important parts of ERAS. You can't have a situation where the anesthesiologist wants to do ERAS and the surgeon's not on board or vice versa, or you haven't involved your nursing care. It has to be a lot of conversations but you don't need or even want a lot of people.” Once you have the buy-in, the goal down the line is to have a multidisciplinary team with representation from surgeons, nursing, anesthesia, informatics, quality teams, and more.
Evolution of Committees as ERAS Programs Scale
When they first embark on their ERAS programs in one or two pathways, most organizations start with smaller ERAS committees. As these healthcare systems scale ERAS programs across multiple service lines, and sometimes across hospitals, ERAS committees continue to evolve in different ways. So how can you scale your ERAS committees as the program evolves, and ensure the role of these committees are aligned with the growth to maintain optimized system-wide programs?
Multi-level ERAS committees
With multiple ERAS pathways underway, there is a need for multiple levels of ERAS committees to ensure that the channels of communication are available for all across service lines, departments, and the entire hospital system.
For multi-hospital healthcare systems, a good approach is to have a system-level ERAS committee, and then committees at each individual hospital who can manage the ERAS programs at the local level and then report back into the system for a more holistic approach.
Dr. Heather McFarland, Vice Chairman of Operations at University Hospitals Cleveland Medical Center, shares that “It's definitely about horizontal learning and vertical learning.” Cleveland has an overarching ERAS committee that reports to the executive sponsorship team on a quarterly basis. Then there’s the system-wide operations committee that is more focused on order sets, or pharmacy representatives for their needs, and a center for perioperative medicine lead who is focused on patient/staff education as well as rehabilitation. The committees are further broken down into community hospital leads and then specific service line needs.
Dr. Elias, too, leads a multi-level ERAS committee at Brigham, which currently has 20 ERAS service lines across the hospital. “One level that's focused on individual service lines, and then we have a second level, which is across the departments of surgery. Then there's sort of the third, which is across the hospital system,” shares Dr. Elias. “At every level, you're involving the appropriate surgery, anesthesia, and nursing members. And then as needed, bringing in your teams like nutrition and pharmacy who usually are going to be more interdisciplinary than a single service line.”
Building core ERAS teams
At Novant Health, there is a core ERAS team that is responsible for managing the different sub-level ERAS committees and ensuring they are constantly reviewing the data and outcomes being reported by them. Vicki, who is responsible for implementation, oversight, and expansion of the ERAS program to 9 facilities within the hospital system across 17 service lines, shares, “Everybody does it a little bit differently. We have an overall ERAS steering committee that we address and discuss things within all institutions and all service lines. And then each of our facilities has their own ERAS committee. Some of them, like our main steering committee, meet every month, some of the hospital committees may meet every other month … All the while, our core team meets every month to get them to look at the data, talk about the data, and get our presentations ready for the next big meeting. And that has pretty much stayed consistent.”
At Baylor Scott & White Health, there is a core team as well and each hospital has their individual team as well as coordinator teams. Charlette Hart, Director Surgery Administration at Baylor, shares, “Our core team is our system team. We help support our facilities with research, resources, and Epic tools. The core team is like our steering committee that helps to facilitate for all of the other committees, including local facility teams.”
Focus on communication
With multidisciplinary and multi-level committees, there can often be conflicting approaches to patient care, which can lead to uncertainty that is further compounded by poor communication. In order to address inconsistencies in daily clinical practice, there needs to be better communication between all healthcare professionals.
Vicki emphasizes, “You have to have great communication between everybody because you can't have teams and subcommittees of things that they're focusing on and not communicating about it because that just doesn't work very well.” Consistent, clear, and transparent communication with the wider management and multidisciplinary is recommended, wherein information and data is shared, success and areas of improvement highlighted, and care plans updated if required.
Dr. Elias holds weekly structured meetings with the service line ERAS committee where they discuss all ERAS cases and “look at compliance with major ERAS metrics” as well as monthly meetings where the ERAS champions from all the different surgical specialties get together to “talk more about hospital-wide initiatives with ERAS.” And then at the systems level, the discussions and updates revolve around “modifying order sets, changing the formulary for new medications related to ERAS, documentation issues, flow sheet issues,” shares Dr. Elias.
Structured plans and continuous efforts to offer visibility to data, metrics and key updates is critical. For instance, Charlette shares that at Baylor, “We have an internal intranet set - we call it VSW Connect - and we have our own website, where any of our internal folks can go online and see what we're doing. We put all of our updates on our internal website where everyone can see any updates that are going on and that helps us to bridge all of that communication. It's a huge geographic footprint, so, definitely communication is key.”
Role of an ERAS Coordinator
Organizations with successful ERAS programs often rely on ERAS Coordinators to assist with the day-to-day management of the ERAS program. This includes providing ERAS education to patients pre-surgery, checking-in on ERAS patients post-surgery, collecting patient data on ERAS protocol adherence, evaluating patient outcomes and more. It is a critical role for advancing an ERAS program within a service line.
What to look for in an ERAS Coordinator
Dr. Elias recommends ideally starting by looking at where you are in your implementation process when appointing an ERAS Coordinator, and ensuring they have close collaboration with the frontline care teams. “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 data across the different groups, and then some sort of hospital coordination of those individuals,” he suggests.
“Making sure that whoever is managing the data is in close contact with the frontline providers is really key, “ adds Dr. Elias. “You really 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.”
Strategies to adopt with limited resources
In circumstances where the administration is currently not in a position to provide the resources to get a formal ERAS Coordinator, there are still ways to rally the frontline teams to help implement an ERAS program.
Dr. Elias proposes thinking in terms of the different phases of ERAS care. For instance, he suggests that in the preoperative setting, it is essential for patients to receive standardized education about enhanced recovery, “and that might be all the surgeons in a particular group agreeing to a handout which goes to patients – a one-page handout, a booklet, a video, or a website that you direct them to. Those are all potential options to make sure that you're getting some sort of standardized ERAS management and that patients are getting standardized guidelines.” The key is to ensure that all the surgeons in the group are consistent in the information and instructions they are providing to their patients.
Similarly, on the anesthesia side, it is about having a conversation with the anesthesiologist to outline how the ERAS committee would like patients undergoing a certain procedure to be managed and asking questions along the lines of “We want to have a conversation about opioid sparing, who's going to write the preemptive medications in pre-op, is it going to be surgery anesthesia? What are we going to write for? What kind of drips do we want intraoperatively?”, says Dr. Elias.
And then comes the post surgery care, where Dr. Elias suggests identifying, for instance, what the order set looks like for patients coming into the PACU and recovery and goes on to add, “These are all things that happen really before you even get a Coordinator involved. You need to have those sorts of discussions. Once you actually move to collecting data, you're not going to collect 30 elements or 20 elements. At first, you're going to maybe collect five things on every patient. And it doesn't really require much of a data coordinator to get that.”
“If you ask me, what are the five things that you should collect to get started, I would say collecting information about the MPO status of the patients … What opioid sparing medications are being given preoperatively and intraoperatively? When did the fluids go off? When did the patient get out of bed, and when did they eat? Those are the five things that you need to know. If you're doing those five things consistently, you are going to be a pretty good part of the way towards getting ERAS done.”
Importance of ERAS Committees, Coordinators or Champions in Ensuring Sustainability
Having a systematic model for implementation is key to ensure that your ERAS program is sustainable. It is hard enough to bring about change in one service line, but to initiate a system-wide change requires extensive collaboration, change management, and optimization strategies that help the healthcare system embrace these programs as seamlessly as possible.
And the real challenge can often begin after implementation - including sustaining consistent standardization of care and compliance across departments. ERAS programs are exciting when you start, and sometimes highly successful in the first pathway or two, but it does require ongoing commitment and compliance with ERAS protocols, which has been seen to wane over time.
Consistent data collection
ERAS leaders suggest the first key step to sustain compliance and achieve long-term success with ERAS programs is ensuring that data collection begins immediately. This helps you both prove the program as well as gather metrics, against which performance can be measured and optimized consistently.
As Gina McConnell, ERAS Cardiac Nurse Coordinator at WakeMed, says, “We started with paper and Excel, but the one thing we did right is we started collecting our data right out of the gate. Immediately we knew we had to prove the program. And no matter how your facility or your hospital can collect that data, start at the beginning. That will help the sustainability of the program because everything's going to revolve around that eventually.”
Vicki echoes those sentiments, sharing, “Typically how I have approached this is – 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.”
There may be some variation in how care teams implement ERAS programs, but ensuring that there is transparency of information, everyone is educated about the variations, and you audit and measure the outcomes regularly this helps keep the programs on track to success.
Find ERAS champions
Second is finding your champions - through the ERAS committees, Coordinators, clinicians, and nurses. “Find your people, resources, experts within each of those pathways and create champions. Really value them and help them be so engaged in the program they have ownership. For me, I have pre-op, post-op and intraop champions, four dieticians … everybody's a champion now and they help WakeMed sustain the program. You cannot do it by yourself for sure,” shares Gina.
Dr. McFarland echoes that sentiment, sharing, “We did not want to scale out until our community teams were in place. For us, that was key. 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.”
Implementing ERAS can be difficult if the necessary elements are not in place, such as effective leadership, engagement, empowerment, and communication. ERAS committees provide strong leadership and ownership of the program, help setup structure for open communication and collaboration while improving outcomes and adherence through consistent data collection.
To hear more insights from these ERAS leaders on creating and scaling committees and other ERAS strategies, watch our on-demand webinars Best Practices for Deploying an Enhanced Recovery After Surgery Program and Leveling Up Your ERAS Program: How to Effectively Optimize and Scale Across Pathways.
And if you’d like to learn how Digital Care Journeys are being used by leading health systems to automate ERAS pathways, measure patient compliance, and improve outcomes, join our upcoming May 4th session on Automating Your ERAS Program for Long Term Sustainability with Digital Care Journeys.
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