Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
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ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.