Enhanced recovery after surgery is a multimodal, evidence-based perioperative care pathway designed to improve recovery for patients undergoing major surgery. ERAS elements address factors that have historically extended a patient's hospital stay, including the need for parenteral analgesia and intravenous fluids, lack of mobility and postoperative complications.
Ibrahim Hussain, MD, neurosurgeon and member of The ERAS Society's USA Chapter, spoke with Detroit-based Henry Ford Hospital's Victor Chang, MD, about ERAS in spine care, barriers when implementing new protocols and the most important feedback he received from patients.
Editor's note: This interview has been edited for style and clarity.
Dr. Ibrahim Hussain: How did the Michigan Spine Surgery Improvement Collaborative and the incorporation of ERAS Protocols get started?
Dr. Victor Chang: Generally speaking, anything that we think is a good opportunity to improve outcomes and quality for spine surgery, we're going to be interested in. When we started, we were looking at high-priority adverse events and how we could reduce those through quality improvement. In 2019, our interest in ERAS peaked. Most surgical disciplines were already implementing some sort of ERAS protocols, like general and colorectal surgery, so it was something that made sense for us to do, and we saw an increase in ERAS for spine surgery in the literature.
In the state of Michigan, one of our biggest payers, Blue Cross Blue Shield of Michigan, funds what is called the Collaborative Quality Initiatives through their value partnerships program. They identify high-dollar areas where there's a lot of variation in care. MSSIC is a CQI in their portfolio. Each year, participating hospitals receive a performance scorecard and pay for performance funds when they demonstrate successful implementation of CQI initiatives. MSSIC proposed our ERAS pay-for-performance measures to BCBSM and with their full support, ERAS initiatives composed 50 out of 100 points possible for 2021.
After we learned what was being done in other states like Pennsylvania and from our own literature review, we identified six Phase 1 ERAS elements that would be required for MSSIC sites. We also encouraged sites to consider other elements supported in the literature. We built an ERAS toolkit on our website with all kinds of resource documents, patient education, publications, example protocols and risk assessment tools and partnered with the American College of Surgeons to educate and provide templates for our sites to work off so they could take them to multidisciplinary team meetings. We created the "MSSIC ERAS Patient Video" for our sites to incorporate into their pre-surgical patient education and our MSSIC CQI leads provided coaching and site-specific support as we launched this statewide initiative.
IH: What has your early experience been so far?
VC: Right now, we have 31 institutions. Two are ASCs and 29 are hospitals. Twenty-five are mature sites that have been enrolled for two or more years. We have six newer sites that recently enrolled. In just one year of phase 1, our mature sites have been phenomenal. The 25 sites had to demonstrate multidisciplinary team engagement toward the development of ERAS. They then documented their site's entire ERAS protocol on the MSSIC ERAS template. Not only were they to describe, in detail, each phase 1 ERAS element, but also the standardized process for implementing them. Additionally, all their supporting documents such as patient education, order sets and risk assessment tools were sent to the coordinating center for review and approval. During phase 2, we are tracking compliance with implementation so processes can be evaluated and adjusted if needed. We are also prescribing an enhancement of risk assessment and optimization. We are requiring they have at least the following risk assessments with optimization in place: smoking cessation, glycemic control, opioid risk assessment and optimization of anemia and nutritional assessment.
IH: What challenges have you run into implementing some of the ERAS-related changes with MSSIC?
VC: ERAS implementation requires extensive support, is labor intensive and requires time and resources, which are hard to come by. However, we believe that to enjoy the clinical and financial gains of ERAS, making the spread and scale of ERAS protocols an expectation for every MSSIC site is necessary to facilitate those gains more quickly. The first thing we did was to link ERAS with their BCBSM — MSSIC pay for performance. This would at least provide a financial reward for the effort and support the platform we use to support our sites. In terms of protocols, we had already demonstrated that we could significantly change the culture and the way care is delivered through early ambulation after spine surgery.
However, ERAS was going to be a much bigger ask of our sites and would require multidisciplinary buy-in as well as executive level support. You can imagine how some places were already doing a great job of that, while others were greatly lacking, and the ERAS mindset was not at all part of their culture. With early ambulation, it was a bit of a process and took a couple of years to get some of the hospitals to get most of their patients ambulating within eight hours of surgery. But I think that gave everyone a taste of the process as far as changing culture or at least figuring out where to implement these kinds of sweeping changes. We also have a fair amount of high-volume private surgeons who are dotted within the collaborative. They can sometimes find themselves with a taller mountain to climb.
Another obstacle was hesitancy or imagined hesitancy with the anesthesia department regarding limited fasting, allowing clear liquids up to three hours before surgery and the carb-rich drink. To address this, we invited the director of neuro-anesthesia at the University of Michigan to speak at one of our collaborative-wide meetings. He is a huge proponent of ERAS and gave a fabulous presentation and provided us with some additional resources that we were able to share with MSSIC sites. He spoke of the positive benefits of ERAS and the way it improves patient outcomes and reduces adverse events. Overall, we’ve created a noncompetitive, collaborative environment where sites can learn from each other and figure out what the best thing is to do at their site.
IH: Have you seen any type of financial benefit or cost effectiveness?
VC: It's too early right now. We just started Phase 2 with the enhanced risk assessments and optimization as well as monitoring compliance of the required ERAS initiatives. Implementation has been a little slow at some sites secondary to the effects of COVID and medical staff shortages. We are hoping that after we have 12 months of implementation, we’ll have enough post-intervention data and can then look at different outcomes. However, with just the early ambulation intervention part of our ERAS, we've raised the bar significantly. To date, the rate of ambulation within eight hours of surgery has improved 152 percent compared with baseline. In the last two years alone, almost 11,000 patients have been ambulated at MSSIC sites within eight hours of surgery who previously would not have been.
That impacted our urinary retention rate, dropping it down from about 9.5 percent to under 3 percent. Given the spine surgery volume across all sites in MSSIC and the dollar figure of urinary retention per event costing around $9,000, this intervention alone has resulted in over $38 million in cost reduction since 2017. Anything linked to reducing length to stay, ED visits, readmissions and such all have real world dollars attached to them. Hopefully, by the end of 2023, we'll be able to look back and tell sites that even though implementing ERAS costs you "X" dollars, you saved "Y" dollars. We expect those savings to continue to accrue as you continue the program.
IH: How are you able to incorporate ERAS strategies into your existing workflow on a regular basis?
VC: Speaking to some of the Henry Ford hospitals, we have RN spine coordinators who do a presurgical education course and meet everyone going to surgery either at their hospital or virtually. They are the point of congruency in the program and the go-to person as far as the rollout of the initiatives, standardization of processes and sustainability. We also have a nurse who makes sure everyone gets their carb-rich presurgical drink.
It's good to have someone who is a bit removed from the day-to-day of getting clinic done and surgeries boarded. They have a chance to step back and look at the whole ERAS care pathway from the time the patient is seen in the clinic, boarded for surgery, has their surgery, is discharged, then followed post-op.
Another example is our process for high-risk patients on high doses of opiates or patients over 80 years old. Our nurse will send an email every week that identifies high-risk patients and allows the anesthesiologists to do a hard stop either to refer them for opioid tapering prior to surgery. They can also discuss with the surgeons the exact indications for sicker, older patients or if elective surgeries — without impending neurologic deficits — can be postponed until they are better optimized, etc.
Overall, it is extremely useful to have an RN spine coordinator position to help quarterback these things. Hands down, our most successful sites and those that were able to implement ERAS with the fewest bumps in the road have been the ones that have a spine coordinator.
IH: Is ERAS being applied to all spine patients and surgeries in MSSIC?
VC: We have a core content that is for all spine surgeries that fall under the MSSIC umbrella. The core content needs to be standardized no matter who the patient is or who the surgeon is. This includes comprehensive presurgical education, standardized protocols to identify patients at risk and to optimize them, opioid-sparing multimodal pain management, early ambulation and detailed discharge instructions. Some cases are excluded. As of now, pure thoracic cases and deformity surgeries that involve extensive cervicothoracic and thoracolumbar fusions are excluded, but hopefully those patients are still benefiting from our general protocols.
We made the ERAS program a general template that could be implemented for all spine surgeries. The idea is to make this the standard of perioperative care so that even patients who aren't considered within the core MSSIC demographic, which is elective degenerative cases, can benefit from the ERAS protocols.
IH: What are you doing differently after the patient is discharged from the facility?
VC: We looked at when patients usually show up in the emergency room or present with a problem. This might be for symptoms of a [surgical site infection], or when that initial post-op prescription is running out or complaints of uncontrolled pain. It usually occurred around seven days after discharge. As a result, we encouraged our sites to provide a formal evaluation or a patient touchpoint at least by phone with a nurse around five to seen days after discharge.
Another prescribed element of our ERAS protocol is the discharge instructions given to patients when they leave the hospital. When our sites submitted discharge instructions for review, we looked for detailed instructions that were step by step in nature, objective and measurable. We asked our sites to frame their discharge instructions with the mindset of the elderly patient who's overwhelmed, at home, and it is now 8 p.m. on a Friday night — are they granular enough? Do they provide step-by-step instructions, assuming the patient knows nothing? How does the patient bathe in a way that prevents an SSI? Do they need to change a dressing? If they do, what materials do they use and how do they do it? Are you instructing them to wash their hands before touching the wound or to perform dressing changes? Can their two dogs still sleep with them? Should they show their friends and family their new incision?
This is back to the basics and you can't assume patients practice good hygiene habits or know SSI prevention principles, even if they attended presurgical class and received verbal information in the hospital before discharge. That was the element of ERAS that was sent back most often to our sites for revision and more detail. One of our most effective patient education tools has been the "MSSIC Personal & Home Hygiene" flier, providing this level of helpful, granular information.
IH: What feedback have you gotten from patients so far?
VC: Everyone is a little different in terms of how receptive they are to certain initiatives, but ERAS is focused on empowering the patient to be more involved in their care. In general, the more information you can provide, in a nonthreatening way, the better. It helps them learn about the whole process of surgery and recovery and has been quite positive. In post-education surveys, patients have commented on how prepared they felt for surgery, how wonderful all the information was and how it calmed their fears and helped them to feel empowered through their recovery.
We had a specific patient from Henry Ford West Bloomfield — an elderly gentleman and his wife that went through the ERAS education and took careful notes. He was expecting to ambulate within hours after his surgery, and when that didn't happen, he questioned his care team and reached out to his wife. It turns out there was a float person caring for him who wasn't aware of the early ambulation protocol. The patient and his wife educated the nurse on what they learned in the class, and sure enough he was ambulated and did great. The big point is that he felt knowledgeable and empowered enough to speak up when things didn't go according to what he was told. He knew why early ambulation was important and he wanted to make sure he was provided the standard of care.
Click here for more information on ERAS protocols in spine care.