MEMORANDUM DATE: TO: Tundra Medical System Surgeon and Anesthesia Champions FROM: Name, Director of Strategic Initiatives SUBJECT: Improving the Surgical Quality Journey with an ERAS Program Surgeons, anesthesiologists, and health care systems strive for excellence in surgical care. This is a time when the Surgical Quality Journey needs to collaborate and implement the most current evidence-based surgical quality initiatives. There is overwhelming literature to support that the use of an Enhanced Recovery After Surgery (ERAS) program significantly improves outcomes, reducing morbidity and decreasing costs. This memo requests that Tundra Medical System Surgeon and Anesthesia Champions support the use of the ERAS program to improve the surgical care and recovery care of patients. Current Surgical Care Model Observation of the process for surgical preparedness in the offices of 15 surgeons of varying specialties was completed for 6 months. In short, it was observed that patients receive limited examination and discussion with surgeons preoperatively. There was no program that addressed patient education, optimization, and assessment for surgical readiness. Patients were not provided with information of what to expect before, during, and after surgery regarding their pain management, mobility expectations, nutritional requirements to optimize healing and other measures they could engage in to prevent complications. Anesthesia care in the medical center was similarly observed. Like the surgeons, the time spent preparing a patient for anesthesia and review of what to expect before, during and after procedure was very limited. Outdated processes such as patient fasting for six to eight hours prior to procedure and heavy intra-operative use of intravenous fluids to maintain perfusion was noted. Pain management included early and often use of narcotics and opioids to manage surgical pain. Changes in care are driven by objective matrix that are measured over time and represent quality of care outcomes. In review of these matrix, data such as length of stay, surgical site infections, length of time for return of bowel function, narcotic and opioid pain medication usage, and overall patient satisfaction have had little movement in the last 3 years. Enhanced Recovery After Surgery (ERAS) Model Enhanced Recovery After Surgery is not a new idea. Melnyk, Megan, et alia found that ERAS has been around since the 1990s and was developed to change the way patients physiologically respond to the stressors of surgical procedures (Melnyk, Megan, et al. 343). It has since been
Commented [MP1]: Purpose of memo is clear
Commented [MP2]: While the current situation is presented here, it must be cited. The student is referencing data in this whole section and it must be cited.
Commented [MP3]: The research is cited effectively with an attributive tag to start and closes with a parenthetical reference, but we, as readers don’t know who the authors are and why we should trust them.
found to have the added benefits including reduced complications, decrease in hospital stay, and improvement in cardiovascular and bowel function as well as a quicker return to baseline status (Melnyk, Megan, et al. 343). The modern approach to ERAS encompasses many aspects of the three stages of surgical care: pre, intra, and post procedure. Preoperatively, ideas such as comprehensive education, patient optimization including evaluation of baseline nutritional status and prior pain management routines, carbohydrate loading, and bowel preparation are addressed. Intraoperatively, care that includes restrictive use of intravenous fluids, maintenance of normothermia, and use of regional anesthesia versus general anesthesia is done. Postoperatively, care including prophylactic management of nausea and vomiting with early alimentation, early mobility, restricted use of narcotics in favor of NSAIDS, and early removal of catheters and drains is employed (Melnyk, Megan, et al., par. 343). The Impact of the Changes The ERAS processes are a paradigm shift in the way elective surgical patients are prepared and cared for. Fitzgerald, in referencing the thoracic surgery program at University of Virginia Health System (UVA), wrote that the challenge was to get the buy-in of the clinicians (Fitzgerald, par. 10). These professionals were very invested in the care they provided to their patients and truly believed they were doing very well (Fitzgerald, par. 10). Per Melnyk, Megan, et alia, even minor changes that are simple to implement, represented what was thought to be fundamental care and thus was difficult to achieve (Melnyk, Megan, et al. 348). Joliat, Gaetan-Romain et alia, also noted that to start to change the way care is delivered, there had to be some challenging to the usual care surgical care trends (Joliat, Gaëtan-Romain, et al., par. 1). They go on the further say that the success of improving care and embracing new challenges and way of thinking depended of the leadership of the clinicians and their willingness to apply evidence-based interventions (Joliat, Gaëtan-Romain, et al., par. 1). Data Analysis At Tundra Medical Center, once there is commitment to embrace the literature and embark upon changes, data collection and assessment will drive sustainability. Fitzgerald noted that at UVA, ERAS resulted in better educated patients both before and after surgery, which in turn proved to result in decreased pain and shorter lengths of stay (Fitzgerald, par. 7). The ERAS program at UVA diminished the use of morphine related medications by 74% in one group and 59% in another, shortened length of stay by two days and saved over $1.3 million for a group of 139 patients (Fitzgerald, par. 22). Joliat, Gaetan-Romain et alia state that ERAS and associated pathways do two things: improve patient outcomes and decrease costs (Joliat, Gaëtan-Romain, et al., par. 4). In review of several studies, there was a 40% reduction in morbidity for colorectal cases and for liver specific procedures, surgery complications were reduced by 30-50% (Joliat, Gaëtan-Romain, et al., par. 4). In those same studies, there was a cost savings realized of $1 million for 198 cases (Joliat, Gaëtan-Romain, et al., par. 5).
Commented [MP4]: It’s not enough to cite at the end of a para—the research must be presented in a meaningful way.
Commented [MP5]: We need to know the author’s title in order to be able to trust what he/she is saying
Commented [MP6]: Excellent job of using support in this section, but it must be presented in a meaningful way.
Commented [MP7]: What data? Headings should be specific, they’re like a summary to the text that follows.
The Road to Change and Success There are many examples of successful programs in the volumes of evidence-based literature. Available to help Tundra Medical Center is Improving Surgical Care and Recovery (ISCR). Wick, Elizabeth, et alia reports ISCR is a program partnership of well-respected organizations including with the American College of Surgeons (ACS), Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality as well as the Agency for Healthcare Research and Quality (AHRQ) Safety Program (Wick, Elizabeth, et al., par. 1). ISCR is an effective program, offering support of the ERAS process that starts from the initial roll out including coaching calls, webinars and a nurse consultant with vast experience in establishing ERAS programs (Wick, Elizabeth, et al., par. 6-7). ISCR program is free, funded by AHRQ and is comprehensive, providing evidence-based literature with the pathways to model helping organizations implement their own unique ERAS programs. Please consider partnering the Executive Team and the Office of Strategic Initiatives to implement an ERAS program to improve the surgical care and recovery care of patients. Your support and engagement in this initiative is appreciated. Please let me know if you have any questions and or if I can help in implementing this change. I look forward to improving the care we provide to our patients.
Fitzgerald, Andrea. "Enhanced Recovery Program Reduces Opioid Use and Costs, Benefits Patients at UVA." A Press Ganey Publication, August 2018. INDUSTRY EDGE, https://www.pressganey.com/docs/default-source/default-document-library/enhanced-recovery-program-reduces-opioid-use-and-costs-benefits-patients-at-uva.pdf.
Joliat, Gaëtan-Romain, et al. "Beyond surgery: clinical and economic impact of Enhanced
Recovery After Surgery programs." BMC Health Services Research, vol. 18, no. 1, 29 December 2018, doi:10.1186/s12913-018-3824-0.
Melnyk, Megan, et al. "Enhanced recovery after surgery (ERAS) protocols: Time to change
practice?" Canadian Urological Association Journal, vol. 5, no. 5, October 2011, p. 342-348, doi:10.5489/cuaj.11002.
Wick, Elizabeth C., et al. "AHRQ Safety Program for ISCR expands scope in 2019." Bulletin of
American College of Surgeons, vol. 103, no. 12, 4 December 2018, pp. 16-20, http://bulletin.facs.org/2018/12/ahrq-safety-program-for-iscr-expands-scope-in-2019/#.
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