By Philip Corvo, MD, MA, FACS, and Wesley Knauft, MD
Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, designed to minimize the effects of surgical stress and safely facilitate early discharge. This multidisciplinary approach to standardizing care of the surgical patient with best practices has been shown to improve outcomes in nearly all surgical specialties, including shortening length of stay (LOS) by 30% to 50%, with similar reductions in complications and decreased readmissions. Compared to standard care, ERAS protocols have produced cost savings of up to $7,129 per patient.
Guidelines for postoperative pain management strongly recommend opioid-sparing techniques, such as regional anesthesia (RA), for perioperative pain control. Many studies have shown that ultrasound-guided regional anesthesia (UGRA) results in faster onset times and improved block success, while reducing the need for opioids. Not only does this technique reduce patients’ exposure to highly addictive drugs , but it can also have a dramatic financial impact. A study at the University of Virginia Healthcare System reported direct cost savings of $777,061 in the first six months after launching an ERAS protocol that included RA. The study also reported that opioid usage fell by 80%, while patient satisfaction doubled, leading the researchers to conclude that, “small investments in the perioperative environment can lead to large returns.”
Our experience at Saint Mary’s Hospital, Trinity Health Of New England, a 347-bed acute care community teaching hospital in Waterbury, Connecticut, demonstrates the clinical and financial benefits of an ERAS program that includes UGRA. Since the October 2015 launch of our opioid-sparing ERAS program, we have seen striking improvements in the safety and quality of care for patients undergoing colorectal surgery, along with substantial reductions in costs, complications, and opioid usage. Moreover, the average LOS has decreased from 6.3 days to 4.3, resulting in increased revenues of $750,000. We have also seen a dramatic reduction in surgical site infections (SSIs), a complication that costs, on average, $28,000 per infection, according to the Centers for Medicare and Medicaid. The decrease in SSIs has yielded cost savings of $1.5 million.
ERAS Dramatically Reduces Length of Stay and Improves Postoperative Pain Control
How did we achieve those outcomes? While we started our program with colon-based surgery, the implications are also applicable to many other procedures and surgical specialties. Indeed, all 26 of Connecticut’s acute care hospitals are working to establish opioid-sparing ERAS protocols as part of the Connecticut Surgical Quality Collaborative. Here is a look at our ERAS program and the lessons learned.
Building our hospital’s ERAS program has been a team effort that required buy-in from all parties. While ERAS is sometimes misconstrued as “fast-track surgery,” the true goal is to optimize every facet of the patient’s surgical experience. That means that the entire hospital staff needs to understand its crucial role in elevating the safety and quality of perioperative care. It is also incumbent on financial leaders of hospital systems to understand the drivers of cost and quality in their organizations and the cost-effective use of technologies, such as point-of-care ultrasound (POCUS).
The use of POCUS to guide regional anesthesia techniques, such as the transversus abdominis plane (TAP) blocks used in our program, is an important example of cost-effective use of technology, since this technique has been shown to be safe and easily performed, with a recent comparative study demonstrating that patients who received TAP blocks while undergoing laparoscopic colon resection had a significantly shorter LOS (3.4 days versus 5.7 days for patients who received epidural). Moreover, the TAP group had lower pain scores and a 51% reduction in opioid use.
Improved Clinical Outcomes and a $2.25 Million Financial Impact
Since the impetus behind ERAS is improving postoperative outcomes and the quality of the patient’s recovery, it is crucial to monitor results, audit compliance and hold all parties accountable. It is also important to celebrate successes, share them with the entire team and strive to take the safety and quality of care to an even higher level. In July 2018, we analyzed the impact of the first three years of our ERAS program with the following findings:
- A two-day decrease in the average LOS has resulted in increased revenue of $750,000 (an increased revenue of nearly $5,000 per patient)
- Many patients were discharged after 2.3 days. For each one-day decrease in LOS, our revenue per patient rose by $2,406.
- Our rate of SSIs has dropped from a statistically acceptable rate of 15% in 2014 to less than 2%, resulting in a $1.5 million savings
- The combined financial impact of ERAS program (cost savings plus increased revenue) was $2.25 million in its first three years.
Improved Patient Satisfaction with Reduced Opioid Use
Opioid-sparing techniques are key components of our ERAS program. Prescription opioid abuse has become an epidemic in the United States, killing more Americans each year than car crashes. Nationally, more than 1,000 Americans are treated in emergency departments every day for misuse of these drugs. Many of them trace their first exposure to narcotics to use for postsurgical pain relief.
Our program has reduced our patients’ consumption of opioids by 60%. Many patients are able to avoid narcotics entirely, yet report that their postsurgical pain is well controlled with UGRA and non-narcotic medications. We have also observed a striking increase in patient satisfaction. One of the first patients treated with our ERAS program, a 44-year-old woman with colon cancer, recently told us that she’d been very nervous when she arrived at Saint Mary’s for her pre-surgical consultation, due to complications she’d experienced with a previous abdominal surgery, performed in 2009 at another hospital.
This patient also feared opioid addiction because that had happened to a friend after he was treated for injuries sustained in a motor vehicle accident. She was extremely relieved to learn that Saint Mary’s had implemented ERAS protocols designed to reduce both of the risks she was concerned about. After the successful removal of her tumor, she recovered quickly without opioid use. She stated, “Compared to my 2009 surgery, everything was better. Instead of being so heavily medicated with morphine that I felt like a zombie – yet was still in such excruciating pain that I could hardly move – I actually felt more comfortable with the non-narcotic medications.”
After her 2009 surgery, the patient had suffered a bleeding complication that doubled her length of stay and required surgical intervention. With our ERAS program, she was able to go home in two days and felt well enough to attend Independence Day celebrations the very next weekend. “You’ve saved my life,” said the patient, who remains cancer-free three years after her surgery. It is stories like this that highlight the priceless satisfaction of using ERAS to make the surgical experience as safe, successful and pain-free as possible for our patients.
– Philip Corvo, MD, MA, FACS, is the chairman of surgery and director of surgical critical care at Saint Mary’s Hospital, Trinity Health Of New England, in Waterbury, Connecticut. He is also governor-at-large of the American College of Surgeons, founding president of the Connecticut Surgical Quality Collaborative and a past president of the Connecticut Chapter of the American College of Surgeons. Corvo has also served as the past health commission for the city of Stamford.
– Wesley Knauft, MD, is the Chairman of Anesthesiology at Saint Mary’s Hospital, Trinity Health Of New England, in Waterbury, Connecticut. Knauft is affiliated with Woodland Anesthesiology Associates PC.