Enhanced recovery initiatives that standardize and coordinate perioperative care are designed to improve patient recovery and decrease aggregate complications after surgery. The enhanced recovery program at Vanderbilt University Medical Center, launched in 2014, developed out of a collaboration between surgery and anesthesiology and now spans multiple specialties.
“We realized that we could deliver higher-quality care through communication and coordination throughout the perioperative care arc,” said Timothy Geiger, M.D., director of Vanderbilt’s Colon and Rectal Surgery Program and executive medical director of the Surgery Patient Care Center. “And, we had an engaged anesthesia group that was willing to take this on.”
“We realized that we could deliver higher-quality care through communication and coordination throughout the perioperative care arc.”
“Vanderbilt leadership wants us to do ‘enhanced recovery pathway for all’,” added Matt McEvoy, M.D., a professor and vice-chair for education in the Department of Anesthesiology. “If there’s a definable service line, whether it’s ambulatory or in-patient, we’re looking to collaborate and implement the principles of care standardization.”
Designing the Program
Geiger and McEvoy began designing their program by looking at all care components within colorectal surgery, matching them up to the latest evidence in perioperative care. They had two goals: improve perioperative communication and decrease unnecessary variability, in order to improve patient recovery while reducing length of stay, complications and cost.
The central component of the enhanced recovery program, they knew, must be a surgical champion. Additional key stakeholders would include anesthesiology, nursing, and pharmacy. The Vanderbilt Anesthesia Perioperative Consult Service was established to contribute to planning the entire surgical episode through post-discharge recovery.
In a 2017 study of 1,182 colorectal surgery patients, Vanderbilt researchers found that the new program was associated with significantly reduced complication rates across a range of ACS NSQIP categories. It also led to a >1.5-day reduction in length of stay and reduced total hospital costs by over 20 percent for the colorectal surgery population.
A second study looked at the addition of goal-directed hemodynamic therapy for colorectal surgery patients, and several additional evaluations are underway.
Safeguarding High-risk Patients
The enhanced recovery team established the High-Risk Surgical Encounter (Hi-RiSE) Optimization Clinic, where surgical patients at higher risk of developing complications are comprehensively evaluated and interventions can be more efficiently coordinated in weeks prior to surgery.
The clinic performs structure evaluations for surgical patients at high risk for complications such as delirium, adverse cardiac events, postoperative pulmonary complications, acute kidney injury and hyperglycemia. Services offered in preparation for surgery may include optimization of anemia and nutrition, as well as help with smoking cessation. This is coordinated with intraoperative and postoperative care planning to ensure patients are fully ready for a successful procedure.
“It is a cultural shift to say, ‘I’m going to hit the brakes.'”
“As surgeons, we really want to operate to fix the problem as soon as we can,” Geiger said. “It is a cultural shift to say, ‘I’m going to hit the brakes, I’m going to let the patient get ready and then we’re going to the OR.’ But being able to get high-risk patients ready for surgery makes all the difference in the world.”
Priority Service Lines
As the team has continued to target more service lines for enhanced recovery protocol implementation, it has grown to include a project manager, dashboard analytics and a design thinking team.
In urology, the pathway for ureteroscopic stone treatment, published in the Journal for Endourology, has demonstrated increased patient satisfaction, and dramatically lowered opioid consumption after surgery.
Recent additions to the enhanced recovery program include major gynecologic surgery – oncology, hysterectomy and complex reconstruction – and a protocol for geriatric hip fracture.