Enhanced recovery after surgery (ERAS) is a protocol designed to achieve early recovery after surgical procedures by helping the patient and reducing the profound stress response following surgery.
Listen in as Kyle Cologne, MD discusses Palmdale Regional Medical Center's commitment to Enhanced recovery after surgery.
Enhanced Recovery After Surgery
Featured Speaker:
Kyle Cologne, MD
Kyle G. Cologne, MD is an Assistant Professor of Clinical Surgery at Keck Medicine of USC and is a member of the medical staff at Palmdale Regional Medical Center and at Keck Medicine of USC. Transcription:
Enhanced Recovery After Surgery
Melanie Cole (Host): Enhanced recovery after surgery is a protocol designed to achieve early and optimal recovery after surgical procedures by helping the patient in reducing the profound stress response following surgery. My guest today is Dr. Kyle Cologne. He’s a colorectal surgeon and a member of the medical staff of Palmdale Regional Medical Center. Welcome to the show, Dr. Cologne. Explain to the listeners what is enhanced recovery and is this something that is done by the medical professionals involved in the procedure from start to finish?
Dr. Kyle Cologne (Guest): Thanks for having me, Melanie. The enhanced recovery is exactly what it sounds like. It’s designed to make patient’s recovery after a stressful event, such as surgery, put themselves really in a better position to handle that stress as they go through the perioperative period.
Melanie: Let’s talk about what that enhanced recovery looks like. Starting with the prehospital phase, what’s involved?
Dr. Cologne: Let me just take that one step further. The enhanced recovery is really evolved in the field of colorectal surgery and now been expanded to other fields or disciplines within surgery. The reason why we use it is it does essentially two major things for us – it decreases the amount of time patients spend in the hospital so they can get back to their families, back to work faster and perhaps, more importantly, it decreases the number of complications they experience by about 50%. That’s a pretty profound statement that the use of this protocol, which we’ll get into in a second, just the use of this protocol alone, doing nothing else differently from what we've normally done, can decrease your complication rate by 50%. That’s a pretty incredible statement and that’s the reason why we've seen such a taken off of this in recent years.
Melanie: That is an amazing number. Then what’s involved? Starting with the patient education – the prehospital phase – what are you telling the patients?
Dr. Cologne: We have at Palmdale and at USC a number of different protocols that are in place and it starts by just explaining to everybody what is enhanced recovery. Basically, what that allows us to do is it gets the patient to be their own advocate. We tell them when you're in the hospital, you're going to be on a number of different medications on a schedule, so it’s not like you're waiting until you have pain and then asking for a medication – you should be getting those medications on a schedule. Should also be things like you are allowed to drink liquids up until the morning of your surgery. It used to be that we would have people fasting for long periods before surgery – we’re trying to minimize the disruption to your daily lifestyle to help you cope better with the stress of something like surgery.
Melanie: There's a bit of education, the pain management plan as you spoke of, really an optimization. Now what about the preoperative phase? What's involved in that?
Dr. Cologne: The other thing that’s involved with the preoperative phase is we’ve incorporated into this bundle, if you will, some things that we’ll try and decrease events after surgery. For example, infections that can happen. It’s part of the enhanced recovery – we want people to shower with specialized soap, we’ll sometimes have them take a mechanical and/or antibiotic bowel preparation – all these things are designed to get them in the best place possible to minimize any of the complications of surgery. The other part to this is we will usually send them either to their primary care doctor or someone else if they have a number of comorbidities or other medical problems to try and optimize those as much as possible so that their impact after surgery will be minimized.
Melanie: What about intraoperative? For patients, this is during the operation. What are you doing to maximize that recovery?
Dr. Cologne: There's a whole separate components of things we do intraoperatively and then continue on postoperatively. The patients may not necessarily see but we’re doing them for the same reasons – to try to get to that 50% reduction of their complication rates and decrease the time they spend in the hospital. This is things like we use specialized antibiotics that cover the bacteria we know that they're at risk for, we use specialized fluid strategy in terms of what we give their body during the surgery – we don’t want to give them too much, we don’t want to give them too little – and one of the big things that we found is an emphasis on using laparoscopic or minimally invasive techniques because that tends to decrease the amount of pain patients have, just decreasing the size of the incision results in less stress on the body. All of these things get back to getting the patient recovered from surgery and out of the hospital faster.
Melanie: You mentioned postoperative and that you're doing some of things and patients may not see that, but you're still doing them with that same 50% goal, but what about the postoperative phase that they might see – like early mobilization or nutrition, pain management education – these types of things?
Dr. Cologne: The postoperative period is again an incredible important component of this bundle and we’re doing things now that it used to be 20 or 30 years would have been unthinkable. We want the patients eating and drinking as soon as possible after surgery. Once they emerge from anesthesia, sometimes there is associated nausea just with the anesthesia medicine, but once they can take in that fluid and eat, we want them doing that because that's what you do when you're at home. Again, we’re trying to minimize the impact that surgery has on your lifestyle. We also want to get patients up and walking around – we don't want them sitting in bed all day long because those types of things are going to minimize complications and get them out of the hospital faster. In surgery, we do a number of other things – sometimes we use drains within an enhanced recovery protocol, we try to minimize the number of drain, sometimes there is a catheter for the urine that we leave and we want to get that out as soon as possible after surgery.
Melanie: What about things like nausea and vomiting management? Because that’s something that patients think about. When they're on pain medication or post anesthesia, they think ‘I'm going to be throwing up and it’s going to hurt so much.’ What do you do to manage that?
Dr. Cologne: There's about 15% to 20% of people whose intestines will go to sleep after surgery – something we call ileus – that’s the medical term for the intestines going to sleep. The reality is it only happens to about 15% or 20% of people in the vast majority of everyone else will do just fine. There is a part of the assessment of patients before they go to surgery that may put them at risk for postoperative nausea and vomiting, and we can do things again in the intraoperative phase and give them medications to try and preemptively prevent some of those symptoms. Yes, we know that there are people that are at high risk for it, but we can know that ahead of time and try to minimize the impact that some of those things have. When you look at the people that have their surgery done with an enhanced recovery protocol, yes there will be a very small percentage of people that do experience that, but the vast majority actually do not.
Melanie: Onto the post discharge phase – after the patient is discharged – how is enhanced recovery involved with follow up, primary care and therapy?
Dr. Cologne: I'm glad you brought that up because one of the initial concerns about using an enhanced recovery protocol is if we are sending the patient's home from the hospital sooner, we worry they might be at more risk for coming back to the hospital and getting readmitted. The fact of the matter is as we've gotten more information about this is that the opposite is actually true. A patient that shows that they are ready to go home, even as soon as the first or the second day after a major colon those are the patient's surgery, that are going to go home, they're going to stay at home and they're going to do just fine. Even knowing that, we still want to have a follow up phone call with these patients and just check in with them because sometimes we can identify something that’s happening at home that we may want to have them come in, get checked out in the office, to prevent them from coming back and being readmitted to the hospital.
Melanie: Afterwards, the continued quality improvement and team activities. You and your team getting together to discuss this particular case, patient surveys, staff input – finish off enhanced recovery for us.
Dr. Cologne: The enhance recovery process has been something that’s always in evolution. If you look at the most successful enhanced recovery programs, it’s not just one or two things – it’s being compliant with everything in the enhanced recovery bundle. That’s part of this follow up that you're talking about. You have to continuously go back and look at how we as providers or doctors or physician extenders doing at explaining this patients, making sure that the patients actually do this, and then afterwards that they do all the components of it. Being compliant with the entire bundle is what makes your successful and get you that decrease by 50% in the complication rate and get your length of hospital stay shorter by one or two days. If you are only compliant with about 80% of the bundle itself, that’s when you start to see fallouts and longer lengths of stay so you have to continuously revisit things from an administrative standpoint to just make sure that we are being as good as we can at implementing this enhanced recovery protocol.
Melanie: What an interesting topic, Dr. Cologne. In summary, what would you like to tell people who may need surgery, about how their team of surgeons and the entire staff can help speed up the process of these recovery with these enhanced recovery protocols?
Dr. Cologne: I think it comes down to asking your surgeon “do you use an enhanced recovery protocol?” There's some data from a few years back that suggests that only about 30% of hospitals nationwide or surgeons are actually using this type of enhanced recovery protocol. If your surgeon has one in place and can explain it to you, that’s the first step, and then just being your own advocate – asking more information about it, trying to figure out what sort of things that I'm going to be doing in the hospital – because then you can act as your own advocate. When that may not be happening, you can ask “what happened to my scheduled pain medicines that I'm supposed to be getting? I thought I was supposed to get this urinary catheter out. How come that hasn’t happened yet?” Doing things like that is what drives the enhanced recovery process so that everyone gets as much out of it as they possibly can.
Melanie: Why should they come to Palmdale Regional Medical Center for their care?
Dr. Cologne: I'm glad you asked that. The quality of care that patients get at Palmdale I think is exceptional, particularly with our group with colorectal surgery. We use this enhanced recovery protocol, we use laparoscopic approaches as much as possible, and particularly administration at Palmdale has been 110% supportive of these types of approaches. I think they realize the type of results, the improvement in quality and the improvement in patient care and outcomes that you can get with something like this.
Melanie: Thank you so much for being with us today, Dr. Cologne. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to PalmdaleRegional.com. That’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.
Enhanced Recovery After Surgery
Melanie Cole (Host): Enhanced recovery after surgery is a protocol designed to achieve early and optimal recovery after surgical procedures by helping the patient in reducing the profound stress response following surgery. My guest today is Dr. Kyle Cologne. He’s a colorectal surgeon and a member of the medical staff of Palmdale Regional Medical Center. Welcome to the show, Dr. Cologne. Explain to the listeners what is enhanced recovery and is this something that is done by the medical professionals involved in the procedure from start to finish?
Dr. Kyle Cologne (Guest): Thanks for having me, Melanie. The enhanced recovery is exactly what it sounds like. It’s designed to make patient’s recovery after a stressful event, such as surgery, put themselves really in a better position to handle that stress as they go through the perioperative period.
Melanie: Let’s talk about what that enhanced recovery looks like. Starting with the prehospital phase, what’s involved?
Dr. Cologne: Let me just take that one step further. The enhanced recovery is really evolved in the field of colorectal surgery and now been expanded to other fields or disciplines within surgery. The reason why we use it is it does essentially two major things for us – it decreases the amount of time patients spend in the hospital so they can get back to their families, back to work faster and perhaps, more importantly, it decreases the number of complications they experience by about 50%. That’s a pretty profound statement that the use of this protocol, which we’ll get into in a second, just the use of this protocol alone, doing nothing else differently from what we've normally done, can decrease your complication rate by 50%. That’s a pretty incredible statement and that’s the reason why we've seen such a taken off of this in recent years.
Melanie: That is an amazing number. Then what’s involved? Starting with the patient education – the prehospital phase – what are you telling the patients?
Dr. Cologne: We have at Palmdale and at USC a number of different protocols that are in place and it starts by just explaining to everybody what is enhanced recovery. Basically, what that allows us to do is it gets the patient to be their own advocate. We tell them when you're in the hospital, you're going to be on a number of different medications on a schedule, so it’s not like you're waiting until you have pain and then asking for a medication – you should be getting those medications on a schedule. Should also be things like you are allowed to drink liquids up until the morning of your surgery. It used to be that we would have people fasting for long periods before surgery – we’re trying to minimize the disruption to your daily lifestyle to help you cope better with the stress of something like surgery.
Melanie: There's a bit of education, the pain management plan as you spoke of, really an optimization. Now what about the preoperative phase? What's involved in that?
Dr. Cologne: The other thing that’s involved with the preoperative phase is we’ve incorporated into this bundle, if you will, some things that we’ll try and decrease events after surgery. For example, infections that can happen. It’s part of the enhanced recovery – we want people to shower with specialized soap, we’ll sometimes have them take a mechanical and/or antibiotic bowel preparation – all these things are designed to get them in the best place possible to minimize any of the complications of surgery. The other part to this is we will usually send them either to their primary care doctor or someone else if they have a number of comorbidities or other medical problems to try and optimize those as much as possible so that their impact after surgery will be minimized.
Melanie: What about intraoperative? For patients, this is during the operation. What are you doing to maximize that recovery?
Dr. Cologne: There's a whole separate components of things we do intraoperatively and then continue on postoperatively. The patients may not necessarily see but we’re doing them for the same reasons – to try to get to that 50% reduction of their complication rates and decrease the time they spend in the hospital. This is things like we use specialized antibiotics that cover the bacteria we know that they're at risk for, we use specialized fluid strategy in terms of what we give their body during the surgery – we don’t want to give them too much, we don’t want to give them too little – and one of the big things that we found is an emphasis on using laparoscopic or minimally invasive techniques because that tends to decrease the amount of pain patients have, just decreasing the size of the incision results in less stress on the body. All of these things get back to getting the patient recovered from surgery and out of the hospital faster.
Melanie: You mentioned postoperative and that you're doing some of things and patients may not see that, but you're still doing them with that same 50% goal, but what about the postoperative phase that they might see – like early mobilization or nutrition, pain management education – these types of things?
Dr. Cologne: The postoperative period is again an incredible important component of this bundle and we’re doing things now that it used to be 20 or 30 years would have been unthinkable. We want the patients eating and drinking as soon as possible after surgery. Once they emerge from anesthesia, sometimes there is associated nausea just with the anesthesia medicine, but once they can take in that fluid and eat, we want them doing that because that's what you do when you're at home. Again, we’re trying to minimize the impact that surgery has on your lifestyle. We also want to get patients up and walking around – we don't want them sitting in bed all day long because those types of things are going to minimize complications and get them out of the hospital faster. In surgery, we do a number of other things – sometimes we use drains within an enhanced recovery protocol, we try to minimize the number of drain, sometimes there is a catheter for the urine that we leave and we want to get that out as soon as possible after surgery.
Melanie: What about things like nausea and vomiting management? Because that’s something that patients think about. When they're on pain medication or post anesthesia, they think ‘I'm going to be throwing up and it’s going to hurt so much.’ What do you do to manage that?
Dr. Cologne: There's about 15% to 20% of people whose intestines will go to sleep after surgery – something we call ileus – that’s the medical term for the intestines going to sleep. The reality is it only happens to about 15% or 20% of people in the vast majority of everyone else will do just fine. There is a part of the assessment of patients before they go to surgery that may put them at risk for postoperative nausea and vomiting, and we can do things again in the intraoperative phase and give them medications to try and preemptively prevent some of those symptoms. Yes, we know that there are people that are at high risk for it, but we can know that ahead of time and try to minimize the impact that some of those things have. When you look at the people that have their surgery done with an enhanced recovery protocol, yes there will be a very small percentage of people that do experience that, but the vast majority actually do not.
Melanie: Onto the post discharge phase – after the patient is discharged – how is enhanced recovery involved with follow up, primary care and therapy?
Dr. Cologne: I'm glad you brought that up because one of the initial concerns about using an enhanced recovery protocol is if we are sending the patient's home from the hospital sooner, we worry they might be at more risk for coming back to the hospital and getting readmitted. The fact of the matter is as we've gotten more information about this is that the opposite is actually true. A patient that shows that they are ready to go home, even as soon as the first or the second day after a major colon those are the patient's surgery, that are going to go home, they're going to stay at home and they're going to do just fine. Even knowing that, we still want to have a follow up phone call with these patients and just check in with them because sometimes we can identify something that’s happening at home that we may want to have them come in, get checked out in the office, to prevent them from coming back and being readmitted to the hospital.
Melanie: Afterwards, the continued quality improvement and team activities. You and your team getting together to discuss this particular case, patient surveys, staff input – finish off enhanced recovery for us.
Dr. Cologne: The enhance recovery process has been something that’s always in evolution. If you look at the most successful enhanced recovery programs, it’s not just one or two things – it’s being compliant with everything in the enhanced recovery bundle. That’s part of this follow up that you're talking about. You have to continuously go back and look at how we as providers or doctors or physician extenders doing at explaining this patients, making sure that the patients actually do this, and then afterwards that they do all the components of it. Being compliant with the entire bundle is what makes your successful and get you that decrease by 50% in the complication rate and get your length of hospital stay shorter by one or two days. If you are only compliant with about 80% of the bundle itself, that’s when you start to see fallouts and longer lengths of stay so you have to continuously revisit things from an administrative standpoint to just make sure that we are being as good as we can at implementing this enhanced recovery protocol.
Melanie: What an interesting topic, Dr. Cologne. In summary, what would you like to tell people who may need surgery, about how their team of surgeons and the entire staff can help speed up the process of these recovery with these enhanced recovery protocols?
Dr. Cologne: I think it comes down to asking your surgeon “do you use an enhanced recovery protocol?” There's some data from a few years back that suggests that only about 30% of hospitals nationwide or surgeons are actually using this type of enhanced recovery protocol. If your surgeon has one in place and can explain it to you, that’s the first step, and then just being your own advocate – asking more information about it, trying to figure out what sort of things that I'm going to be doing in the hospital – because then you can act as your own advocate. When that may not be happening, you can ask “what happened to my scheduled pain medicines that I'm supposed to be getting? I thought I was supposed to get this urinary catheter out. How come that hasn’t happened yet?” Doing things like that is what drives the enhanced recovery process so that everyone gets as much out of it as they possibly can.
Melanie: Why should they come to Palmdale Regional Medical Center for their care?
Dr. Cologne: I'm glad you asked that. The quality of care that patients get at Palmdale I think is exceptional, particularly with our group with colorectal surgery. We use this enhanced recovery protocol, we use laparoscopic approaches as much as possible, and particularly administration at Palmdale has been 110% supportive of these types of approaches. I think they realize the type of results, the improvement in quality and the improvement in patient care and outcomes that you can get with something like this.
Melanie: Thank you so much for being with us today, Dr. Cologne. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to PalmdaleRegional.com. That’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.