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Melanie Cole (Host): Enhanced recovery after surgery or ERAS programs aim to hasten functional recovery and improve postoperative outcomes. Here to tell us about the success of these kinds of programs is Dr. Daniel Chu. He’s an Assistant Professor in the Division of Gastrointestinal Surgery at UAB Medicine. Dr. Chu tell us a little bit about the rationale of the ERAS programs and enhanced recovery programs in general.

Daniel Chu, MD (Guest): Absolutely. Well, you know enhanced recovery after surgery is a term that has been used for over a decade now. It’s a program that’s meant to recover patients better and it started in Europe and moved to the United States about several years ago and it was designed primarily for colorectal surgery patients. These patients after undergoing big surgeries, stayed in the hospital the longest, had the most complications, had the highest readmission rates. So, there were many opportunities for improvement. And some very smart people recognized this, and thought are there ways that we can decrease the stress, the insults that are caused by major surgery. And what they did is they put together best practices in surgery meaning individual things that we can do to help recover patients better and linked it all together under one kind of big umbrella. And so, ERAS really basically describes the eighteen to twenty different individual recovery methods that we can use to get patients to recover faster and better.

Melanie: Are they also associated Dr. Chu with overall healthcare costs, improvement even in patient satisfaction for providers?

Dr. Chu: Yeah, absolutely and they are. Traditionally, ERAS, when they first started looking at outcomes; it was really length of stay, it was really a hard metric that was noted to be dramatically improved with ERAS. So, stays in the hospital typically after colon resections were upwards of six to seven days. With ERAS, this is reduced to three to five days. So, that was just kind of the traditional metric that was looked at. And over time now, more recently, because of all the different pressures now placed on hospital systems; we have looked at costs, which are reduced essentially with the reductions in length of stay and decreased readmission rates and patient satisfaction. Patients definitely are more engaged with enhanced recovery since ERAS emphasizes so much on preop education and getting patients to really understand what it means to recover. So, I think patient satisfaction as we are looking at it is something that we are probably going to see more in the next few years, in terms of being improved with enhanced recovery program.

Melanie: Have these programs been considered or are they now considered standard of care across a variety of surgical disciplines or and have they been widely adapted in gastroenterology?

Dr. Chu: Yes, that’s a really good question. So, enhanced recovery started with colon resections, really the first publication came out in 2012 and what’s happened over every year is that it’s been adopted into other surgical specialties. So, from colon resection it went to rectal resections, starting again in colorectal surgery. It has moved on to Whipple procedures or pancreas surgeries into cystectomies in urology, gastric resections and in specialties like gynecology/oncology and bariatric and liver surgeries. So, it has really expanded across the whole spectrum of surgical disciplines. And I would say that it really has started to become standard of care and even the government is really interested in this through AHRQ, they are expanding ERAS across colorectal and to hospitals system wide across the United States. So, even though we know that it has good benefits to patients and it is being adopted across the US; there are still more hospitals that really it can be adopted in. So, bottom line, I think it should be standard of care and we are going to see this kind of increase more in the next several years.

Melanie: So, then identify for us some of the key elements in establishing the successful program. Is there a high degree of coordination that’s required? What kinds of providers are involved?

Dr. Chu: Absolutely. So, the beauty of the ERAS is that if you look at what it requires on paper; these individual recovery methods for patients from preop to postop; it’s fairly simple. These protocols are out there. But the hardest part about ERAS is what you are saying, it’s actually adopting it and implementing it successfully within your institution and so a lot of ERAS focuses on the implementation side. And what it requires I think first and foremost and even in our experience too is, it’s all about the people, the champions who are there and this is a multidisciplinary effort meaning it is not just the surgeon. There are many other champions from anesthesia, from nursing, from informatics, from the administration and so ERAS in a sense it actually forces everyone to get together at the same table and work together to implement this. Since surgical recovery is so complicated, it covers so many different arenas. But when you have those champions there; that’s really, I think how you can successfully implement enhanced recovery.

Melanie: So, is the adoption and implementation of a program like this, it’s not without barriers, correct Dr. Chu, so how should surgical providers be informed on this program and how to apply it to their patients and institution?

Dr. Chu: Yeah, so there are plenty of barriers. That’s absolutely true. And people have actually studied this and some of these barriers include things such as nursing education. You know we find nurses who said that we don’t believe in this. We have always done it this way. Surgeons themselves, anesthesiologists also have a dogma that we have done it always this way, this is the way to do it. So, I think that kind of change, not just for ERAS or for any program, is hard to do, but I think it always again boils down to finding those kind of those key champions and seeing who is in this division who is willing to change and then leveraging that person to work on their colleagues is I think the key. And it starts small. I think it really starts in the trenches so to speak to kind of enact that change, but I think you just have to identify the right people and then start from there.

Melanie: How are you evaluating the impact of a program such as this on outcomes? Do you have any predictors of treatment response or some of the challenges in adherence or in follow up? What strategies are you using to evaluate the impact?

Dr. Chu: Yeah, great question. So, I think the flip side of all that we do in ERAS, sure you can develop it and implement it, but the third part is auditing the results. So, tracking it through a database is absolutely key. And that’s actually a very challenging part about ERAS. One of the things that we measure besides kind of the “traditional outcomes” which is things like length of stay, readmissions, mortality, and complications, and patient satisfaction and cost; we also look kind of on the backside of compliance or adherence to each of these kinds of twenty parameters within ERAS. So, there is a metric where we try to record ERAS compliance and kind of out of those twenty different things that I talked about; people have started to show that if you can follow more than 70% of those ERAS processes; it kind of predicts that you have higher success in achieving lower length of stay, lower readmission, all of those kind of positive metrics. So, a lot of work is really focused on can we improve compliance and adherence to these metrics. And a lot of that then has to do with auditing, just to even identify where you might be deficient and then kind of going back and working on that particular kind of process.

Melanie: So, in summary Dr. Chu, tell other physicians what you would like them to know about the importance of enhanced recovery after surgery and specifically in gastroenterology and when you want them to refer and when you want them to come to you with questions about implementation.

Dr. Chu: Yeah, so I think enhanced recovery really should be standard of care. Now ERAS, it’s a fancy name but it boils down to just providing the best evidence surgical care across the entire spectrum of surgeries for a patient. That’s really what ERAS is. And it just links these all together in a collaborative and multidisciplinary effort. So, it’s simple, it’s not a two-million-dollar robot. It’s not super fancy and it definitely works. So, I think, bottom line, is enhanced recovery or however you want to call it should be kind of done at every institution because it really helps the patients and their families. I think questions about recovery, those are questions that we are always happy to answer. We have gone around Alabama and kind of shared some of the work that’s been done here with all the different champions with ERAS and so here at our institution, we are always happy to share our work. None of this is proprietary. This is all kind of very public knowledge. So, I think we are always open to receive questions about this and even kind of advising in terms of how to implement it. It’s certainly different for every institution, for every culture. So, I think it has to be adapted somewhat, but again, it’s all about finding kind of the right people and the right champions to drive it forward at your institution.

Melanie: Well you speak of it so well Dr. Chu. You explain it and the importance of it so, so very well that other providers have to really sit up and take notice because it is something that as you say, hospitals all around the country should be doing. Tell us about your team as we wrap up. Why is UAB so great to work with?

Dr. Chu: Yeah, so when I came here about four years ago, we had no enhanced recovery program and so this is something that I learned up at the Mayo Clinic where I did some of my training and what’s impressed me greatly about UAB is just how there are champions in every division and so our team really has involved – is truly multidisciplinary and if it wasn’t for ERAS, I actually don’t think I would have had met everyone so quickly. And our team spans the spectrum from anesthesia to nursing and HSIS which is our informatics team to our pharmacists and resident team and also to administration team with UAB Care here at UAB. And so, this team is on paper, truly multidisciplinary and out of every division I can tell you specific basically names and leaders who have really driven this forward. You know this is not a single person’s effort. This is absolutely a team effort which is how we did it at UAB. And especially how it’s expanded now across multiple surgical disciplines. You know we just started in the vascular surgery division led by Dr. Beck and that’s really been a kind of – that’s really novel. ERAS hasn’t been done really in vascular surgery. But so because of that team, those champions, ERAS is now expanding into a really a new frontier there.

Melanie: Thank you so much for joining us today Dr. Chu and sharing your expertise and explaining why this is so important. You’re listening to UAB Med Cast. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.