Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and joining me today to highlight the Enhanced Recovery Program at UAB Medicine is Dr. Daniel Chu. He's a Professor of Surgery, the Division Director in the Division of GI Surgery, and a colorectal surgeon at UAB Medicine. Dr. Chu, thank you for joining us again. I'd like you to tell us a little bit about the ERP model. As a comprehensive initiative that works to improve patient recovery through methods such as promoting multimodal anesthesia methods, working to reduce postoperative opioid use, there are a lot of uses for this model. Tell us a little bit about that in general.

Dr Daniel Chu: Absolutely. Well, thank you for having me on this program. So, enhanced recovery programs, it's a fancy word, but really all it does is describe how we recover patients during surgery. And so, this program is really comprehensive and it works on patients before the day we do the surgery, the day of the surgery, and in the days after the surgery as the patients recover. And all it does is it just organizes all the best practices that we know is out there and puts it into one organized way and delivers it to the patients from the beginning to the very end. And it really takes about 15 to 16 different steps that we give to help the patients achieve the best possible recovery and then the best possible outcome.

Melanie Cole, MS: Dr. Chu, for other providers that are looking to establish an ERP program at their centers, tell us about starting this new model, assembling your task force. Who does your team consist of?

Dr Daniel Chu: So, as we know with surgery and how we recover patients, it's not just one person doing everything. It's not just the surgeon. The Anesthesia team is incredibly important. The Nursing teams are important. And so, enhanced recovery is actually a great excuse to get everyone together. And so, your task force really should be multidisciplinary. It should be the surgeon. It should be an anesthesiologist. It should be an entire team of nurses who are involved with surgical patients from pre-op clinics to the floors. And so, that's sort of the team that's assembled around enhanced recovery. And it's the most critical part of getting it to work at any institution, any hospital, any type of location.

Melanie Cole, MS: So, you told us about the multidisciplinary aspect and who you brought into this task force, but identify for us some of the key elements to establish a successful ERP program. As you say, it takes place before, during, and after surgical procedures. So, what does that mean for other providers? Take us through that whole program.

Dr Daniel Chu: So, the program development, I think is going to be similar to kind of any other program that one might think about, but enhanced recovery programs, people have studied this extensively and have nailed down some of those critical phases. So, this phase really, number one, starts with identifying champions IN each of those disciplines, Surgery, Anesthesia, and Nursing, once you get that team together into a room just to communicate and to talk with each other, you have to identify the actual protocol. So, what order sets, what are the actual components that would work for your situation?

And so, this is something that can be pulled from societies like the International Enhanced Recovery Society has a website that have protocols for almost every surgical specialty. So, it's already been done. you do not need to reinvent the wheel. Once you get a protocol down and it's established, then the team works to get other buy-In from the larger teams that are out there. And once everyone can agree on the protocol and how to deliver it at the institution, then it gets implemented. And so, that implementation is really the key. And I think, there's a lot of nuances in terms of how to do it. It certainly depends on the institution, how small or how big it is, whether or not you have an electronic medical record system. If you have that, that's great. You can put this protocol into that system. That'll help a lot with how to deliver it. And then, once you deliver it, then you have to maintain it, and then you have to audit it, meaning you have to get data on the backend to see how you're actually delivering all those different pieces of enhanced recovery.

And so, we typically like to say, with enhanced recovery, that there's a development phase, there's a implementation phase, there's a maintenance phase, and there's an auditing phase. And so, those are the four areas that anyone will find themselves in when they're developing and putting forth this program.

Melanie Cole, MS: What benefits have you seen as a provider since implementing this? How are the patients reacting to it?

Dr Daniel Chu: Patients love it, providers love it too, because what it does is it standardizes care. So, there's no variations, you don't have to think too hard here, you deliver what we know are best practices to all patients. And by doing that, and if you can achieve and hit 15 out of those 15 components, patients are at the highest probability of having the best outcome, meaning minimal pain, minimal nausea, vomiting, minimal complications. And because of that, their recovery is much faster, they get closer to going home much sooner. And so we see in the literature that length of stays, for example, are much shorter for patients who go through enhanced recovery programs.

And it's important to point out that enhanced recovery programs aren't designed to reduce length of stay. Enhanced recovery programs are designed to improve and accelerate the good recovery of patients. And if you do that, and you happen to have really great recovery, and then you get reduced length of stay, great. But again, the point of it is to improve the recovery of patients. So, patients love it. They have minimal pain after major surgery, minimal nausea, vomiting, and providers love it because the order sets are very straightforward and very easy to follow. Nurses love it because they know exactly what the protocol is. And the expectations that patients need to achieve to hit all the checkpoints for them to get home.

Melanie Cole, MS: Dr. Chu, in my first question, I mentioned how it's also been helpful to reduce postoperative opioid use and encouraging patients to engage with their own healing process. Tell us a little bit about that. How have you seen it working to reduce that postoperative opioid use? How does it work in that case?

Dr Daniel Chu: So, one of the tenants or one of the key principles of enhanced recovery programs is, as you've alluded to, minimizing the amount of opioids or narcotics that patients get. Back in the days, patients would come out of the operating rooms on a PCA, on a bunch of morphine, a bunch of Dilaudid to help with pain management. And what you find is that those opioids, guess what it does? It actually slows your gut down and it prevents you from recovering quickly and you actually are in so much pain that you need it. It's a Catch 22 and it's a vicious cycle that happens. And so, enhanced recovery works on this early evidence that's really now been shown to be clearly true, that if you give patients before surgery, for example, while they're in the holding area, before they're even going to the operating room, Tylenol, Motrin, and give them those medications and do a regional block, meaning you give an anesthetic either to the spine, called a spinal, or to the muscles on the side like a tap block. If you do all of that before you even put an incision on the patient, you actually put that patient on a completely different curve of recovery, meaning they will wake up with much, much less pain. And when you set someone on that curve, guess what? You actually don't need to put the patient on opioids after surgery. You can put them only on around-the-clock Tylenol and around-the-clock Motrin if allowed. And so, we have many patients who go through major abdominal surgery who are never on any opioids and are only on Tylenol and Motrin, because we've used this technique of doing all these things even before we make the incision.

And when you set patients on that curve, they use little to no opioids, which is great. And then, when they go home, they're on little to no opioids. And so, that is how enhanced recovery has really touched upon the opioid crisis, and it's a great way to take care of surgical patients now.

Melanie Cole, MS: Isn't that something? This is such a great initiative and it really puts a spotlight on how well these kinds of multimodal approaches work. And as you say, starting even before makes such a difference afterwards. As we wrap up, I'd like you to reiterate the medical impact of this type of program today and how it really has encouraged patients to engage and be involved with their own healing process. Because if they are not listless and on opioids and concerned about that or in pain, they're going to be more adherent to the whole process and to your approach. So, tie that all together for us, Dr. Chu.

Dr Daniel Chu: Yeah, that's absolutely right. So, I think before we thought of surgical recovery as a very passive process, it's just an order, everyone follows it, and that's it. But now, we know through enhanced recovery, we have a great view now and understand that actually patient engagement, just like providers have to be engaged, matters a lot.

Enhanced recovery, these sort of 15 to different components, a lot of these components actually require patient engagement. Early walking, for example. This is one big component that we know benefits patients and accelerates their recovery. So walking, this requires input and engagement. Patients need to want to walk and know how important it is. It's not just the nurses and the providers saying you have to walk. So we need sort of that engagement, on that one component. Early diet, another area that we need patients to understand why it's important to stimulate the gut early after surgery. Opioids, setting the expectations for patients that Tylenol and Motrin is the foundation of post-op pain management. We also need patients engaged with that. So, you can see that many of the components of enhanced recovery require patient input and patient engagement. And so, that's really a change in paradigm of how we look at surgical recovery.

What's interesting, you know, we did a research project that was just published where we looked at the role of pre-op education and how important that was to this whole recovery process. And what's really interesting is that if a patient receives quality education before surgery, that itself is a determinant of everything that happens downstream, meaning like the chances of a patient walking. The chances of a patient having an early diet, that all matters with that singular component early on in this whole journey.

If you do not have good education, then what we see is that there's non-adherence to all kinds of components of enhanced recovery downstream. So, enhanced recovery really has been sort of a model you can really see how critical it is for patients to also be engaged in that recovery.

Melanie Cole, MS: Thank you so much, Dr. Chu, for joining us today and really filling us in on the advancements made in Enhanced Recovery Programs. Thank you so much. And for more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.