VCU Health is working to improve patient outcomes for expedited recovery after surgery.
Dr. Michael Scott, Director of Critical Care Anesthesiology at Virginia Commonwealth University, discusses the Enhanced Recovery After Surgery (ERAS) program.
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How You Can Get Better, Faster After Surgery
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Learn more about Michael Scott, MD
Michael Scott, MD
Michael Scott, MD is the Director of Critical Care Anesthesiology at Virginia Commonwealth University.Learn more about Michael Scott, MD
Transcription:
How You Can Get Better, Faster After Surgery
Prakash Chandran (Host): VCU Health is making changes to the care of patients received before, during and after surgery so they can get better faster. They are doing this through a program called ERAS or Enhanced Recovery After Surgery. It’s a standardized series of small measures that physicians, care teams and the patients themselves take that make a big impact on how they recover after an operation. I am Prakash Chandra and in this episode of Healthy with VCU Health, we talk to Dr. Michael Scott who comes to us from the UK and is the Director of Critical Care Anesthesiology at VCU Health. Dr. Scott also spearheads the ERAS program at the VCU Medical Center. Dr. Scott, it is a pleasure to have you here today. Can you tell us a little bit more about yourself and your experience with the ERAS program?
Michael Scott, MD (Guest): ERAS started in Europe at about 15 years ago and I was one of the pioneers of developing this program, which does not actually change the surgical procedure itself, but changes what happens to the patient around the time of surgery both before, during and after. The general principles are to make the patient fitter for surgery, reduce the injury and the harm caused sometimes by interventions that we do in medicine, reduce the amount of opioids patients get and then accelerate recovery afterwards by removing drips, drains and mobilizing patients and feeding them very quickly.
My experience really first started in about 2002 in colorectal surgery, and my hospital back in the UK started pioneering this. In addition, slowly in the next few years, the whole program has formalized. There was a society called the Enhanced Recovery after Surgery Society formed, guidelines written, and since then it has really been the most profound change in surgical care around the world. It has been adopted everywhere. In addition, everyone is doing it because it is something that does not really cost very much money, which empowers patients, reduces complications and its good news for everyone.
About three years ago, I was asked by VCU whether I would like to join Virginia Commonwealth University and come and lead the ERAS roll-out so that’s why I have moved myself and my family and we’re now living in Virginia.
Host: Well it is certainly wonderful to have you here at VCU, Dr. Scott and what a phenomenal set of principles that you have laid out for everyone to follow. You mentioned a couple of things, but I would like to first unpack what exactly the ERAS program looks like in practice. You mentioned trying to get the patient fit before the operation, but what does that look like and does this apply to all types of surgery? Maybe talk a little bit about that.
Dr. Scott: Yeah, so what we are trying to do is – particularly for major surgery where you do [sometimes] get significant complications, whether it be pneumonia or some form of sepsis – we look at those patients having major surgery where there is a high risk of these complications or patients themselves who have lots of comorbidities who are at higher risk. And that’s the patients we target most. And I think the analogy is, is you wouldn’t get in a plane and fly across the Atlantic without making sure the engines work, there’s enough fuel in the tanks and that we know which direction we’re going.
So, we start basically by reviewing the patient, optimizing all their comorbid healthcare conditions, optimize diabetes, improve their anemia and blood pressure control, and get all that sorted prior to surgery happening rather than just getting straight into surgery.
Host: I see, so once a patient finds out that they need surgery, then what happens? What is the set of procedures that ERAS I guess puts forward for them and what is their experience like at VCU?
Dr. Scott: Yes, all the patients come to a preoperative clinic or the “PACE” clinic and they see a specialist provider – either a nurse practitioner or a physician or both. And we refer them to diabetologists who will sort their diabetes out, nutrition specialists sometimes if they have got cancer and they are losing weight. So, it’s all about building them up before surgery and making things better. So, even for iron deficiency anemia, we might give intravenous iron because it works quicker than just giving oral iron.
Host: Yeah, some of the things that you are mentioning sound so common sense, but I can totally see that in the absence of a program like ERAS, a lot of these things falling through the cracks. So, one of the next things I wanted to talk about was what does this actually look like for the clinical staff? We talked about getting the patient ready to undergo the operation but how do things change day-to-day for the clinical staff when they are about to go into the operation?
Dr. Scott: So, obviously patient engagement is vital at the start and also the engagement of staff, so they know what’s going to happen. I think one of the most fundamental changes is everyone knows what’s happening in each stage of the pathway –whether antibiotics need to be given, whether the patients need to be mobilized and when to start giving them protein supplements. So, we’ve introduced both what we call a vertical and horizontal implementation. What I mean by that is: “Horizontal” means it’s specialty by specialty so it would be bariatric surgery, orthopedic surgery for hip and knee arthroplasty, or colorectal resection – and we’re going through all the major specialties. But because all patients should be on an ERAS pathway, all patients go to the preoperative clinic for optimization, all patients are not dehydrated prior to surgery and are carbohydrate-loading unless there’s a specific reason not to. And they arrive in the hospital in the pre-surgical unit and get non-opioid analgesics so that it reduces the amount of pain killers they need after surgery.
And then we have a standardized way during the operating room, we maintain homeostasis using short-acting anesthetics, keeping the flow of blood around the body constant and the blood pressure normal by the anesthesiologists, reducing nausea and vomiting and keeping the patients warm. And then the same process once the patients are waking in the postoperative care unit. We make sure they are ready to go to the floor and keep optimizing them and making any small changes needed so that when they are going to the floor, we know the patient is going to be stable and make a good recovery.
And then the morning after surgery, is when a lot of what we call de-escalation of care happens because that’s when the drip is taken down, Foley catheters are removed, and the patient is fed. So, basically, they are made free of all the other things that otherwise would keep them in bed and disrupt their physiology. So, the patient will be basically mobilizing and eating and drinking and looking after themselves, rather than lying in bed with tubes and drains waiting for nurses to either come around and give painkillers or to be fed.
So, we’re empowering patients to make their own recovery and we are finding the patients very much prefer this. And because we are not doing all these other things, it actually accelerates recovery and people get home faster.
Host: Yeah, it sounds like you have a good way to de-escalate the assistance that a patient is getting so they can recover on their own. But maybe talk more specifically about some of the measures that they can take on themselves after a surgery to help them recover faster.
Dr. Scott: Yeah so, we engage patients right from the preoperative clinic and try and give them patient diaries, so they know what they are trying to do every day. To makes sure that if they can’t take a full diet then they at least take protein drinks, and they get out of the bed regularly. We do monitor their pain, but we stress the fact that function is more important. No longer are we taking the approach to pain of the fact that it is a vital sign, which is what’s lead to the opioid crisis in America. So, we now use very little opioids in our pathways. We use Tylenol with some nonsteroidals if appropriate, with other drugs called gabapentinoids and our acute pain team will put in a lot of regional blocks or catheters, which pump local anesthetic to numb the area of the surgery so that patients can still function without getting any pain and that in turn reduces the stress response, which means they feel much better.
Host: One of the things that I really like about this is it really does seem like it is a true partnership between the medical staff and the patient, and everyone needs to work together to make sure – like you said in that analogy – that the engine is working properly before the flight, during the flight and after flight. So, it’s a really good framework to operate under. I’m curious as to what kind of results patients are seeing under this ERAS program.
Dr. Scott: The thing that’s always driven ERAS is the headlines of the short length of stay. Wherever you are in the world, if ERAS is implemented there’s always a reduction in the length of stay. But the stress is not really on length of stay, it’s on improved, faster recovery to baseline. That’s really where the benefit is for the patient. But the interesting thing is now that this has been going on for 15 years, we’ve been showing that the last data sets for tens of thousands of patients – for instance in the UK – that every patient is on an ERAS pathway where I was National Clinical Advisor a few years ago. So, it’s the standard of care. And we saw complications reduced. We are seeing the same things at VCU. So, we are seeing surgical site infection go down and we are one of the top performers in the USA on this – so some of the lowest rates.
And the other great news is that we have almost 40 percent of our patients don’t get major opioids during surgery and we’ve almost halved the use of opioids in other specialties. So, we know now that one of the major complications of having major surgery is actually opioid addiction and about six to eight percent. ERAS is making a major impact on the downstream effect of opioid addiction in patients having major surgery. And I’m sure everyone will agree that that’s a great position to be in.
Host: So, let’s say someone is listening to this and they have a surgery at VCU coming up; is this something that they need to ask for, is this something that is standard with all operating procedures? Maybe talk a little bit what they can expect and what they need to ask for.
Dr. Scott: All patients having major surgery – so I’m not talking about day case or minor surgery – will now go to our preoperative clinic and that’s when the whole pathway starts. ERAS is becoming the standard of care. We have already introduced it in seven specialties with another two joining very quickly. But the patients will find that they get the bulk of ERAS principles all the way through now because in the operating room, all the anesthesiologists adhere to all the ERAS principles – in the postoperative care unit, or the PACU as it’s called. So, they’ll find that really this is now the new standard of care at VCU.
Host: All right Dr. Scott, I really appreciate your time today. That’s Dr. Michael Scott, the Director of Critical Care Anesthesiology at VCU Health. Thanks for tuning into this episode and to hear more about how you can take control of your health listen to other episodes of Healthy with VCU Health at www.vcuhealth.org/podcasts. Thanks again and we’ll talk soon.
How You Can Get Better, Faster After Surgery
Prakash Chandran (Host): VCU Health is making changes to the care of patients received before, during and after surgery so they can get better faster. They are doing this through a program called ERAS or Enhanced Recovery After Surgery. It’s a standardized series of small measures that physicians, care teams and the patients themselves take that make a big impact on how they recover after an operation. I am Prakash Chandra and in this episode of Healthy with VCU Health, we talk to Dr. Michael Scott who comes to us from the UK and is the Director of Critical Care Anesthesiology at VCU Health. Dr. Scott also spearheads the ERAS program at the VCU Medical Center. Dr. Scott, it is a pleasure to have you here today. Can you tell us a little bit more about yourself and your experience with the ERAS program?
Michael Scott, MD (Guest): ERAS started in Europe at about 15 years ago and I was one of the pioneers of developing this program, which does not actually change the surgical procedure itself, but changes what happens to the patient around the time of surgery both before, during and after. The general principles are to make the patient fitter for surgery, reduce the injury and the harm caused sometimes by interventions that we do in medicine, reduce the amount of opioids patients get and then accelerate recovery afterwards by removing drips, drains and mobilizing patients and feeding them very quickly.
My experience really first started in about 2002 in colorectal surgery, and my hospital back in the UK started pioneering this. In addition, slowly in the next few years, the whole program has formalized. There was a society called the Enhanced Recovery after Surgery Society formed, guidelines written, and since then it has really been the most profound change in surgical care around the world. It has been adopted everywhere. In addition, everyone is doing it because it is something that does not really cost very much money, which empowers patients, reduces complications and its good news for everyone.
About three years ago, I was asked by VCU whether I would like to join Virginia Commonwealth University and come and lead the ERAS roll-out so that’s why I have moved myself and my family and we’re now living in Virginia.
Host: Well it is certainly wonderful to have you here at VCU, Dr. Scott and what a phenomenal set of principles that you have laid out for everyone to follow. You mentioned a couple of things, but I would like to first unpack what exactly the ERAS program looks like in practice. You mentioned trying to get the patient fit before the operation, but what does that look like and does this apply to all types of surgery? Maybe talk a little bit about that.
Dr. Scott: Yeah, so what we are trying to do is – particularly for major surgery where you do [sometimes] get significant complications, whether it be pneumonia or some form of sepsis – we look at those patients having major surgery where there is a high risk of these complications or patients themselves who have lots of comorbidities who are at higher risk. And that’s the patients we target most. And I think the analogy is, is you wouldn’t get in a plane and fly across the Atlantic without making sure the engines work, there’s enough fuel in the tanks and that we know which direction we’re going.
So, we start basically by reviewing the patient, optimizing all their comorbid healthcare conditions, optimize diabetes, improve their anemia and blood pressure control, and get all that sorted prior to surgery happening rather than just getting straight into surgery.
Host: I see, so once a patient finds out that they need surgery, then what happens? What is the set of procedures that ERAS I guess puts forward for them and what is their experience like at VCU?
Dr. Scott: Yes, all the patients come to a preoperative clinic or the “PACE” clinic and they see a specialist provider – either a nurse practitioner or a physician or both. And we refer them to diabetologists who will sort their diabetes out, nutrition specialists sometimes if they have got cancer and they are losing weight. So, it’s all about building them up before surgery and making things better. So, even for iron deficiency anemia, we might give intravenous iron because it works quicker than just giving oral iron.
Host: Yeah, some of the things that you are mentioning sound so common sense, but I can totally see that in the absence of a program like ERAS, a lot of these things falling through the cracks. So, one of the next things I wanted to talk about was what does this actually look like for the clinical staff? We talked about getting the patient ready to undergo the operation but how do things change day-to-day for the clinical staff when they are about to go into the operation?
Dr. Scott: So, obviously patient engagement is vital at the start and also the engagement of staff, so they know what’s going to happen. I think one of the most fundamental changes is everyone knows what’s happening in each stage of the pathway –whether antibiotics need to be given, whether the patients need to be mobilized and when to start giving them protein supplements. So, we’ve introduced both what we call a vertical and horizontal implementation. What I mean by that is: “Horizontal” means it’s specialty by specialty so it would be bariatric surgery, orthopedic surgery for hip and knee arthroplasty, or colorectal resection – and we’re going through all the major specialties. But because all patients should be on an ERAS pathway, all patients go to the preoperative clinic for optimization, all patients are not dehydrated prior to surgery and are carbohydrate-loading unless there’s a specific reason not to. And they arrive in the hospital in the pre-surgical unit and get non-opioid analgesics so that it reduces the amount of pain killers they need after surgery.
And then we have a standardized way during the operating room, we maintain homeostasis using short-acting anesthetics, keeping the flow of blood around the body constant and the blood pressure normal by the anesthesiologists, reducing nausea and vomiting and keeping the patients warm. And then the same process once the patients are waking in the postoperative care unit. We make sure they are ready to go to the floor and keep optimizing them and making any small changes needed so that when they are going to the floor, we know the patient is going to be stable and make a good recovery.
And then the morning after surgery, is when a lot of what we call de-escalation of care happens because that’s when the drip is taken down, Foley catheters are removed, and the patient is fed. So, basically, they are made free of all the other things that otherwise would keep them in bed and disrupt their physiology. So, the patient will be basically mobilizing and eating and drinking and looking after themselves, rather than lying in bed with tubes and drains waiting for nurses to either come around and give painkillers or to be fed.
So, we’re empowering patients to make their own recovery and we are finding the patients very much prefer this. And because we are not doing all these other things, it actually accelerates recovery and people get home faster.
Host: Yeah, it sounds like you have a good way to de-escalate the assistance that a patient is getting so they can recover on their own. But maybe talk more specifically about some of the measures that they can take on themselves after a surgery to help them recover faster.
Dr. Scott: Yeah so, we engage patients right from the preoperative clinic and try and give them patient diaries, so they know what they are trying to do every day. To makes sure that if they can’t take a full diet then they at least take protein drinks, and they get out of the bed regularly. We do monitor their pain, but we stress the fact that function is more important. No longer are we taking the approach to pain of the fact that it is a vital sign, which is what’s lead to the opioid crisis in America. So, we now use very little opioids in our pathways. We use Tylenol with some nonsteroidals if appropriate, with other drugs called gabapentinoids and our acute pain team will put in a lot of regional blocks or catheters, which pump local anesthetic to numb the area of the surgery so that patients can still function without getting any pain and that in turn reduces the stress response, which means they feel much better.
Host: One of the things that I really like about this is it really does seem like it is a true partnership between the medical staff and the patient, and everyone needs to work together to make sure – like you said in that analogy – that the engine is working properly before the flight, during the flight and after flight. So, it’s a really good framework to operate under. I’m curious as to what kind of results patients are seeing under this ERAS program.
Dr. Scott: The thing that’s always driven ERAS is the headlines of the short length of stay. Wherever you are in the world, if ERAS is implemented there’s always a reduction in the length of stay. But the stress is not really on length of stay, it’s on improved, faster recovery to baseline. That’s really where the benefit is for the patient. But the interesting thing is now that this has been going on for 15 years, we’ve been showing that the last data sets for tens of thousands of patients – for instance in the UK – that every patient is on an ERAS pathway where I was National Clinical Advisor a few years ago. So, it’s the standard of care. And we saw complications reduced. We are seeing the same things at VCU. So, we are seeing surgical site infection go down and we are one of the top performers in the USA on this – so some of the lowest rates.
And the other great news is that we have almost 40 percent of our patients don’t get major opioids during surgery and we’ve almost halved the use of opioids in other specialties. So, we know now that one of the major complications of having major surgery is actually opioid addiction and about six to eight percent. ERAS is making a major impact on the downstream effect of opioid addiction in patients having major surgery. And I’m sure everyone will agree that that’s a great position to be in.
Host: So, let’s say someone is listening to this and they have a surgery at VCU coming up; is this something that they need to ask for, is this something that is standard with all operating procedures? Maybe talk a little bit what they can expect and what they need to ask for.
Dr. Scott: All patients having major surgery – so I’m not talking about day case or minor surgery – will now go to our preoperative clinic and that’s when the whole pathway starts. ERAS is becoming the standard of care. We have already introduced it in seven specialties with another two joining very quickly. But the patients will find that they get the bulk of ERAS principles all the way through now because in the operating room, all the anesthesiologists adhere to all the ERAS principles – in the postoperative care unit, or the PACU as it’s called. So, they’ll find that really this is now the new standard of care at VCU.
Host: All right Dr. Scott, I really appreciate your time today. That’s Dr. Michael Scott, the Director of Critical Care Anesthesiology at VCU Health. Thanks for tuning into this episode and to hear more about how you can take control of your health listen to other episodes of Healthy with VCU Health at www.vcuhealth.org/podcasts. Thanks again and we’ll talk soon.