Introduction
The measures of medical intervention and nursing care of patients are aimed not only at the efficiency and success of the surgery but also at minimizing the adverse effects of surgical intervention and possible complications. The Enhanced Recovery After Surgery (ERAS) is a multimodal surgical patient care strategy aimed at optimizing all stages of the perioperative period, including preparation for surgery, preventive measures, adequate analgesia, and post-operative rehabilitation.
According to several scholars, the program both helps patients to get through the surgery faster and more comfortable and reduces the cost of surgery (Carli, 2015; Ljungqvist, Scott, & Fearon, 2017; Nelson et al., 2016a). This paper examines the issues addressed by ERAS, analyzes the relevant research literature, evaluates the evidence presented to support the efficiency and applicability of this approach, and makes evidence-based recommendations.
Problem Statement
As a rule, surgery is time-consuming and expensive, and certain types of surgical interventions have their typical complications. For instance, according to Carmichael et al. (2017), “contemporary colorectal surgery is often associated with long length of stay” (5-8 days), “high cost, and rates of surgical site infection approaching 20%” (p. 762). Researchers also note that during their stay in the hospital, surgical patients can become much more easily exposed to infectious diseases, which may have complications (Carmichael et al., 2017). These circumstances combine to make surgery a very expensive procedure.
The finances are required for the purchase and preparation of all operational equipment, necessary medicines, and supplies, as well as for the remuneration of nursing and medical personnel. At the same time, given the considerable cost of medical services and surgical interventions, in particular, the issue of appropriateness and reasonableness of using these resources is especially acute.
In any case, surgery is always a severe injury to the body that results in a series of reactive processes described as a stress response. The list of stress response components includes changes in the hormonal activity of the body and emergency activation of the immune system, which affect many internal organs of the patient, including the heart and brain (Carli, 2015). These phenomena are accompanied by extremely unpleasant psychological and physical experiences, such as pain, sleep disorders, and increased excitability.
Moreover, the researchers point out that health conditions, certain diseases, or unhealthy habits that a patient has can significantly affect both the success of the surgery and the rehabilitation process (Carli, 2015; Nelson et al., 2016a). Many possible deviations from the norm among the population usually require urgent and complex decisions.
Thus, nursing and healthcare personnel should have a practical guideline that describes the methods of pre-, intra-, and post-operative patient care. It bears mentioning that these instructions should include a description of typical situations and interventions in a number of common complication cases. Moreover, this guideline should imply the efficient and economical use of resources, which will reduce the cost of surgical interventions and accompanying activities.
Background
The ERAS is a multimodal program, based on a multidisciplinary approach to attending to surgical patients. It has strong infrastructure support represented by medical research centers and healthcare organizations, as well as the maintenance of high-quality standards through the activities of an international professional association – the ERAS Society. This international non-profit community develops the research and evidence base for the application of ERAS strategies and publishes relevant papers (Ljungqvist et al., 2017). It should be noted that applying the EPAC approach requires the participation of a group of specialists: “surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient” (Ljungqvist et al., 2017, p. 1).
Moreover, a considerable amount of research literature is devoted to the implementation of ERAS in various surgical procedures. An overview article on this approach presents the 24 key operational impacts within ERAS, which have strong scientific support (Ljungqvist et al., 2017). It details the program stages, healthcare and financial implications, implementation peculiarities, and long-term benefits.
Several studies focus on a particular area of ERAS application. For instance, two articles of the medical research team discussed the recommendations of this approach for pre-, intra- and post-operative patient care in gynecological and oncological surgeries (Nelson et al., 2016a; Nelson et al., 2016b). These works address various measures, including patient informing and counseling, quitting smoking and taking harmful substances, ways to reduce metabolic stress, and prescribing specific medications. The recommendations also contain specific prescriptions and precautions, such as performing “minimally invasive surgery” in some instances and avoiding “routine nasogastric intubation” (Nelson et al., 2016a, p. 314). Each element of the guidelines is matched by evidence level and recommendation grade.
For example, a recommendation stating that “patients should wear well-fitting compression stockings and have intermittent pneumatic compression,” has a high evidence level and a strong recommendation grade (Nelson et al., 2016b, p. 324). The article devoted to the application of the ERAS approach to colon and rectal surgery has a similar structure (Carmichael et al., 2017). It consists of a description of recommendations, an assessment of benefits, risks, and burdens, a specification of the methodological quality of the evidence base.
Furthermore, ERAS strategies are considered in application to the specific phases of all surgical operations. For instance, an article published in the Canadian Journal of Anesthesia analyzed the application of this approach to the post-operative stress response of the body (Carli, 2015). This paper considers insulin resistance as the primary pathogenic factor and provides the reasons for this phenomenon and ERAS measures aimed at its minimization.
Efficiency and Applicability
All studies claim the feasibility and effectiveness of the measures provided by the EPAC program. According to Nelson et al. (2016a), the application of appropriate perioperative patient care “has resulted in an average reduction in length of stay of 2.5 days and a decrease in complications by as much as 50%” (p. 313). Improved treatment and availability of hospital beds together will enable hospitals to perform the full range of surgical interventions more efficiently and in a shorter time. Moreover, Ljungqvist et al. (2017) state that, according to ERAS Society research, “there were 8% fewer readmissions and a shorter stay for those readmitted, saving $2800 to $5900 per patient” (p. 296). Thus, this approach demonstrates its clear infrastructure and resource advantages.
Moreover, the researchers agree that ERAS strategies help patients to get better out of surgery and improve perioperative care. According to Carli (2015), ERAS measures provide a multimodal approach to minimize insulin resistance. They include “perioperative optimization,” “perioperative feeding,” “maintaining physiologic homeostasis,” performing “minimally invasive surgery” and “mobilization” (Carli, 2015, p. 115). Together, these measures are factors contributing to rapid recovery and the prevention of complications.
It should be noted that ERAS recommendations are most effective precisely because they concern a variety of different areas, from patient counseling and mobilization after surgery to the specifics of medication prescription and intubation. The review article concludes that “ERAS practices improve the opportunity for rapid, uncomplicated recovery after surgery with both short- and long-term benefits for patients while improving quality and saving money” (Ljungqvist et al., 2017, p. 297). It should be noted that healthcare research and specialized guidelines in different areas of surgery confirm this conclusion.
Recommendations
The main recommendation for implementing an ERAS approach in the operating room of a particular hospital will be an analysis of the relevant literature and a selection of the most general prescriptions. Those which are given regardless of the surgery type should be delivered to medical and nursing staff for review and use. In addition, physicians with particular specializations can use ERAS instructions for specific types of surgeries.
It would be highly reasonable to involve an ERAS coordinator with relevant experience, as this professional would assist the health care institution in implementing the relevant strategies most efficiently and quickly. If a hospital or other medical facility is a large organization, an educational program on the application of the guidelines can be organized. Although the ERAS approach ultimately results in lower costs for surgical interventions and faster treatment of patients, it will be necessary to allocate a budget to initiate the implementation of the recommendations.
Conclusion
It should be noted that the healthcare scientific community has recognized the ERAS strategy as an effective program to improve the quality of pre-, intra- and post-operative patient care. Due to the infrastructural support of the international ERAS Society and other medical institutions, there are currently many guidelines for the application of relevant recommendations in different surgical fields. As noted above, these guidelines not only provide a list of recommendations but also indicate their effectiveness and scientific evidence. Thus, the measures provided for in the ERAS approach can be implemented in the specific operational activities of a particular healthcare facility with the participation of a professional if required.
References
Carli, F. (2015). Physiologic considerations of Enhanced Recovery After Surgery (ERAS) programs: implications of the stress response. Canadian Journal of Anesthesia, 62(2), 110-119.
Carmichael, J. C., Keller, D. S., Baldini, G., Bordeianou, L., Weiss, E., Lee, L.,… & Steele, S. R. (2017). Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Diseases of the Colon & Rectum, 60(8), 761-784.
Ljungqvist, O., Scott, M., & Fearon, K. C. (2017). Enhanced recovery after surgery: A review. JAMA surgery, 152(3), 292-298.
Nelson, G., Altman, A. D., Nick, A., Meyer, L. A., Ramirez, P. T., Achtari, C.,… & Dowdy, S. C. (2016a). Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – Part I. Gynecologic oncology, 140(2), 313-322.
Nelson, G., Altman, A. D., Nick, A., Meyer, L. A., Ramirez, P. T., Achtari, C.,… & Dowdy, S. C. (2016b). Guidelines for post-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations – Part II. Gynecologic oncology, 140(2), 323-332.