Enhanced recovery: joining the dots

Eight years ago, we wrote an editorial for the British Journal of Anaesthesia exploring whether rapid, uncomplicated recovery after surgery would have downstream benefits other than just reduction in hospital length stay (LOS).1Fawcett W.J. Mythen M.G. Scott M.J.P. Enhanced recovery—more reducing stay?.Br J Anaesth. 2012; 109: 671-674Abstract Full Text PDF PubMed Scopus (40) Google Scholar At that time, concept Recovery After Surgery (ERAS®) was more 15 yr old (and had been practised under various names, such as fast-track or accelerated recovery); yet, its uptake initially sporadic. National implementation measures across UK (such NHS Improvement and Partnership) meant most hospitals departments adopted some form a standardised care pathway by 2012. stage, established ERAS units recognised there were very large potential gains to be patients undergoing major elective surgery. Many arose from evidenced-based, multimodal, multidisciplinary management surgery, creating optimised preoperatively, minimised injury stress at time protocolised de-escalation accelerate return functional recovery. Here, explore evidence developments this field, why pathways not universally implemented, their relevance current healthcare during coronavirus disease 2019 (COVID-19) pandemic. A key driver release bed capacity, therefore, easy-to-measure endpoint LOS historically used compare judge success programmes. Recording still has merit; least remaining environment is risk free, associated with fasting, sleep disturbance, immobilisation, infection, medication errors.2Rasmussen L.S. Jørgensen C.C. Kehlet H. programmes elderly.Eur Anaesthesiol. 2016; 33: 391-392Crossref (6) However, measurement on own somewhat limited metric assessing efficacy patient-centred care, are consequences patients. Other areas studied recorded patients, including reduced pathophysiological responses organ dysfunction, quicker metabolic function, complications readmissions, improved cancer survival, costs, improving patient satisfaction, faster preoperative function.3Ljungqvist O. M. Fearon K.C. surgery: review.JAMA Surg. 2017; 152: 292-298Crossref (1224) Moreover, 10 million operations performed annually 300 worldwide (with both rising annually),4Abbott T.E. Fowler A.J. Dobbs T.D. Harrison E.M. Gillies M.A. Pearse R.M. Frequency surgical treatment related procedures UK: national ecological study using episode statistics.Br 119: 249-257Abstract (79) harnessing these enormous. Since 2012, many proposed realised, formal With good compliance programmes, only does decrease, but readmissions usually unchanged, increased, which valid concern when attempting reduce LOS.5ERAS Compliance GroupThe impact enhanced protocol colorectal resection: results international registry.Ann 2015; 261: 1153-1159Crossref (384) Readmissions area, early discharge without sufficient can increase family anxiety, readmission. It noteworthy do occur, they challenging ASA physical status 3 more, complexity, operation times excess 6 h surgery,6Bennedsen A.L. Eriksen J.R. Gögenur I. Prolonged readmission rate cohort surgery.Colorectal Dis. 2018; 20: 1097-1108Crossref (9) caution should taken identified higher risk. recent retrospective analysis shown greater use elements hip knee arthroplasty fewer shorter LOS.7Memtsoudis S.G. Fiasconaro Soffin et al.Enhanced components perioperative outcomes: nationwide observational study.Br 2020; 124: 638-647Abstract (28) Whilst important, it within systems, impacts short- long-term outcomes.8Khuri S.F. Henderson W.G. DePalma R.G. al.Determinants survival adverse effect postoperative complications.Ann 2005; 242: 326-341Crossref (923) estimated all-cause deaths third biggest cause mortality USA following heart cancer.9Bartels K. Karhausen J. Clambey E.T. Grenz A. Eltzschig H.K. Perioperative injury.Anesthesiology. 2013; 1474-1489Crossref Non-fatal may permanently terms disability-free recovery, health-related quality life, enormous socio-economic impact. consistently complications, site infection acute kidney injury, strict adherence promoting greatest (both especially medical).3Ljungqvist systematic review meta-analysis RCTs examine prevention pulmonary found benefit conferred enrolled pathways,10Odor P.M. Bampoe S. Gilhooly D. Creagh-Brown B. Moonesinghe S.R. interventions complications: meta-analysis.BMJ. 368: m540Crossref (34) rather single targeted respiratory intervention. also confers procedure-specific benefits; example, joint replacement possible demonstrate reductions variety common delirium cognitive dysfunction.11Petersen P.B. al.Delirium arthroplasty—a 6331 elderly patients.Acta Anaesthesiol Scand. 61: 767-772Crossref (26) In another arthroplasty, omission venous thromboembolism (VTE) prophylaxis apparently increasing incidence VTE complications.12Wainwright T.W. Fast-track arthroplasty—have reached goal?.Acta Orthop. 2019; 90: 3-5Crossref (27) Early data supported receiving disease-free survival,13Gustafsson U.O. Hausel Thorell al.Adherence outcomes surgery.Arch 2011; 146: 571-577Crossref (521) same group showing (>70%) lowered 5 cancer-specific death 42%.14Gustafsson Oppelstrup Nygren Ljungqvist Adherence 5-year study.World 40: 1741-1747Crossref (188) The factors involved multifactorial include stress, nutrition, pre-habilitation, anaesthetic technique, immune function earlier commencement therapies chemotherapy), etc.; feature protocols difficulty singling out critical intervention(s). cost-effective spite initial financial outlay (e.g. reorganising delivery, equipment, training minimal access surgery). Data support sustained varied costs (up $7000 per direct cost),15Thiele R.H. Rea K.M. Turrentine F.E. al.Standardization care: stay, surgery.J Am Coll 220: 430-443Abstract (244) investment $3.8 (range $2.4–$5.1) every $1 invested ERAS.16Thanh N.X. Chuck A.W. Wasylak T. al.An economic evaluation (ERAS) multisite program Alberta.Can 59: 415-421Crossref (67) even if reduced, must borne mind significant post-discharge spending required implementation.17Bozic K.J. Ward L. Vail T.P. Maze Bundled payments total arthroplasty: targeting opportunities improvement cost reduction.Clin Orthop Relat Res. 2014; 472: 188-193Crossref (280) Some studies take into account calculations, inclusion primary spending,16Thanh whilst others appear to.15Thiele spread specialties original four (colorectal, gynaecology, musculoskeletal, urology) practically specialty, cardiac, thoracic, neurological, vascular, paediatric, head neck bariatric obstetrics,18ERAS® SocietyERAS/guidelines/list guidelines.https://erassociety.org/guidelines/list-of-guidelines/Date accessed: August , 2020Google development, spinal fusion vulvar vaginal cytoreductive hyperthermic intraperitoneal chemotherapy. achieved marked successes older patients.2Rasmussen principles applied emergency general surgery,19Jordan L.C. Cook T.M. S.C. al.Sustaining better laparotomy.Anaesthesia. 75: 1321-1330Crossref (2) great globally, higher-income countries, low- middle-income countries.18ERAS® successes, number issues need addressing future. paradox encompasses term ‘enhanced recovery’ inasmuch definition what constitutes universal. Only recently due focus centred crucial area. 2015 outcome defined formalised medicine.20Jammer Wickboldt N. Sander al.Standards definitions clinical effectiveness research medicine: European Clinical Outcome (EPCO) definitions: statement ESA-ESICM taskforce measures.Eur 32: 88-105Crossref (321) Classically, divided three phases21Bowyer Royse C.F. Postoperative outcomes—what measuring whom?.Anaesthesia. 71: 72-77Crossref (61) familiar all anaesthetists: (i) restoration biological physiological parameters, adequate ventilation, BP, oxygen delivery (if measured), urine output measured rarely guide management), temperature postanaesthetic unit; (ii) symptom-based approach treating pain, gastrointestinal ability perform basic activities before leaving hospital; (iii) possibly importantly definitely neglected past, resumption full prior life. This last area subject much interest, well months baseline capacity,22Miller Successful moving beyond stay.Perioper Med (Lond). 3: 4Crossref latest Quality Programme (PQIP) report 60% resumed usual frame.23Periopertive Programmehttps://pqip.org.uk/pages/ar2019Date There described latter stages patient-reported scores.24Kingsley C. Patel Patient-reported experience measures.BJA Educ. 17: 137-144Abstract (167) useful, simple, widely ‘days home up 30 days surgery’, measure easy useful marker complications.25Myles P.S. More morbidity mortality—quality surgery.Anaesthesia. e143-e150Crossref (31) Scholar,26Jørgensen Petersen Lundbeck Foundation Center Hip Knee Replacement Collaborative Group. Days alive 16 137 patients.Br 123: 671-678Abstract (10) advent medicine pioneered Royal College Anaesthetists embraces complements themes ERAS. itself driven improvements led initiatives system. philosophy, no variation, high-quality collection, audit, drive improvement. For PQIP includes ‘Top Priorities 2019–20’,23Periopertive drinking, eating, mobilising similar principles.27Levy Mills P. Is pursuit DREAMing (drinking, eating mobilising) ultimate goal anaesthesia?.Anaesthesia. 1008-1012Crossref (32) differs close involvement members team: surgeons, nurses, pharmacists, physiotherapists, dietitians, etc., addition anaesthetists.3Ljungqvist Although substantial heterogeneity date, pre-optimisation; reduction; rapid de-escalation; transition functions mobilising, sleeping constant themes. Finally, balance between individualised, patient-tailored weighed against value standardisation characterised pathways. attempts made standardise writing pathways28Brindle Nelson G. Lobo D.N. Gustafsson Recommendations ERAS® Society standards development guidelines.BJS Open. 4: 157-163Crossref (42) different surgeries, authorship resulted elements, often 20, seen daunting.18ERAS® now care. generated few practical concerning attaining posing question ‘Which really necessary?’ closely related, analogous dose–response curve, unlikely) carry weight benefit.13Gustafsson covered WHO checklist maintenance euglycaemia, avoidance hypothermia, administration antibiotics), whereas viewed generic avoiding fluid excess, ensuring multimodal analgesia, etc.). therefore logical modifiable confer benefits. papers editorials two emerge. Firstly, concepts Kehlet29Kehlet implementation—time move forward.Ann 267: 998-999Crossref (39) 25 ago reiterated re-emphasise his view five required. information, thoracic epidural anaesthesia open (but laparoscopic) colon overload hypovolaemia, nasogastric tube, oral feeding mobilisation. addition, importance which, although difficult implement, strongly optimal These removal urinary catheters, assistance ambulation, feeding.30Aarts Rotstein O.D. Pearsall E.A. al.Postoperative recovery: multiple hospitals.Ann 992-997Crossref (80) recurring theme poses barriers subsequent proven evidenced-based concept, referred ‘knowing–doing gap’, continues obstacle delivering ERAS.31Kehlet colonic ‘knowing–doing’ gap.Nat Rev Gastroenterol Hepatol. 8: 539-540Crossref (19) patient, professional, institutional barriers, reasons, meeting expectations perspectives, medical nursing staff (resistance change, turnover workload, inadequate support) poor leadership, funding, lack collection will turn allow reliable auditing continuous feedback.32Tanious M.K. Urman R.D. Surgery: history, evolution, guidelines, future directions.Int Anesthesiol Clin. 55: 1-11Crossref (15) One issue fundamental benchmarking judging whole good-quality collection. Contemporaneous required, then benchmarked centres compared over time. Where collected, Interactive Audit System (vide supra), valuable produced change future, live dashboard regular updates.23Periopertive Scholar,33Currie Soop Demartines Kennedy R. interactive audit system: years’ web-based database.Clin Colon Rectal 75-81Crossref (16) adoption electronic records, huge harness health systems improve necessary changes. conducting frustrated variation practice centres, investigating several elements.34Kehlet afar, far good?.Anaesthesia. e54-61Crossref (52) losing any signal emphasis thus towards tightly controlled patient-specific interventions.35Joshi G.P. Alexander J.C. Large pragmatic randomised trials peri-operative decision making: gold standard?.Anaesthesia. 73: 799-803Crossref standardising facilitate comparison trials.36Moonesinghe Jackson A.I. Boney al.Systematic consensus Standardised Endpoints Medicine initiative: outcomes.Br 664-670Abstract (46) fit trajectory. focuses issues, nevertheless pose challenge, exaggerated response neuroendocrine inflammatory). reviewed.37Manou-Stathopoulou V. Korbonits Ackland G.L. Redefining response: narrative review.Br 570-583Abstract particular, response, affected relative expression glucocorticoid mineralocorticoid receptors, determined genetically, further modified illness, age, deconditioning. changes conditions, myocardial immunosuppression muscle wasting, slow expected progress patient.37Manou-Stathopoulou those who high-dose opioid, pain catastrophisers analgesic planned advance.34Kehlet Our 2012 editorial1Fawcett focused trimodal approach: goal-directed therapy (GDFT), ‘all others’. analgesia GDFT appeared pivotal ERAS; however, advances modest: delivered basis,38European Regional & Pain TherapyBetter management.https://esraeurope.org/prospect/Date away central neuraxial block (in control) because problems hypotension, immobility, catheter. modify response,39Levy B.F. M.J. Fawcett Rockall T.A. 23-hour laparoscopic colectomy.Dis Rectum. 2009; 52: 1239-1243Crossref (99) Scholar,40Day A.R. Smith R.V.P. Randomized trial versus intravenous morphine responses.Br 102: 1473-1479Crossref (23) peripherally sited blocks, combined regularly administered analgesia. Similarly, endpoints agreed, too little highest cardiac reserve probably benefiting most), way debated. seems likely timing volume administered. Recent FEDORA suggests haemodynamic moderate-risk intermediate reduces LOS, overall mortality.41Calvo-Vecino J.M. Ripolles-Melchor al.Effect low–moderate patients: multicentre (FEDORA trial).Br 120: 734-744Abstract (65) Overall, arrive relatively euvolaemic theatre carbohydrate loading, bowel preparation, thus, main aims replace ongoing requirements losses. maintaining perfusion pressure optimizing flow.42Futier E. Lefrant J.Y. Guinot P.G. individualized vs standard blood strategies dysfunction among high-risk randomized trial.JAMA. 318: 1346-1357Crossref (282) intraoperative encouraging results, attempt recurrence),43Wigmore T.J. Mohammed Jhanji Long-term volatile IV anesthesia analysis.Anesthesiology. 69-79Crossref (237) deep neuromuscular (to intra-abdominal pressures minimally invasive surgery), opioid-free nausea vomiting), yet find clear, evidence-based place. An requires renewed attention adequately reversed end residual curarisation sequalae high, quantitative monitoring.44Carvalho Verdonck Cools W. Geerts Forget Poelaert Forty monitoring curarisation: confidence network meta-analysis.Br 125: 466-482Abstract (13) physicians areas, management, glycaemic control, recognition opioid stewardship minimise risks opioid-related harm). COVID-19 pandemic significantly our operating capacity availability, together inevitable constraints face global economies, scenario set flourish, costs. (from nosocomial transmission). aspects remotely consultations advice), (including where appropriate), conducted safe testing, isolation, personal protective equipment. So, how join dots future? If outlined here intervention, drug procedure, represent advance years, mandated. make bad good, optimal. Yet, multistep pathway, always temptation bypass hoping lies perhaps so tweaks existing pathways, strategic concepts:(i)Defining endpoint(s) constitute recovery(ii)Instituting, optimising, systems(iii)Producing best-quality simplified important outcomes(iv)Producing contemporaneous benchmarking, via dashboards) rapidly directing local unwanted best occurs(v)Recognition funders engagement planning Leaders work managers, promote optimal, evidence-based, continuously audited To already joined create Kehlet's45Kehlet Multimodal control pathophysiology rehabilitation.Br 1997; 78: 606-617Abstract (1610) ‘pain risk-free operation’, line, put pencils. WJF received speaker, travel, advisor honoraria Grünenthal, Baxter, Merck, Smiths. He website editor executive committee member Society. MGM board Anaesthesia, consultant Edwards Lifesciences, Deltex Medical. MJS Merck; education chair Society; president-elect USA.