ERAS (Enhanced Recovery after Surgery) programmes use the combination of a multidisciplinary approach with technologies such as ultrasound-guided transversus abdominis plane (TAP) blocks to reduce opioid use following surgical procedures, speeding patient recovery and reducing costs.
Dr Philip Corvo, Chairman of the Stanley J. Dudrick Department Surgery and Director of Surgical Critical Care at Saint Mary's Hospital, Trinity Health of New England, leads an innovative ERAS programme and describes its success.
Learning a new approach
I first learnt about enhanced recovery at my previous institution, Stamford Hospital, while working with the Chairwoman of Anaesthesia Dr Teresa Bowling. Dr Bowling took the principle of regional blocks that our anaesthesia colleagues were already using on orthopaedic patients and applied it to abdominal surgery. This helped us become successful in decreasing pain and narcotic use in many of our general surgery patients. I then learned more about ERAS at an American College of Surgeons Quality and Safety conference.
In my role as Chairman of Surgery, I am always striving to improve our programme efficiency, to improve patient safety by decreasing infections and opioid use, to increase patient satisfaction, and to reduce the financial impact on the hospital by cutting the patients’ length of stay. I knew that I would have to think creatively to achieve these aims and an ERAS approach made sense.
Pain reduction from ultrasound-guided blocks
A core component of our opioid-sparing ERAS protocol is using ultrasound-guided TAP blocks but it is important that this happens preoperatively; the effect is diminished if the blocks are carried out by surgeons during the procedure because the nervous system and brain have already registered the pain.
Outstandingly positive results from the outset
We saw positive results of the new approach with our very first patient. We have decreased length of stay from an industry average of six days down to two days with almost no narcotic use, and have now reached the point where some colorectal patients go home on the day after surgery, having taken no narcotics (except for during the procedure itself). Specifically, using preoperative ultrasound-guided TAP blocks, plus long-acting bupivacaine and a mixture of non-opioid medications that are given around the clock (not PRN), most patients require two thirds less narcotic than they would have otherwise needed, and many go home never having taken a narcotic while in the hospital. We’ve also seen drastic reductions in our colorectal infection rate – down to as low as 2 % – over a two-year period.
National estimates suggest that the average surgical site infection costs a facility $28,000, and an average hospital stay is $2,400 per day. Based on these figures, I estimate our ROI to be over $2 million since our programme began in 2015. Perhaps just as importantly, the satisfaction of patients who have expressed an opinion has definitely increased.
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