Enhanced Recovery after Surgery: A Conversation with Sandeep J. Khandhar, MD, FACS


Tue Mar 29 13:00:00 CDT 2016
Sandeep Khandhar, M.D.
Surgical Director of Thoracic Oncology, Inova Thoracic Oncology Program

Enhanced recovery after surgery (ERAS) is a multidimensional, evidence-based perioperative care pathway with the goal of early recovery after major surgery. The ERAS Society says enhanced recovery replaces traditional practices with evidence-based ones and covers “all areas of the patient’s journey through the surgical process”.


As part of the ERAS program at Inova Health System in Virginia, patients’ expectations for pain management and ambulation are established before surgery. “ERAS turns the spotlight on the most important part of the healthcare continuum—the patient’s recovery,” says Sandeep J. Khandhar, MD, FACS, Chief of Thoracic Surgery and Director of Inova’s Thoracic Oncology Program.


Despite the advantages, strategies such as very early ambulation require a big change in thinking and practice for many patients and clinicians. Understanding the principles of ERAS and how to implement it helps facilitate change and achieve optimal outcomes.


Focus on the patient

As strides have been made in minimally invasive techniques and other surgical technology, the focus of clinicians has too often shifted from the patient to the technique, the operation, and the success of the technology. “Technology is great—it’s phenomenal to see and sexy to talk about, but the danger is that technology and other advances can become the sole focus,” Khandhar says.


Instead, the goal should be for patients to have the procedure and return to their lives as quickly as possible. “ERAS returns the focus back on the most important goal—getting patients back to their lives,” Khandhar notes.


Build a multidisciplinary team

It takes a multidisciplinary team to make an enhanced recovery program successful. Such a team builds on the advantages of modern medical subspecialization. “Specialists can pick up the nuances and filter unnecessary details to differentiate one patient from another and provide the highest level of care,” Khandhar says. To leverage their expertise and broaden their view, specialists need to partner with others who have expertise in various aspects of care.


At Inova, each member of the team plays a vital role in the recovery of a patient. For example, preoperative and postoperative nursing teams prepare and recover patients with a unified focus. The surgical team’s familiarity with the disease processes and techniques is of paramount importance. Anesthesiologists plan the delivery of anesthesia based on the case and the expected timeframe for recovery. Respiratory therapists immediately engage the patients in the postanesthesia care unit to initiate appropriate therapies that facilitate a speedy recovery.


“Putting all these specialists together brings the best of every discipline to the forefront,” Khandhar says. An important feature of ERAS is that, as Khandhar says, “Everybody is in charge.” Each team member does his or her part and each discipline has a designated point person who team members can contact with issues or questions.


At Inova, the thoracic surgery division was the driver for starting such an initiative, but the ERAS leader does not have to be a surgeon. One can find leadership potential for an ERAS program in a nurse, physician assistant, nurse practitioner, anesthesiologist, or administrator. The key is to have a dedicated and respected leader with the ability to build an effective team. Communication and collaboration are key elements for success.


It’s not enough to assemble a team; the team has to truly be invested in the program. “Without buy-in from every discipline, it doesn’t work because each one is critical for success,” Khandhar says. Representatives from disciplines include perioperative staff, physician assistants, nurse practitioners, respiratory therapists, anesthesiologists, surgeons, administrators, and patients and their loved ones. The best strategy for obtaining buy-in is to set goals and expectations for all involved.


Set expectations

Achieving this goal safely and successfully requires effort throughout the perioperative continuum. Preoperative nurses, physician assistants, nurse practitioners, and surgeons prepare patients and families before surgery by telling them what to expect and prescribing specific activity requirements and goals. Anesthesia providers deliver anesthesia during surgery to ensure patients are awake and alert quickly after surgery, while thoracic surgeons use their technical expertise so patients experience the least possible trauma. Postoperative nurses ambulate patients safely, effectively manage pain and nausea, and work closely with the respiratory therapists to build back lung function immediately.


Administrators need to understand the resources necessary at every level to achieve results and will quickly see the fruits of this labor in the form of increased patient satisfaction, decreased complications, shorter lengths of stay, and increased volume and revenue.


Develop a culture

A culture that supports ERAS backs up goals and expectations. That culture starts with providing the necessary resources and having buy-in from every member of team from administrator to patient. For example, typically two nurses are needed when the patient first walks, but most postanesthesia care units have either one-to-one staffing or one nurse for two patients. With ERAS, resources must be allocated so that for a short time, two nurses can care for one patient.


Changing the culture is not easy. “As a group, medical professionals generally like to be tech savvy and up-to-date with the latest techniques, but practices tend to be somewhat static,” Khandhar says. Nurses and physicians who graduated years ago learned how to practice in a certain way that may not have changed to reflect newer developments. For example, Khandhar says that surgeons are “quick to evolve but that evolution is often limited to the operative technique. Somehow, as a group, we often forget the preoperative preparation and the postoperative follow-through.”


The ERAS culture is all about preparation and follow-through. It’s also about changing how clinicians—and patients—view postoperative recovery. Traditionally, patients rested after surgery as part of their recovery. ERAS turns that around with a philosophy of active recovery immediately after surgery.


“A recovery of resting doesn’t fit well into that paradigm of bringing patients back to the place they were before—leading an active life with family, work, play, and responsibility,” says Khandhar. Explaining this to clinicians, patients, and families helps to achieve culture change.


Enhanced recovery focuses on three main areas: pain management, fluid management, and early mobility. (See ERAS and pain management.)


ERAS and pain management

Pain is subjective and influenced by many factors, including culture, past experiences, and type of surgery. These factors—and varying pain thresholds—make it impossible to have a set dose of medicine to control pain.


Perhaps a bigger issue is attitude towards pain. “I think in a large part we have come to believe that pain is evil, and that we have to eradicate it,” Khandhar says. With ERAS he says, “Pain is not the enemy, and we simply refuse to focus on it.” The true enemy is complications, which, unlike pain, can kill patients. Treating pain with narcotics in an effort to achieve “no pain” can simply contribute to complications such as pneumonia by limiting the patient’s respiratory drive and ability to walk.


Patients need not suffer, however. Instead, they are told preoperatively to expect some pain and the reason why. The key is to set realistic expectations by saying that narcotics will be given judiciously, but pain is not the focus—optimal recovery and the avoidance of complications are the real endpoints. Once the culture has been established and team members experience success, practices will become embedded into the system.


Return patients to their lives

ERAS focuses on returning patients to their lives, where they can engage in activities they enjoy and spend time with family and friends. That focus aligns with one of clinicians’ primary goals—helping patients.


Sandeep Khandhar, M.D., is surgical director of thoracic oncology in the Inova Thoracic Oncology Program.