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Enhanced Recovery in a Minimally Invasive Thoracic Surgery Program
Enhanced Recovery in a Minimally Invasive Thoracic Surgery Program CHRISTY SCHATZ, MSN, RN, FNP-BC, CRNFA
ABSTRACT Enhanced Recovery After Surgery (ERAS) is a strategy that seeks to reduce patients’ perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay, and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the changes in patient care using an ERAS framework in a minimally invasive thoracic surgery program, barriers to implementation, and patient outcomes. AORN J 102 (November 2015) 482-492. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.09.006 Key words: enhanced recovery after surgery, ERAS, VATS, minimally invasive, thoracic.
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n the past 30 years, there has been a revolution in operative techniques and postoperative management of surgical patients. For example, in 1985, patients undergoing inguinal hernia repairs remained in the hospital for three days.1 Care providers rarely expected that surgical patients would participate in their own care or that they should be walking within hours after surgery. In the past, patients were hospitalized for several days after procedures that are now performed as same-day procedures.
focus of care now is on safely returning patients to their full functional status in a reduced amount of time. Hospitals and providers no longer receive reimbursement for care that results from the negative outcomes of interventions or that results in hospital-acquired infections or other outcomes deemed preventable.3 The incentive for clinicians is to provide evidence-based care and services that reduce the incidence of serious consequences for patients and make reimbursement costs more manageable.
Other changes reflect reimbursement mechanisms. On April 16, 2015, President Obama signed into law House Resolution (HR) 2 e Medicare Access and CHIP Reauthorization Act of 20152 in an effort to decrease the high cost of health care associated with the traditional “fee-for-service” model. The law replaces the fee-for-service model; hospital reimbursement is now based on the quality of patient outcomes rather than the number of procedures performed.2 This change is designed to improve patient outcomes, promote use of best practices, and encourage the use of evidence-based innovations in care delivery. The
If a patient has a complicated course with a prolonged hospitalization as a result of a preventable complication (eg, surgical site infection, urinary tract infection related to a catheter), the costs are borne by the institution. In addition to changes in the structure of reimbursement, the era of public outcomes and benchmark reporting encourages providers and institutions to focus on new and innovative ways to improve outcomes.4 Advances in technology (eg, laparoscopy, thoracoscopy) have allowed many complex surgical procedures to be performed with minimally invasive techniques, thus enabling patients to more quickly return to http://dx.doi.org/10.1016/j.aorn.2015.09.006 ª AORN, Inc, 2015
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their preoperative functional status. All these factors have played a significant role in creating a new era in surgical patient management. The idea of enhanced recovery and fasttracking have arisen because of the need to maintain quality while decreasing costs.
ENHANCED RECOVERY AFTER SURGERY The concept of Enhanced Recovery After Surgery (ERAS) as a model of care was introduced in the late 1990s by Kehlet.5 This model provides a multimodal approach that attempts to reduce a patient’s perioperative stress response, reduce potential complications, decrease hospital length of stay, and enable a faster return to baseline functional status.6-8 These enhanced recovery strategies were first described in patients undergoing open colorectal procedures.9,10 Care providers implemented ERAS strategies in an effort to decrease the incidence of postoperative ileus, which affects cost11 and length of stay.11,12 Initial ERAS strategies used in this specific population have been adapted for use in patients undergoing multiple kinds of surgeries, including vascular,13 thoracic,14 and urological.15 The key elements of ERAS protocols include
preoperative counseling, optimizing nutrition, standardizing analgesic and anesthetic regimens, and encouraging early mobilization.6,8,16,17
The use of these modalities has positively affected patient care and produced significant evidence that ERAS protocols improve patient outcomes.11,18-20
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surgery who were cared for using a fast-track clinical pathway. Their prospective, randomized, controlled pilot study included patients who had undergone lung resection and who were cared for using either a conservative (ie, traditional) treatment regimen or a fast-track treatment regimen. The conservative patient group fasted for six hours and had an intraoperative intercostal nerve block followed by IV patient-controlled analgesia (PCA). Enteral feeding and ambulation started on the day after surgery. The fast-track group fasted for two hours and were provided patient-controlled epidural analgesia.22 In this group, enteral feeding and ambulation started on the evening of the operation.22 The primary end points of the study were the presence of postoperative pulmonary complications of atelectasis, pneumonia, prolonged air leak (ie, more than seven days), and pleural effusion.22 The researchers found that the overall rates of postoperative pulmonary complications were 36% in the conservative group and 7% in the fast-track group (P ¼ .009).2 Complications for each category were as follows. Pneumonia was 11% in the conservative group and 0% in the fast-track group. Atelectasis was 7% in the conservative group and 0% in the fast-track group. Prolonged air leak was 11% in the conservative group and 3% in the fast-track group. Pleural effusion was 7% in the conservative group and 3% in the fast-track group. In this study, researchers found no significant difference in overall morbidity or mortality.22
OUR PROGRAM ERAS in Thoracic Surgery Many health care facilities worldwide and in the United States have implemented ERAS protocols in the thoracic surgical patient population. In 2009, Das-Neves-Pereira and colleagues21 published their five-year experience with 109 lobectomy patients who were provided care in a fast-track rehabilitation program. Patients in this study underwent traditional, open, muscle-sparing (ie, muscles are not cut to perform the procedure) lobectomies. Comparison of their postoperative complications and hospital length of stay showed that non-fast-tracked patients experienced more frequent postoperative complications and a longer average hospital stay.21 Of particular importance, early patient ambulation was the only predictive (ie, protective) independent variable of postoperative complications.21 In 2008, Muehling and associates22 monitored patients with postoperative pulmonary complications following lung
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While there is clearly significant evidence supporting the concept of ERAS, there is no evidence to support the specific interventions that are implemented in our minimally invasive thoracic surgery program. We have sought and received institutional review board approval to monitor outcomes in our patient population, which we will evaluate and publish at a later date. In 2007, the thoracic surgery team began the process of creating a minimally invasive thoracic surgery program. A minimally invasive trained thoracic surgeon, Sandeep Khandhar, MD, FACS, was recruited to spearhead the program’s development. The physical structure of the facility, as well as the mindset of staff members, had to change to accomplish the goal of implementing enhanced recovery interventions to create a cutting-edge minimally invasive thoracic program that provides extraordinary patient care, as evidenced by exemplary patient outcomes. AORN Journal j 483
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For example, there was no postanesthesia care unit (PACU) in the surgical suite when the program began. Because we perform minimally invasive thoracic procedures in the cardiovascular OR suite and at the time we transferred all cardiac surgery patients in the facility directly to the cardiovascular intensive care unit, there was no PACU in which to recover the minimally invasive thoracic surgery patients. As a result, the facility had to construct a PACU adjacent to the cardiovascular OR to recover the thoracic surgery patients. More important than the physical structure was changing the culture surrounding the delivery of the postoperative care. To accomplish this, personnel providing all aspects of patient care had to undergo a paradigm shift to care for this patient population. The goal was to change the focus from disease management to health promotion. Our team sought to maintain and improve the functional status of our patients. To increase the potential for long-term success, we instituted changes that started with the initial outpatient office visit and continued through the inpatient discharge. Specific interventions included increasing staffing in the inpatient and outpatient areas to be able to provide the focused care necessary to achieve the goals associated with enhanced recovery. We provided extensive in-services to staff members to outline their specific role in the achievement of the program’s goals. In conjunction with nursing leaders, the thoracic surgeon interviewed PACU nurses who wanted to be part of the selection process to hire new staff members based on their clinical abilities and their willingness to adopt the aggressive enhanced recovery goals that we set for our patients. Changes on the nursing units included extensive education, both group and individual, on enhanced recovery techniques and decreased nurse to patient ratios to handle the demands associated with implementing enhanced recovery in these thoracic patients.
Preoperative Period The success of any endeavor, particularly surgical, depends on the level of preparation. Patients also require extensive preparation for surgery, which ideally begins at the time of the patient’s first appointment in the surgeon’s office. In our program, this is a lengthy visit in which the patient first meets with our outpatient nurse practitioner (NP). The NP performs an extensive history and physical examination that includes assessment of the patient’s functional status, exercise patterns, and pulmonary function to help determine the ability of the patient to participate in postoperative exercise and the risk for complications. All patients who have thoracic surgery by our minimally invasive surgeon participate in the ERAS program, which aims
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to have the patient progress rapidly, but safely, from the preoperative phase to discharge. Patients who have chronic pain or mobility issues may take longer to progress because of their potential inability to achieve ambulation or pain management goals. Patients who are more ill or who may be inpatients at the time of surgery also can be treated using the ERAS principles; however, this group of patients is much more likely to have poor functional status at baseline from deconditioning related to their physical compromises, comorbidities, or the length of time in the hospital before surgery. After physicians identify the need for a thoracic procedure, patients are strongly encouraged to participate in their care and to increase their physical activity in preparation for surgery. The only patient criterion that contraindicates the use of thoracic ERAS strategies is a physical limitation that prevents the patient from walking (eg, severity of illness, ventilated, sedated). However, at some institutions, patients who are being ventilated also are encouraged to ambulate to improve their outcomes.23 Patient education is perhaps the most critical component for the success of any ERAS program, and positive surgical outcomes are made possible when patients take ownership and responsibility for the role they play in the surgical process. At the initial preoperative visit, if patients are current smokers, they are informed that to be considered for surgery under this program, complete smoking cessation is required immediately. Being an active smoker at the time of resection is associated with a higher likelihood of death within the 30-day period after surgery and increases the risk for serious postoperative complications, including pneumonia, cardiac arrest, myocardial infarction, and stroke.24 If the patient is unable to meet the smoking cessation requirement, the surgeon refers him or her to another thoracic surgeon or postpones the surgery until the patient is able to comply with this requirement for at least two weeks before the scheduled surgery date. Care providers recognize that if the patient is to be successful in achieving the highest level of function as soon as possible after surgery, he or she must participate in physical activity preoperatively. Members of the team inform patients and their families of the exercise regimen that is to begin before surgery. While there are clearly some clinical conditions that would make it impossible for the patient to comply with increasing their ambulation (eg, wheelchair bound, unable to ambulate because of various physical conditions), the vast majority of patients comply with the instructions after they understand the rationale for the request and its importance in achievement of a successful outcome. At a minimum, we ask that the patient walk at a brisk pace for 20 minutes three times per day.
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This is not a metric that is backed by specific evidence, but our team felt that it was a specific, measurable, and attainable goal that if met, would increase the patient’s cardiopulmonary function and increase the likelihood of a successful surgical outcome. Although we recognize that we have no ability to verify the patient’s compliance with this instruction, more times than not, the patient will come to surgery having at least attempted to comply and will have increased their activity to some degree, which will benefit them in the postoperative period. During the preoperative visit, the nurse explains to the patient and family that another expectation is that the patient will walk 250 feet within one hour after extubation in the PACU. Of all the ERAS principles, early ambulation is seen as the most critical.7 All interventions in the surgical process from the timing of extubation to pain management are tailored to facilitate early ambulation. The goal is for patients to be ambulatory as soon as possible to facilitate bronchial/ pulmonary hygiene and maximum lung expansion. The preoperative and postoperative phases are critical to achieving the goal of early ambulation, and each member of the team reinforces the goal.
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anti-inflammatory medications, and oral narcotics. Nursing personnel explain the side effects of narcotics and their potential effect on recovery. o o
The negative effects of traditional pain management strategies can be particularly devastating in the thoracic surgical patient and are illustrated in Figure 1. To facilitate postoperative pain control and avoid negative outcomes, the anesthesia provider frequently administers preemptive analgesia (ie, before the patient is experiencing pain), which includes the preoperative administration of oral acetaminophen, gabapentin, and oxycodone. Preemptive analgesia is thought to decrease postoperative pain and reduce analgesic requirements.26 The anesthesia professional also avoids administering agents during surgery that would result in excessive postoperative sedation or increase the risk for nausea and vomiting. He or she uses short-acting narcotics and non-narcotic pain relievers such as IV ketorolac and IV acetaminophen when clinically appropriate.
Pain Control At the outpatient visit, all patients are given information about pain management. The following concepts are discussed. Patients will have pain after surgery and nursing personnel will assist them in maintaining a level of comfort that will facilitate the ambulation goal. Nursing personnel will ask patients to rate their pain using a 0 to 10 numeric pain rating scale in which 0 indicates no pain, 5 indicates moderate pain, and 10 indicates the worst possible pain. Nursing personnel counsel patients that it is unrealistic to expect that their pain scores will be zero. Although the perception of pain is subjective and specific to every individual, we counsel the patients that a pain score of 5 or less is reasonable and to be expected after thoracic surgery. In addition to assessment of the patient’s pain score is the assessment of the patient’s pain as “tolerable” or “intolerable.” Chauhan discusses the possibility that the “use of the [pain] scale may unintentionally deteriorate into a bureaucratic check-list item supplanting, rather than enhancing communication.”25(p2330) Care providers will use multiple modalities to manage pain, including o local anesthetics, o non-narcotic analgesics,
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Figure 1. Schematic shows the negative outcomes of traditional pain management techniques. AORN Journal j 485
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Although often effective in the management of postoperative pain, epidural catheters also tend to cause autonomic nervous system sympathetic effects including hypotension, which can prevent early ambulation. For this reason, we do not use them in our minimally invasive thoracic program. The use of IV narcotics is limited to the first few minutes in the PACU when the patients are not deemed to be awake enough to safely take oral medications. The cascade of negative consequences related to the traditional management of postoperative pain led us to adopt the following approach to managing postoperative pain. After the patient is awake enough to safely take oral medications, the PACU RN administers 1,000 mg of oral acetaminophen and nursing unit staff members continue to administer this every six hours during the first 24 hours after surgery. Anti-inflammatory agents including ketorolac and/or ibuprofen are used on a case-by-case basis. The clinical criteria used to evaluate their appropriate use include o patient age, o cardiac history, o baseline renal function, o risk for postoperative bleeding, and o current operative intervention. To minimize the potential side effects of sedation and nausea, oral narcotics are administered sparingly in the postoperative period.
OPERATIVE PROCEDURE As in all surgical procedures, thoracic procedures have a multitude of safety concerns that need to be addressed by the entire team. Immediately before taking the patient to the OR, the nurse assesses for comorbidities or conditions that will affect the patient during surgery and could affect postoperative care and reports any concerns to the surgeon and anesthesia professional. In accordance with The Joint Commission’s Universal Protocol 2013 National Patient Safety Goals, we use the AORN surgical checklist before all procedures as a tool to help prevent never events (ie, preventable errors that should never occur).27 The preinduction time-out pause is of particular importance to identify a difficult airway. Placement of the double-lumen endotracheal tube, which anesthesia professionals use to provide preferential atelectasis on the operative side while the nonoperative lung is ventilated normally, can be a challenge to insert even in a patient with a normal airway. If the anesthesia professional identifies the patient as having a difficult airway, the RN circulator should gather the appropriate equipment and 486 j AORN Journal
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supplies to facilitate safe intubation (eg, difficult airway cart, tracheotomy tray). Laterality is an issue in every thoracic procedure. Use of the time out before the skin incision confirms the patient’s identity, procedure, incision site, and side. In addition, the surgical team displays relevant radiological studies on two monitors in the room so all members of the team can easily identify the abnormality in question and verify the correct surgical side and site. Perioperative hypothermia is associated with many adverse outcomes, including delayed clearance of inhaled and IV anesthetic agents, thus increasing the length of time these medications are active and delaying postanesthetic recovery.28 Perioperative staff members attempt to prevent hypothermia by using AORN’s “Guideline for prevention of unplanned perioperative hypothermia,”29 including minimizing skin exposure by covering parts of the body not involved in the surgical procedure, using forced-air warming devices, warming irrigation solutions to body temperature, and keeping the OR warmer than is customary in a cardiothoracic OR (ie, approximately 75 F [24 C]). Intraoperatively, the anesthesia professional monitors IV fluids to avoid fluid overload. Judicious fluid administration minimizes the risk for pulmonary edema and acute lung injury (ALI). Researchers have repeatedly demonstrated that postoperative ALI is associated with excess fluid administration.30-34 Because fluid administration is kept to a minimum, urinary drainage catheters are rarely required for patients undergoing minimally invasive pulmonary resections in our program. This significantly decreases the risk for catheter-associated urinary tract infection (CAUTI) and frees the patient from having to deal with an additional “tube” when ambulating.
POSTANESTHESIA CARE Within one hour of arrival in the PACU, the nurse helps the patient take his or her first walk. The PACU nurses recognize the physiological importance of returning the patient to his or her preprocedure baseline and are the first caregivers to help the patient ambulate.
Potential Postoperative Concerns Pulmonary complications are the major factor in postoperative mortality after lung resection, accounting for up to 84% of all deaths.35 As early as 1949, Leithauser recognized that “early ambulation is indispensable to the well-being and safety of the surgical patient.”36(p368) In addition, early ambulation “has been found to save lives by hastening recovery, thereby
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preventing many fatal complications.”36(p368) Historically, physicians prescribed bed rest because it was thought to be beneficial to providing patient comfort and preventing complications.37 It is now widely recognized that even small amounts of bed rest can cause complications, including thromboembolic events and pulmonary complications.38-40
Atelectasis The potential complications of atelectasis, which include hypoxia, pneumonia, and respiratory failure, are a major concern in the surgical patient who has undergone a thoracic procedure. The postoperative pain associated with chest tubes and incisions often causes patients to take small shallow breaths. Additionally, patients who do not ambulate quickly after surgery are much more likely to experience atelectasis because lung compliance in the supine position is reduced substantially.37 Atelectasis may predispose the patient to pneumonia, and it increases pulmonary vascular resistance.37 Additionally, atelectasis causes intrapulmonary shunting, a physiological condition that occurs when there is normal perfusion of blood to a lung that is not being ventilated normally, as can occur with pneumonia. When there is decreased ventilation, the blood going to the lung involved is not appropriately oxygenated, resulting in potential hypoxia, which can increase supplemental oxygen requirements.37
Deep vein thrombosis (DVT) and pulmonary embolism (PE) An additional complication that can be attributed to inactivity or prolonged bed rest is the formation of DVTs and their potential progression to PEs.37,39 Thoracic surgery patients are at significant risk for DVT formation because several, and sometimes all, of the aspects of Virchow’s triad (ie, stasis, injury to vein endothelium, hypercoagulability) are present in this population.38 Patients with cancer are at an increased risk for venous thromboembolism (VTE); the risk for VTE is fourto seven-fold higher in these patients than in those without cancer,41,42 and VTE and thrombotic complications are the second most frequent cause of mortality.43 The pathophysiology of cancer-associated thrombosis is not completely understood. The hypercoagulability in cancer involves several complex mechanisms, including interaction among cancer cells, host cells, and the coagulation system.44 Venous stasis is more likely to occur in surgical patients who do not ambulate after surgery because blood flow through the legs varies with activity of muscles.37 Inactivity associated with general anesthesia, surgery, and any prolonged period of bed rest promotes venous stasis. The compression of veins that
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occurs as a result of surgical positioning and from the contact of extremities with the bed may also contribute to stasis and may damage vascular endothelium.39
Nausea and vomiting If the patient has minimal postoperative nausea, the PACU nurses begin offering oral intake. However, the intake of plain water is restricted to minimize the risk for postoperative hyponatremia. We offer the patient electrolyte replacement drinks during the first 24 to 36 hours after surgery to maintain optimal fluid and electrolyte balance. If the patient has issues with nausea and vomiting, standard antinausea agents are administered (eg, ondansetron); however, we make every attempt to avoid the use of promethazine because of its known sedation side effect.
Bronchopulmonary Hygiene Although every thoracic surgical patient has a chest tube, we have streamlined its management to facilitate the physiological state of the pleural space by placing the tube to water seal after a very brief period of suction to evacuate the iatrogenic pneumothorax that is created by entrance into the thoracic cavity and single-lung ventilation. Placing the chest tube to water seal eliminates the tubing associated with suction, thus freeing the patient from unnecessary attachments, and provides increased freedom to ambulate. While the patient is still in the PACU, respiratory therapists help the patient begin breathing exercises using an incentive spirometer and a handheld device that combines positive expiratory pressures with airway vibrations to facilitate movement of mucus that helps the patient clear it from his or her lungs. This device employs a counterweighted plug and magnet that directs exhaled air through a pivoting cone that generates airflow vibrations between 0 and 30 Hz.45 Proper bronchopulmonary hygiene activities help patients expand their lungs in a physiological fashion, rather than relying on suction.
Discharge For patients who have had minor pulmonary resections (eg, wedge resections), the goal is for them to be discharged from the PACU to home within approximately three hours after extubation. For patients to meet this goal, they must be hemodynamically stable and have no air leak from the chest tube, have no significant nausea or vomiting, be minimally sedated, be taking oral medication with adequate pain control, and
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be able to ambulate with minimal assistance without episodes of hypotension. Patients who have had more extensive pulmonary resections (eg, lobectomy) remain in the hospital for at least one night after surgery. The PACU goals for these patients are identical to those for patients having minor resections. Goals instituted within the PACU include the patient ambulating within one hour of arrival to the PACU, tolerating oral intake, and performing bronchopulmonary exercises. Of all the interventions instituted in the postoperative period, the early mobilization of the patients has the greatest effect on improving patient outcomes.18 With very few exceptions, our patients go to a regular nursing unit after the PACU. What is unusual is that our patients walk to their rooms. The distance from the PACU to the nursing unit is approximately 500 to 750 feet, depending on the location of their room on the unit. A patient walks from the PACU pushing a wheelchair with the family alongside him or her and the PACU nurse in attendance. On arrival to the patient’s room, nurses assist the patient to a seated position in a reclining chair because most patients who have undergone thoracic surgery find the upright position much more comfortable than lying flat. The goal for patients is to walk 10 to 12 laps around the unit on the night of surgery. The nursing unit is in the shape of a square, and one complete lap around the unit is approximately 1,000 feet. The vast majority of patients attain this goal and are proud to demonstrate this with “check boxes” on their white boards that they are sure to point out to the team on rounds the next morning. The goal for patients who have undergone pulmonary resections such as a lobectomy is to go home on postoperative day one. Similar to patients who are discharged from the PACU, these patients must be hemodynamically stable. They must tolerate their usual diet without significant nausea or vomiting. Their pain must be controlled with oral pain medication. The chest tube is removed if there is no air leak and the quality and amount of drainage is within normal limits (ie, less than 200 mL). If there is an air leak, this does not preclude patients from being discharged. If the physician believes that the air leak will likely seal within 24 hours, the patient may be kept in the hospital for an additional day. However, if he or she believes that the air leak is unlikely to seal within 24 hours, the patient often will be discharged with the chest tube in place. The patient and family receive extensive teaching on care of the chest tube and drainage
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collection chamber. Patients are taught how to shower with the tube in place and how to re-dress the chest tube when necessary. They are instructed on how to empty the collection chamber and troubleshoot potential issues. The NP reviews potential problems that may require a call to the physician and provides a telephone number. A postoperative follow-up appointment is scheduled for all patients so that they are discharged with a specific date and time to return. One of the major “successes” of our approach to thoracic surgery is the speed with which patients can return to their baseline function. At discharge, patients’ physical activities are not limited. We recognize that patients will “self-limit” their activities based on pain; however, we instruct them to pursue any activity they feel comfortable doing and do not limit them. In abdominal surgery or even the traditional open approach to thoracic surgery, there is concern for hernia with heavy lifting or activity. Such concerns do not exist in patients who have undergone minimally invasive thoracic procedures because there is no rib spreading, which significantly disrupts the muscular and ligamentous attachments of the rib cage. If they are taking narcotic pain medications, they are told not to drive. We instruct them to continue to ambulate 20 minutes three times a day. Walking is the best exercise, and although they may feel more fatigued than they did before surgery, it is of the utmost importance that they stay active. The ability for the patient to return quickly to a normal routine is a welcome surprise for the patient and his or her family.
BARRIERS TO IMPLEMENTATION As with implementation of any change, there were barriers encountered during the implementation of our ERAS program. There were safety concerns, concerns regarding having the appropriate staffing ratios to implement the program, concerns about patient compliance, and concerns about how the program would affect patients’ pain. Perhaps the most formidable barrier to implementation of the ERAS principles in our minimally invasive thoracic surgery program was concern for patient safety. Traditionally, patients rarely, if ever, ambulated during their time in the recovery room. Most typical PACUs have no patient chairs, such as in an ambulatory care PACU, and they have only bays awaiting patients on stretchers arriving from the ORs. Nursing staff members had valid concerns, as did some of our anesthesia colleagues, regarding potential postoperative hypotension or dizziness that could cause the patient to lose consciousness while walking. The nurses in both the PACU area and the nursing units had concerns about the patient’s safety and the nurse’s liability if the patient was injured as a result of
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ambulating so soon after anesthesia. There is ample evidence in the literature supporting the idea of early mobilization, even in critically ill patients.37,40,46,47 In 2007, Bailey and colleagues40 demonstrated in a case series report that early activity is feasible and safe in patients with respiratory failure and might improve clinical outcomes. Implementation of the ERAS principles in our thoracic surgical service required increased staffing resources. Pearsall et al48 conducted a study in seven University of Toronto-affiliated hospitals to identify potential barriers to ERAS interventions. When discussing barriers specific to nursing, they described “lack of manpower and time as a barrier to implementation”48(p94) of ERAS principles. The authors stated that although nurses saw value in ERAS, they expressed concern that the interventions would create more work for nurses that were already spread thin because of shortages.48 This issue was a barrier to implementation in our program as well. Decreased nurse to patient ratios were needed to implement the walking regimen (eg, walking in the PACU after surgery) because we recognized that the increased ambulation component required more of the nurses’ time. Because it takes more staff members to aggressively ambulate patients who have just had thoracic surgery, one of the major barriers to implementation of this regimen was obtaining adequate personnel on inpatient units. Both licensed and unlicensed personnel are used for the one-on-one patient assistance. At a time when nurse to patient ratios were increasing because of staff cutbacks related to declining hospital reimbursement, we were asking for more nurses to facilitate the positive outcomes that implementation of the ERAS program could provide. Overcoming this barrier required significant collaboration between hospital administrators and the leaders of the thoracic surgery team. Through this collaboration, we hired additional nursing staff members (ie, RNs, nursing assistants) to increase the number of nurses on the inpatient unit that cares for these patients. Having the additional personnel facilitates the successful attainment of the aggressive patient ambulation goals. Patient pain is a significant barrier to early ambulation. Focusing on pain and its elimination is the natural tendency of nursing and medical providers and is now a regulatory requirement. In 1999, the Joint Commission on Accreditation of Healthcare Organizations (now known as The Joint Commission) stated that there were physical and psychological patient consequences to unrelieved pain, which can also increase health care costs.49 The Joint Commission officially declared pain to be “the fifth vital sign,” requiring mandatory pain
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assessment for proper patient care.49 The organization also believes that pain assessment and treatment is important and as basic for accurate patient care as assessing temperature, blood pressure, respiratory rate, and heart rate.49 Through the use of preoperative preemptive analgesia, intraoperative infiltration of local anesthetic agents at surgical sites, shortacting IV analgesia intraoperatively as well as in the immediate postoperative period, and scheduled non-narcotic analgesia and PRN oral narcotic administration, we are able to successfully manage the patient’s pain, thus increasing the ability to participate in early ambulation. Despite our extensive preoperative preparation, patients are occasionally reluctant to ambulate. When our ERAS program initially started, it was difficult for the PACU nurses to implement the early ambulation goal. In a discussion of barriers to implementation of an ERAS program, Pearsall et al state that nursing culture is a significant barrier to early ambulation programs and “that because of their culture they might feel that they’re [patients are] too sick to be up and moving around.”48(p93) We needed the nurses, the patient, and the patient’s family to focus on the positive consequences of early ambulation rather than the perceived negative aspects. Our extensive preoperative education of the patient and family facilitates their “buy in.” By focusing on the positive aspects of ambulation, we have been able to minimize the administration of opioids and the spiral of adverse events associated with their use.
OUTCOMES The ERAS care approach in the thoracic surgical population is feasible and safe. We have analyzed patient data from July 2010 to July 2013. During this time, 750 patients who had video-assisted thoracic surgery procedures recovered in the PACU and either transferred to the nursing unit or were directly discharged to home. There have been no patient falls or injuries in the PACU or the nursing unit. When we compare the specific data points of postoperative length of stay, postoperative pneumonia rates, and rates of patients requiring bronchoscopy because of atelectasis in both patients who underwent lobectomy and wedge resection, our outcomes compare very favorably against the national average as reported by The Society of Thoracic Surgeons’ General Thoracic National Database.50 In 2013, patients undergoing a lobectomy in our institution had a postoperative length of stay of 1.9 days compared to the national average of 6.2 days. Patients undergoing wedge resection stayed in the hospital an average of one day compared to the reported average of 4.1 days.50 The rate of postoperative
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pneumonia in patients who underwent a lobectomy was 2.6% compared to the national average of 4.3%. After wedge resection, patients had a 0% pneumonia rate compared to the national average of 1.3%.50 Atelectasis requiring bronchoscopy occurred 0% of the time in both the lobectomy and wedge resection populations compared to the national averages of 4.5% and 0.7%, respectively.50
PATIENT SATISFACTION Hospital reimbursement is increasingly tied to patient satisfaction rates. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are reported to payers (specifically the Centers for Medicare & Medicaid Services), with the score comprising a portion of the formula that dictates reimbursement rates.51 The HCAHPS survey is administered to a random sample of discharged patients between 48 hours and six weeks after discharge. There are 27 questions about the patient’s perception of his or her hospital experience. Topics range from cleanliness and quietness of the facility and communication with providers to perception of adequate pain control.52 During the last quarter of 2014, our HCAHPS scores with respect to pain control were in the 97th to 98th percentile compared with similar facilities (ie, 500þ bed teaching facilities) and our patients ranked us in the 99th percentile with respect to recommending our facility.53 We know based on anecdotal reports from patients, their significant others, and hospital staff members that our patients report increased satisfaction with their ability to more quickly return to feeling less like a “patient” by being out of bed and able to independently perform their activities of daily living.
CONCLUSION In an era in which both patients and hospitals benefit from decreased hospital length of stay, the ERAS techniques and interventions applied in our program enable the patient to return more quickly to full functional status while minimizing many of the postoperative complications associated with thoracic surgery. By engaging the patient and his or her family members through extensive preoperative education and helping patients recognize that their actions and active participation directly affect their recovery, clinicians have been able to move patients quickly through the perioperative continuum and return them to their optimal functional status. In today’s health care environment, the programs that will survive are the ones that are able to push past traditional barriers to create
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innovative strategies designed to deliver the highest quality care in the most cost-effective manner. Editor’s note: ERAS is a registered trademark of the ERAS Society, Kista, Sweden.
References 1. Janu PG, Sellers KD, Mangiante EC. Recurrent inguinal hernia: preferred operative approach. Am Surg. 1998;64(6):569-573. 2. HR 2 - Medicare Access and CHIP Reauthorization Act of 2015. Congress.gov. https://www.congress.gov/bill/114th-congress/house -bill/2/text. Accessed August 24, 2015. 3. Peasah SK, McKay NL, Harman JS, Al-Amin M, Cook RL. Nonpayment of hospital-acquired infections: infection rates three years post implementation. Medicare Medicaid Res Rev. 2013;3(3): e1-e13. https://www.cms.gov/mmrr/Downloads/MMRR2013_ 003_03_a08.pdf. Accessed July 27, 2015. 4. Understanding publicly available healthcare data. AHIMA.org. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_ 050345.hcsp?dDocName¼bok1_050345. Accessed July 27, 2015. 5. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606-617. 6. Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ. 2001;322(7284):473-476. 7. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641. 8. Kehlet H, Wilmore DW. Fast-track surgery. Br J Surg. 2005;92(1): 3-4. 9. Wind J, Polle SW, Fung Kon Jin PH, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg. 2006;93(7):800-809. 10. Kibler VA, Hayes RM, Johnson DE, Anderson LW, Just SL, Wells NL. Cultivating quality: early postoperative ambulation: back to basics. Am J Nurs. 2012;112(4):63-69. 11. Kariv Y, Delaney CP, Senagore AJ, et al. Clinical outcomes and cost analysis of a “fast track” postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum. 2007;50(2):137-146. 12. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum. 2003;46(7):851-859. 13. Podore PC, Throop EB. Infrarenal aortic surgery with a 3-day hospital stay: a report on success with a clinical pathway. J Vasc Surg. 1999;29(5):787-792. 14. Tovar EA, Roethe RA, Weissig MD, Lloyd RE, Patel GR. One-day admission for lung lobectomy: an incidental result of a clinical pathway. Ann Thorac Surg. 1998;65(3):803-806. 15. Koupparis A, Dunn J, Gillatt D, Rowe E. Improvement of an enhanced recovery protocol for radical cystectomy. Br J Med Surg
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16. 17.
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Urol. 2010;3(6):237-240. http://uro.sagepub.com/content/3/6/ 237. Accessed September 19, 2015. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362(9399):1921-1928. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86(2):227-230. Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, McLeod RS. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009;13(12):2321-2329. Lassen K, Soop M, Nygren J, et al; and the Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009; 144(10):961-969. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg. 2007;245(6):867-872. Das-Neves-Pereira J, Bagan P, Coimbra-Israel AP, et al. Fasttrack rehabilitation for lung cancer lobectomy: a five-year experience. Eur J Cardiothorac Surg. 2009;36(2):383-392. Muehling BM, Halter GL, Schelzig H, et al. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg. 2008;34(1):174-180. Schweickert WD, Kress JP. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. 2011;140(6):1612-1617. Turan A, Mascha E, Roberman D, et al. Smoking and perioperative outcomes. Anesthesiology. 2011;114(4):837-846. Chauhan C. The perception of perception. J Clin Oncol. 2007; 25(16):2329-2330. Pandey CK, Priye S, Singh S, Singh U, Singh RB, Singh PK. Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy. Can J Anesth. 2004;51(4):358-363. Comprehensive surgical checklist. AORN, Inc. https://www.aorn .org/Clinical_Practice/ToolKits/Correct_Site_Surgery_Tool_Kit/Com prehensive_checklist.aspx. Accessed July 28, 2015. Reynolds L, Beckmann J, Kurz A. Perioperative complications of hypothermia. Best Pract Res Clin Anaesthesiol. 2008;22(4): 645-657. Guideline for prevention of unplanned perioperative hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:479-490. Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg. 2003;97(6):1558-1565. Arslantas M, Kara H, Tuncer B, et al. Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections. J Thorac Cardiovasc Surg. 2015;149(1):314-321. Evans R, Naidu B. Does a conservative fluid management strategy in the perioperative management of lung resection patients reduce
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the risk of acute lung injury? Interact Cardiovasc Thorac Surg. 2012;15(3):498-504. Chau E, Slinger P. Perioperative fluid management for pulmonary resection surgery and esophagectomy. Semin Cardiothorac Vasc Anesth. 2014;18(1):36-44. Alam N, Park B, Wilton A. Incidence and risk factors for lung injury after lung cancer resection. Ann Thorac Surg. 2007;84(4): 1085-1091. Agostini P, Cieslik H, Rathinam S, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax. 2010;65(9):815-818. Leithauser DJ. Rational principles of early ambulation. J Int Coll Surg. 1949;12(3):368-374. Brower RG. Consequences of bed rest. Crit Care Med. 2009; 37(10)(Suppl):S422-S428. Meeker MH, Rothrock JC. Alexander’s Care of the Patient in Surgery. 14th ed. St. Louis, MO: Mosby-Year Book, Inc; 2011. Virchow RLK. Thrombosis and Emboli. 1846-1856. Canton, MA: Science History Publications; 1997. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1): 139-145. Elyamany G, Alzahrani A, Bukhary E. Cancer-associated thrombosis: an overview. Clin Med Insights Oncol. 2014 Dec 4;8: 129-137. Stein P, Beemath A, Meyers F, Kayali F, Skaf E, Olson RE. Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med. 2006;119(2):60-68. Haddad T, Greeno E. Chemotherapy-induced thrombosis. Thromb Res. 2006;118(5):555-568. Karimi M, Cohan N. Cancer-associated thrombosis. Open Cardiovasc Med J. 2010 Feb 23;(4):78-82. Acapella Fact Sheet. cmamaine.com. www.cmamaine.com/_pdf/ Acapellafactsheet.pdf. Accessed August 24, 2015. Hodgson C, Berney S, Harrold M, Saxena M, Bellomo R. Clinical review: early patient mobilization in the ICU. Crit Care. 2013;17(1): 207. Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012; 23(1):5-13. Pearsall E, Meghji Z, Pitzul K, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2015; 261(1):92-96. Dahl J. Implementing the JCAHO Pain Management Standards. Presented at the American Pain Society 19th Annual Meeting. November 2-5, 2000; Atlanta, GA. Data AnalysisdGeneral Thoracic Surgery Database. Spring 2014 Harvest Report. Society of Thoracic Surgeons. http://www.sts.org/ national-database. Accessed August 24, 2015. Hospital Value-Based Purchasing. Centers for Medicare & Medicaid Services, Department of Health and Human Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment -Instruments/hospital-value-based-purchasing/index.html?redirect¼/ Hospital-Value-Based-Purchasing/. Accessed August 24, 2015.
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Schatz 52. HCAHPS: Patients’ Perspective of Care Survey. Centers for Medicare & Medicaid Services, Department of Health and Human Services. http://www.cms.gov/Medicare/Quality-Initiatives -Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCA HPS.html. Accessed August 24, 2015. 53. Inova Fairfax Hospital HCAHPS Inpatient Report. 4th Quarter Report. October-December 2014: Press Ganey report. Falls Church, VA: Inova Fairfax Hospital; 2014.
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Christy Schatz, MSN, RN, FNP-BC, CRNFA, is a nurse practitioner/RN first assistant in Thoracic Surgery at Inova Fairfax Hospital, Falls Church, VA. Ms Schatz has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT Enhanced Recovery After Surgery (ERAS) is a strategy that seeks to reduce patients’ perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay, and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the changes in patient care using an ERAS framework in a minimally invasive thoracic surgery program, barriers to implementation, and patient outcomes. AORN J 102 (November 2015) 482-492. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.09.006 Key words: enhanced recovery after surgery, ERAS, VATS, minimally invasive, thoracic.
I
n the past 30 years, there has been a revolution in operative techniques and postoperative management of surgical patients. For example, in 1985, patients undergoing inguinal hernia repairs remained in the hospital for three days.1 Care providers rarely expected that surgical patients would participate in their own care or that they should be walking within hours after surgery. In the past, patients were hospitalized for several days after procedures that are now performed as same-day procedures.
focus of care now is on safely returning patients to their full functional status in a reduced amount of time. Hospitals and providers no longer receive reimbursement for care that results from the negative outcomes of interventions or that results in hospital-acquired infections or other outcomes deemed preventable.3 The incentive for clinicians is to provide evidence-based care and services that reduce the incidence of serious consequences for patients and make reimbursement costs more manageable.
Other changes reflect reimbursement mechanisms. On April 16, 2015, President Obama signed into law House Resolution (HR) 2 e Medicare Access and CHIP Reauthorization Act of 20152 in an effort to decrease the high cost of health care associated with the traditional “fee-for-service” model. The law replaces the fee-for-service model; hospital reimbursement is now based on the quality of patient outcomes rather than the number of procedures performed.2 This change is designed to improve patient outcomes, promote use of best practices, and encourage the use of evidence-based innovations in care delivery. The
If a patient has a complicated course with a prolonged hospitalization as a result of a preventable complication (eg, surgical site infection, urinary tract infection related to a catheter), the costs are borne by the institution. In addition to changes in the structure of reimbursement, the era of public outcomes and benchmark reporting encourages providers and institutions to focus on new and innovative ways to improve outcomes.4 Advances in technology (eg, laparoscopy, thoracoscopy) have allowed many complex surgical procedures to be performed with minimally invasive techniques, thus enabling patients to more quickly return to http://dx.doi.org/10.1016/j.aorn.2015.09.006 ª AORN, Inc, 2015
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their preoperative functional status. All these factors have played a significant role in creating a new era in surgical patient management. The idea of enhanced recovery and fasttracking have arisen because of the need to maintain quality while decreasing costs.
ENHANCED RECOVERY AFTER SURGERY The concept of Enhanced Recovery After Surgery (ERAS) as a model of care was introduced in the late 1990s by Kehlet.5 This model provides a multimodal approach that attempts to reduce a patient’s perioperative stress response, reduce potential complications, decrease hospital length of stay, and enable a faster return to baseline functional status.6-8 These enhanced recovery strategies were first described in patients undergoing open colorectal procedures.9,10 Care providers implemented ERAS strategies in an effort to decrease the incidence of postoperative ileus, which affects cost11 and length of stay.11,12 Initial ERAS strategies used in this specific population have been adapted for use in patients undergoing multiple kinds of surgeries, including vascular,13 thoracic,14 and urological.15 The key elements of ERAS protocols include
preoperative counseling, optimizing nutrition, standardizing analgesic and anesthetic regimens, and encouraging early mobilization.6,8,16,17
The use of these modalities has positively affected patient care and produced significant evidence that ERAS protocols improve patient outcomes.11,18-20
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surgery who were cared for using a fast-track clinical pathway. Their prospective, randomized, controlled pilot study included patients who had undergone lung resection and who were cared for using either a conservative (ie, traditional) treatment regimen or a fast-track treatment regimen. The conservative patient group fasted for six hours and had an intraoperative intercostal nerve block followed by IV patient-controlled analgesia (PCA). Enteral feeding and ambulation started on the day after surgery. The fast-track group fasted for two hours and were provided patient-controlled epidural analgesia.22 In this group, enteral feeding and ambulation started on the evening of the operation.22 The primary end points of the study were the presence of postoperative pulmonary complications of atelectasis, pneumonia, prolonged air leak (ie, more than seven days), and pleural effusion.22 The researchers found that the overall rates of postoperative pulmonary complications were 36% in the conservative group and 7% in the fast-track group (P ¼ .009).2 Complications for each category were as follows. Pneumonia was 11% in the conservative group and 0% in the fast-track group. Atelectasis was 7% in the conservative group and 0% in the fast-track group. Prolonged air leak was 11% in the conservative group and 3% in the fast-track group. Pleural effusion was 7% in the conservative group and 3% in the fast-track group. In this study, researchers found no significant difference in overall morbidity or mortality.22
OUR PROGRAM ERAS in Thoracic Surgery Many health care facilities worldwide and in the United States have implemented ERAS protocols in the thoracic surgical patient population. In 2009, Das-Neves-Pereira and colleagues21 published their five-year experience with 109 lobectomy patients who were provided care in a fast-track rehabilitation program. Patients in this study underwent traditional, open, muscle-sparing (ie, muscles are not cut to perform the procedure) lobectomies. Comparison of their postoperative complications and hospital length of stay showed that non-fast-tracked patients experienced more frequent postoperative complications and a longer average hospital stay.21 Of particular importance, early patient ambulation was the only predictive (ie, protective) independent variable of postoperative complications.21 In 2008, Muehling and associates22 monitored patients with postoperative pulmonary complications following lung
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While there is clearly significant evidence supporting the concept of ERAS, there is no evidence to support the specific interventions that are implemented in our minimally invasive thoracic surgery program. We have sought and received institutional review board approval to monitor outcomes in our patient population, which we will evaluate and publish at a later date. In 2007, the thoracic surgery team began the process of creating a minimally invasive thoracic surgery program. A minimally invasive trained thoracic surgeon, Sandeep Khandhar, MD, FACS, was recruited to spearhead the program’s development. The physical structure of the facility, as well as the mindset of staff members, had to change to accomplish the goal of implementing enhanced recovery interventions to create a cutting-edge minimally invasive thoracic program that provides extraordinary patient care, as evidenced by exemplary patient outcomes. AORN Journal j 483
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For example, there was no postanesthesia care unit (PACU) in the surgical suite when the program began. Because we perform minimally invasive thoracic procedures in the cardiovascular OR suite and at the time we transferred all cardiac surgery patients in the facility directly to the cardiovascular intensive care unit, there was no PACU in which to recover the minimally invasive thoracic surgery patients. As a result, the facility had to construct a PACU adjacent to the cardiovascular OR to recover the thoracic surgery patients. More important than the physical structure was changing the culture surrounding the delivery of the postoperative care. To accomplish this, personnel providing all aspects of patient care had to undergo a paradigm shift to care for this patient population. The goal was to change the focus from disease management to health promotion. Our team sought to maintain and improve the functional status of our patients. To increase the potential for long-term success, we instituted changes that started with the initial outpatient office visit and continued through the inpatient discharge. Specific interventions included increasing staffing in the inpatient and outpatient areas to be able to provide the focused care necessary to achieve the goals associated with enhanced recovery. We provided extensive in-services to staff members to outline their specific role in the achievement of the program’s goals. In conjunction with nursing leaders, the thoracic surgeon interviewed PACU nurses who wanted to be part of the selection process to hire new staff members based on their clinical abilities and their willingness to adopt the aggressive enhanced recovery goals that we set for our patients. Changes on the nursing units included extensive education, both group and individual, on enhanced recovery techniques and decreased nurse to patient ratios to handle the demands associated with implementing enhanced recovery in these thoracic patients.
Preoperative Period The success of any endeavor, particularly surgical, depends on the level of preparation. Patients also require extensive preparation for surgery, which ideally begins at the time of the patient’s first appointment in the surgeon’s office. In our program, this is a lengthy visit in which the patient first meets with our outpatient nurse practitioner (NP). The NP performs an extensive history and physical examination that includes assessment of the patient’s functional status, exercise patterns, and pulmonary function to help determine the ability of the patient to participate in postoperative exercise and the risk for complications. All patients who have thoracic surgery by our minimally invasive surgeon participate in the ERAS program, which aims
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to have the patient progress rapidly, but safely, from the preoperative phase to discharge. Patients who have chronic pain or mobility issues may take longer to progress because of their potential inability to achieve ambulation or pain management goals. Patients who are more ill or who may be inpatients at the time of surgery also can be treated using the ERAS principles; however, this group of patients is much more likely to have poor functional status at baseline from deconditioning related to their physical compromises, comorbidities, or the length of time in the hospital before surgery. After physicians identify the need for a thoracic procedure, patients are strongly encouraged to participate in their care and to increase their physical activity in preparation for surgery. The only patient criterion that contraindicates the use of thoracic ERAS strategies is a physical limitation that prevents the patient from walking (eg, severity of illness, ventilated, sedated). However, at some institutions, patients who are being ventilated also are encouraged to ambulate to improve their outcomes.23 Patient education is perhaps the most critical component for the success of any ERAS program, and positive surgical outcomes are made possible when patients take ownership and responsibility for the role they play in the surgical process. At the initial preoperative visit, if patients are current smokers, they are informed that to be considered for surgery under this program, complete smoking cessation is required immediately. Being an active smoker at the time of resection is associated with a higher likelihood of death within the 30-day period after surgery and increases the risk for serious postoperative complications, including pneumonia, cardiac arrest, myocardial infarction, and stroke.24 If the patient is unable to meet the smoking cessation requirement, the surgeon refers him or her to another thoracic surgeon or postpones the surgery until the patient is able to comply with this requirement for at least two weeks before the scheduled surgery date. Care providers recognize that if the patient is to be successful in achieving the highest level of function as soon as possible after surgery, he or she must participate in physical activity preoperatively. Members of the team inform patients and their families of the exercise regimen that is to begin before surgery. While there are clearly some clinical conditions that would make it impossible for the patient to comply with increasing their ambulation (eg, wheelchair bound, unable to ambulate because of various physical conditions), the vast majority of patients comply with the instructions after they understand the rationale for the request and its importance in achievement of a successful outcome. At a minimum, we ask that the patient walk at a brisk pace for 20 minutes three times per day.
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This is not a metric that is backed by specific evidence, but our team felt that it was a specific, measurable, and attainable goal that if met, would increase the patient’s cardiopulmonary function and increase the likelihood of a successful surgical outcome. Although we recognize that we have no ability to verify the patient’s compliance with this instruction, more times than not, the patient will come to surgery having at least attempted to comply and will have increased their activity to some degree, which will benefit them in the postoperative period. During the preoperative visit, the nurse explains to the patient and family that another expectation is that the patient will walk 250 feet within one hour after extubation in the PACU. Of all the ERAS principles, early ambulation is seen as the most critical.7 All interventions in the surgical process from the timing of extubation to pain management are tailored to facilitate early ambulation. The goal is for patients to be ambulatory as soon as possible to facilitate bronchial/ pulmonary hygiene and maximum lung expansion. The preoperative and postoperative phases are critical to achieving the goal of early ambulation, and each member of the team reinforces the goal.
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anti-inflammatory medications, and oral narcotics. Nursing personnel explain the side effects of narcotics and their potential effect on recovery. o o
The negative effects of traditional pain management strategies can be particularly devastating in the thoracic surgical patient and are illustrated in Figure 1. To facilitate postoperative pain control and avoid negative outcomes, the anesthesia provider frequently administers preemptive analgesia (ie, before the patient is experiencing pain), which includes the preoperative administration of oral acetaminophen, gabapentin, and oxycodone. Preemptive analgesia is thought to decrease postoperative pain and reduce analgesic requirements.26 The anesthesia professional also avoids administering agents during surgery that would result in excessive postoperative sedation or increase the risk for nausea and vomiting. He or she uses short-acting narcotics and non-narcotic pain relievers such as IV ketorolac and IV acetaminophen when clinically appropriate.
Pain Control At the outpatient visit, all patients are given information about pain management. The following concepts are discussed. Patients will have pain after surgery and nursing personnel will assist them in maintaining a level of comfort that will facilitate the ambulation goal. Nursing personnel will ask patients to rate their pain using a 0 to 10 numeric pain rating scale in which 0 indicates no pain, 5 indicates moderate pain, and 10 indicates the worst possible pain. Nursing personnel counsel patients that it is unrealistic to expect that their pain scores will be zero. Although the perception of pain is subjective and specific to every individual, we counsel the patients that a pain score of 5 or less is reasonable and to be expected after thoracic surgery. In addition to assessment of the patient’s pain score is the assessment of the patient’s pain as “tolerable” or “intolerable.” Chauhan discusses the possibility that the “use of the [pain] scale may unintentionally deteriorate into a bureaucratic check-list item supplanting, rather than enhancing communication.”25(p2330) Care providers will use multiple modalities to manage pain, including o local anesthetics, o non-narcotic analgesics,
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Figure 1. Schematic shows the negative outcomes of traditional pain management techniques. AORN Journal j 485
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Although often effective in the management of postoperative pain, epidural catheters also tend to cause autonomic nervous system sympathetic effects including hypotension, which can prevent early ambulation. For this reason, we do not use them in our minimally invasive thoracic program. The use of IV narcotics is limited to the first few minutes in the PACU when the patients are not deemed to be awake enough to safely take oral medications. The cascade of negative consequences related to the traditional management of postoperative pain led us to adopt the following approach to managing postoperative pain. After the patient is awake enough to safely take oral medications, the PACU RN administers 1,000 mg of oral acetaminophen and nursing unit staff members continue to administer this every six hours during the first 24 hours after surgery. Anti-inflammatory agents including ketorolac and/or ibuprofen are used on a case-by-case basis. The clinical criteria used to evaluate their appropriate use include o patient age, o cardiac history, o baseline renal function, o risk for postoperative bleeding, and o current operative intervention. To minimize the potential side effects of sedation and nausea, oral narcotics are administered sparingly in the postoperative period.
OPERATIVE PROCEDURE As in all surgical procedures, thoracic procedures have a multitude of safety concerns that need to be addressed by the entire team. Immediately before taking the patient to the OR, the nurse assesses for comorbidities or conditions that will affect the patient during surgery and could affect postoperative care and reports any concerns to the surgeon and anesthesia professional. In accordance with The Joint Commission’s Universal Protocol 2013 National Patient Safety Goals, we use the AORN surgical checklist before all procedures as a tool to help prevent never events (ie, preventable errors that should never occur).27 The preinduction time-out pause is of particular importance to identify a difficult airway. Placement of the double-lumen endotracheal tube, which anesthesia professionals use to provide preferential atelectasis on the operative side while the nonoperative lung is ventilated normally, can be a challenge to insert even in a patient with a normal airway. If the anesthesia professional identifies the patient as having a difficult airway, the RN circulator should gather the appropriate equipment and 486 j AORN Journal
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supplies to facilitate safe intubation (eg, difficult airway cart, tracheotomy tray). Laterality is an issue in every thoracic procedure. Use of the time out before the skin incision confirms the patient’s identity, procedure, incision site, and side. In addition, the surgical team displays relevant radiological studies on two monitors in the room so all members of the team can easily identify the abnormality in question and verify the correct surgical side and site. Perioperative hypothermia is associated with many adverse outcomes, including delayed clearance of inhaled and IV anesthetic agents, thus increasing the length of time these medications are active and delaying postanesthetic recovery.28 Perioperative staff members attempt to prevent hypothermia by using AORN’s “Guideline for prevention of unplanned perioperative hypothermia,”29 including minimizing skin exposure by covering parts of the body not involved in the surgical procedure, using forced-air warming devices, warming irrigation solutions to body temperature, and keeping the OR warmer than is customary in a cardiothoracic OR (ie, approximately 75 F [24 C]). Intraoperatively, the anesthesia professional monitors IV fluids to avoid fluid overload. Judicious fluid administration minimizes the risk for pulmonary edema and acute lung injury (ALI). Researchers have repeatedly demonstrated that postoperative ALI is associated with excess fluid administration.30-34 Because fluid administration is kept to a minimum, urinary drainage catheters are rarely required for patients undergoing minimally invasive pulmonary resections in our program. This significantly decreases the risk for catheter-associated urinary tract infection (CAUTI) and frees the patient from having to deal with an additional “tube” when ambulating.
POSTANESTHESIA CARE Within one hour of arrival in the PACU, the nurse helps the patient take his or her first walk. The PACU nurses recognize the physiological importance of returning the patient to his or her preprocedure baseline and are the first caregivers to help the patient ambulate.
Potential Postoperative Concerns Pulmonary complications are the major factor in postoperative mortality after lung resection, accounting for up to 84% of all deaths.35 As early as 1949, Leithauser recognized that “early ambulation is indispensable to the well-being and safety of the surgical patient.”36(p368) In addition, early ambulation “has been found to save lives by hastening recovery, thereby
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preventing many fatal complications.”36(p368) Historically, physicians prescribed bed rest because it was thought to be beneficial to providing patient comfort and preventing complications.37 It is now widely recognized that even small amounts of bed rest can cause complications, including thromboembolic events and pulmonary complications.38-40
Atelectasis The potential complications of atelectasis, which include hypoxia, pneumonia, and respiratory failure, are a major concern in the surgical patient who has undergone a thoracic procedure. The postoperative pain associated with chest tubes and incisions often causes patients to take small shallow breaths. Additionally, patients who do not ambulate quickly after surgery are much more likely to experience atelectasis because lung compliance in the supine position is reduced substantially.37 Atelectasis may predispose the patient to pneumonia, and it increases pulmonary vascular resistance.37 Additionally, atelectasis causes intrapulmonary shunting, a physiological condition that occurs when there is normal perfusion of blood to a lung that is not being ventilated normally, as can occur with pneumonia. When there is decreased ventilation, the blood going to the lung involved is not appropriately oxygenated, resulting in potential hypoxia, which can increase supplemental oxygen requirements.37
Deep vein thrombosis (DVT) and pulmonary embolism (PE) An additional complication that can be attributed to inactivity or prolonged bed rest is the formation of DVTs and their potential progression to PEs.37,39 Thoracic surgery patients are at significant risk for DVT formation because several, and sometimes all, of the aspects of Virchow’s triad (ie, stasis, injury to vein endothelium, hypercoagulability) are present in this population.38 Patients with cancer are at an increased risk for venous thromboembolism (VTE); the risk for VTE is fourto seven-fold higher in these patients than in those without cancer,41,42 and VTE and thrombotic complications are the second most frequent cause of mortality.43 The pathophysiology of cancer-associated thrombosis is not completely understood. The hypercoagulability in cancer involves several complex mechanisms, including interaction among cancer cells, host cells, and the coagulation system.44 Venous stasis is more likely to occur in surgical patients who do not ambulate after surgery because blood flow through the legs varies with activity of muscles.37 Inactivity associated with general anesthesia, surgery, and any prolonged period of bed rest promotes venous stasis. The compression of veins that
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occurs as a result of surgical positioning and from the contact of extremities with the bed may also contribute to stasis and may damage vascular endothelium.39
Nausea and vomiting If the patient has minimal postoperative nausea, the PACU nurses begin offering oral intake. However, the intake of plain water is restricted to minimize the risk for postoperative hyponatremia. We offer the patient electrolyte replacement drinks during the first 24 to 36 hours after surgery to maintain optimal fluid and electrolyte balance. If the patient has issues with nausea and vomiting, standard antinausea agents are administered (eg, ondansetron); however, we make every attempt to avoid the use of promethazine because of its known sedation side effect.
Bronchopulmonary Hygiene Although every thoracic surgical patient has a chest tube, we have streamlined its management to facilitate the physiological state of the pleural space by placing the tube to water seal after a very brief period of suction to evacuate the iatrogenic pneumothorax that is created by entrance into the thoracic cavity and single-lung ventilation. Placing the chest tube to water seal eliminates the tubing associated with suction, thus freeing the patient from unnecessary attachments, and provides increased freedom to ambulate. While the patient is still in the PACU, respiratory therapists help the patient begin breathing exercises using an incentive spirometer and a handheld device that combines positive expiratory pressures with airway vibrations to facilitate movement of mucus that helps the patient clear it from his or her lungs. This device employs a counterweighted plug and magnet that directs exhaled air through a pivoting cone that generates airflow vibrations between 0 and 30 Hz.45 Proper bronchopulmonary hygiene activities help patients expand their lungs in a physiological fashion, rather than relying on suction.
Discharge For patients who have had minor pulmonary resections (eg, wedge resections), the goal is for them to be discharged from the PACU to home within approximately three hours after extubation. For patients to meet this goal, they must be hemodynamically stable and have no air leak from the chest tube, have no significant nausea or vomiting, be minimally sedated, be taking oral medication with adequate pain control, and
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be able to ambulate with minimal assistance without episodes of hypotension. Patients who have had more extensive pulmonary resections (eg, lobectomy) remain in the hospital for at least one night after surgery. The PACU goals for these patients are identical to those for patients having minor resections. Goals instituted within the PACU include the patient ambulating within one hour of arrival to the PACU, tolerating oral intake, and performing bronchopulmonary exercises. Of all the interventions instituted in the postoperative period, the early mobilization of the patients has the greatest effect on improving patient outcomes.18 With very few exceptions, our patients go to a regular nursing unit after the PACU. What is unusual is that our patients walk to their rooms. The distance from the PACU to the nursing unit is approximately 500 to 750 feet, depending on the location of their room on the unit. A patient walks from the PACU pushing a wheelchair with the family alongside him or her and the PACU nurse in attendance. On arrival to the patient’s room, nurses assist the patient to a seated position in a reclining chair because most patients who have undergone thoracic surgery find the upright position much more comfortable than lying flat. The goal for patients is to walk 10 to 12 laps around the unit on the night of surgery. The nursing unit is in the shape of a square, and one complete lap around the unit is approximately 1,000 feet. The vast majority of patients attain this goal and are proud to demonstrate this with “check boxes” on their white boards that they are sure to point out to the team on rounds the next morning. The goal for patients who have undergone pulmonary resections such as a lobectomy is to go home on postoperative day one. Similar to patients who are discharged from the PACU, these patients must be hemodynamically stable. They must tolerate their usual diet without significant nausea or vomiting. Their pain must be controlled with oral pain medication. The chest tube is removed if there is no air leak and the quality and amount of drainage is within normal limits (ie, less than 200 mL). If there is an air leak, this does not preclude patients from being discharged. If the physician believes that the air leak will likely seal within 24 hours, the patient may be kept in the hospital for an additional day. However, if he or she believes that the air leak is unlikely to seal within 24 hours, the patient often will be discharged with the chest tube in place. The patient and family receive extensive teaching on care of the chest tube and drainage
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collection chamber. Patients are taught how to shower with the tube in place and how to re-dress the chest tube when necessary. They are instructed on how to empty the collection chamber and troubleshoot potential issues. The NP reviews potential problems that may require a call to the physician and provides a telephone number. A postoperative follow-up appointment is scheduled for all patients so that they are discharged with a specific date and time to return. One of the major “successes” of our approach to thoracic surgery is the speed with which patients can return to their baseline function. At discharge, patients’ physical activities are not limited. We recognize that patients will “self-limit” their activities based on pain; however, we instruct them to pursue any activity they feel comfortable doing and do not limit them. In abdominal surgery or even the traditional open approach to thoracic surgery, there is concern for hernia with heavy lifting or activity. Such concerns do not exist in patients who have undergone minimally invasive thoracic procedures because there is no rib spreading, which significantly disrupts the muscular and ligamentous attachments of the rib cage. If they are taking narcotic pain medications, they are told not to drive. We instruct them to continue to ambulate 20 minutes three times a day. Walking is the best exercise, and although they may feel more fatigued than they did before surgery, it is of the utmost importance that they stay active. The ability for the patient to return quickly to a normal routine is a welcome surprise for the patient and his or her family.
BARRIERS TO IMPLEMENTATION As with implementation of any change, there were barriers encountered during the implementation of our ERAS program. There were safety concerns, concerns regarding having the appropriate staffing ratios to implement the program, concerns about patient compliance, and concerns about how the program would affect patients’ pain. Perhaps the most formidable barrier to implementation of the ERAS principles in our minimally invasive thoracic surgery program was concern for patient safety. Traditionally, patients rarely, if ever, ambulated during their time in the recovery room. Most typical PACUs have no patient chairs, such as in an ambulatory care PACU, and they have only bays awaiting patients on stretchers arriving from the ORs. Nursing staff members had valid concerns, as did some of our anesthesia colleagues, regarding potential postoperative hypotension or dizziness that could cause the patient to lose consciousness while walking. The nurses in both the PACU area and the nursing units had concerns about the patient’s safety and the nurse’s liability if the patient was injured as a result of
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ambulating so soon after anesthesia. There is ample evidence in the literature supporting the idea of early mobilization, even in critically ill patients.37,40,46,47 In 2007, Bailey and colleagues40 demonstrated in a case series report that early activity is feasible and safe in patients with respiratory failure and might improve clinical outcomes. Implementation of the ERAS principles in our thoracic surgical service required increased staffing resources. Pearsall et al48 conducted a study in seven University of Toronto-affiliated hospitals to identify potential barriers to ERAS interventions. When discussing barriers specific to nursing, they described “lack of manpower and time as a barrier to implementation”48(p94) of ERAS principles. The authors stated that although nurses saw value in ERAS, they expressed concern that the interventions would create more work for nurses that were already spread thin because of shortages.48 This issue was a barrier to implementation in our program as well. Decreased nurse to patient ratios were needed to implement the walking regimen (eg, walking in the PACU after surgery) because we recognized that the increased ambulation component required more of the nurses’ time. Because it takes more staff members to aggressively ambulate patients who have just had thoracic surgery, one of the major barriers to implementation of this regimen was obtaining adequate personnel on inpatient units. Both licensed and unlicensed personnel are used for the one-on-one patient assistance. At a time when nurse to patient ratios were increasing because of staff cutbacks related to declining hospital reimbursement, we were asking for more nurses to facilitate the positive outcomes that implementation of the ERAS program could provide. Overcoming this barrier required significant collaboration between hospital administrators and the leaders of the thoracic surgery team. Through this collaboration, we hired additional nursing staff members (ie, RNs, nursing assistants) to increase the number of nurses on the inpatient unit that cares for these patients. Having the additional personnel facilitates the successful attainment of the aggressive patient ambulation goals. Patient pain is a significant barrier to early ambulation. Focusing on pain and its elimination is the natural tendency of nursing and medical providers and is now a regulatory requirement. In 1999, the Joint Commission on Accreditation of Healthcare Organizations (now known as The Joint Commission) stated that there were physical and psychological patient consequences to unrelieved pain, which can also increase health care costs.49 The Joint Commission officially declared pain to be “the fifth vital sign,” requiring mandatory pain
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assessment for proper patient care.49 The organization also believes that pain assessment and treatment is important and as basic for accurate patient care as assessing temperature, blood pressure, respiratory rate, and heart rate.49 Through the use of preoperative preemptive analgesia, intraoperative infiltration of local anesthetic agents at surgical sites, shortacting IV analgesia intraoperatively as well as in the immediate postoperative period, and scheduled non-narcotic analgesia and PRN oral narcotic administration, we are able to successfully manage the patient’s pain, thus increasing the ability to participate in early ambulation. Despite our extensive preoperative preparation, patients are occasionally reluctant to ambulate. When our ERAS program initially started, it was difficult for the PACU nurses to implement the early ambulation goal. In a discussion of barriers to implementation of an ERAS program, Pearsall et al state that nursing culture is a significant barrier to early ambulation programs and “that because of their culture they might feel that they’re [patients are] too sick to be up and moving around.”48(p93) We needed the nurses, the patient, and the patient’s family to focus on the positive consequences of early ambulation rather than the perceived negative aspects. Our extensive preoperative education of the patient and family facilitates their “buy in.” By focusing on the positive aspects of ambulation, we have been able to minimize the administration of opioids and the spiral of adverse events associated with their use.
OUTCOMES The ERAS care approach in the thoracic surgical population is feasible and safe. We have analyzed patient data from July 2010 to July 2013. During this time, 750 patients who had video-assisted thoracic surgery procedures recovered in the PACU and either transferred to the nursing unit or were directly discharged to home. There have been no patient falls or injuries in the PACU or the nursing unit. When we compare the specific data points of postoperative length of stay, postoperative pneumonia rates, and rates of patients requiring bronchoscopy because of atelectasis in both patients who underwent lobectomy and wedge resection, our outcomes compare very favorably against the national average as reported by The Society of Thoracic Surgeons’ General Thoracic National Database.50 In 2013, patients undergoing a lobectomy in our institution had a postoperative length of stay of 1.9 days compared to the national average of 6.2 days. Patients undergoing wedge resection stayed in the hospital an average of one day compared to the reported average of 4.1 days.50 The rate of postoperative
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pneumonia in patients who underwent a lobectomy was 2.6% compared to the national average of 4.3%. After wedge resection, patients had a 0% pneumonia rate compared to the national average of 1.3%.50 Atelectasis requiring bronchoscopy occurred 0% of the time in both the lobectomy and wedge resection populations compared to the national averages of 4.5% and 0.7%, respectively.50
PATIENT SATISFACTION Hospital reimbursement is increasingly tied to patient satisfaction rates. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are reported to payers (specifically the Centers for Medicare & Medicaid Services), with the score comprising a portion of the formula that dictates reimbursement rates.51 The HCAHPS survey is administered to a random sample of discharged patients between 48 hours and six weeks after discharge. There are 27 questions about the patient’s perception of his or her hospital experience. Topics range from cleanliness and quietness of the facility and communication with providers to perception of adequate pain control.52 During the last quarter of 2014, our HCAHPS scores with respect to pain control were in the 97th to 98th percentile compared with similar facilities (ie, 500þ bed teaching facilities) and our patients ranked us in the 99th percentile with respect to recommending our facility.53 We know based on anecdotal reports from patients, their significant others, and hospital staff members that our patients report increased satisfaction with their ability to more quickly return to feeling less like a “patient” by being out of bed and able to independently perform their activities of daily living.
CONCLUSION In an era in which both patients and hospitals benefit from decreased hospital length of stay, the ERAS techniques and interventions applied in our program enable the patient to return more quickly to full functional status while minimizing many of the postoperative complications associated with thoracic surgery. By engaging the patient and his or her family members through extensive preoperative education and helping patients recognize that their actions and active participation directly affect their recovery, clinicians have been able to move patients quickly through the perioperative continuum and return them to their optimal functional status. In today’s health care environment, the programs that will survive are the ones that are able to push past traditional barriers to create
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innovative strategies designed to deliver the highest quality care in the most cost-effective manner. Editor’s note: ERAS is a registered trademark of the ERAS Society, Kista, Sweden.
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Christy Schatz, MSN, RN, FNP-BC, CRNFA, is a nurse practitioner/RN first assistant in Thoracic Surgery at Inova Fairfax Hospital, Falls Church, VA. Ms Schatz has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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