We recently published initial findings after the implementation of renal enhanced recovery after surgery (RERAS) protocol. The headlining results encourage consideration of similar protocol adoption, but a deeper look provides some pearls for the implementation of any ERAS protocol.
As has become common among ERAS protocols, we found that RERAS institution was associated with a decrease in length of stay as well as a decrease in post operative narcotic utilization, without any increase in surgical complications or readmissions. There is limited data thus far in this space and our study offers evidence that the traditional benefits of ERAS can translate to a renal protocol.
While these findings suggest the feasibility of a RERAS protocol, we were also interested in approaching this protocol with quality improvement in mind. To explore this, we reported compliance with the protocol over time relative to implementation and provided insight into the implementation process we employed. We also measured the milligram morphine equivalent (MME) of narcotics prescribed at discharge.
Compliance with protocol components increased over time and was similar between each of the four different surgeons. We feel one of our ERAS protocol's strengths is consistency built into the protocol. Order sets for pre-op, intra-op, and post-op ensure that initial orders comply with protocol aims. Further care is then executed by advanced practice providers (APP’s) and residents who are familiar with the protocol and likely are drivers of consistent care.
The position that APP’s and residents hold as gatekeepers of care is also highlighted by our analysis of discharge narcotic prescriptions. In the RERAS protocol cohort, 10.9% of patients went home without narcotic scripts compared to only 1.5% pre-protocol. For those that did have narcotic scripts sent home, the MME was halved in the RERAS cohort (100 v. 200 MME at discharge). ERAS protocols reliably decrease narcotic utilization. We must consider that as much as anything physiologic, a protocol’s ability to set expectations for patients and providers, contributes to more judicious narcotic use. The emphasis on narcotic limitation communicated by the RERAS protocol leads prescribers to decrease the frequency and volume of narcotic scripts they write.
Here are some other takeaways regarding RERAS and protocolized care in general. The organization of a protocol with clearly defined checkpoints that can be monitored, audited, and adjusted is crucial. This is the foundation for reproducible care. Equally important is the development of culture and expectations. Patients will look for information on their surgery and recovery. If it is not detailed and clearly outlined by members of their care team both pre- and post-op they will find it online. The opportunity to empower patients and align their expectations with that of the surgical team should not be overlooked. Finally, it is worthwhile to identify the gatekeepers of care, the providers who will be executing the protocol- in pre-op visits, inpatient rounds, discharge, and beyond. Early engagement of these parties allows the protocol and its culture to grow with a wide base rather than need to be pushed downhill from surgeon stakeholders.
Written by: Samuel J. Ivan, MD & Stephen B. Riggs, MD, Department of Urology, Carolinas Medical Center/Atrium Health, Charlotte, NC
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