Standardizing Total Joint ERAS Pathways

Structured checklists and handoffs, hands-on training and data sharing can get everyone on board.

Enhanced Recovery After Surgery (ERAS) pathways have been around for 20 years and are fine-tuned all the time. Optimizing patients preoperatively so they’ll ambulate quickly after their procedures leads to faster and better recoveries. There’s no better place for ERAS protocols than outpatient total joint procedures.

Standardize to success

Multimodal anesthesia is one of the ERAS pathways that promotes patient mobility hours after surgery. Narcotic-sparing nerve blocks prevent post-op grogginess and nausea and provide extended pain control for days. The standardized mobility protocols that follow get patients ambulating quickly and safely.

The ERAS process starts weeks before surgery with standard protocols for patient education and health optimization. Research shows that ERAS protocols targeting healthy weight, stopping unhealthy habits like smoking and upping physical activity are key factors to improve post-op recovery.

SCA Health in Deerfield, Ill., launched ERAS pathways for outpatient total joint procedures in 2022. Since then, ERAS pathways for total knee and hip procedures have been put in place for all new total hip and knee programs at many of the 129 SCA Health facilities nationwide.

Three main factors have helped SCA Health clinical leaders establish ERAS as standard practice, according to Beth Schmit, BSN, RN, SCA’s director of strategic program development, who leads ERAS program implementation in the company’s total joint programs. First, evidence-based guidance on ERAS implementation continues to emerge for specific surgical specialties from organizations such as the American Academy of Orthopaedic Surgeons and the National Association of Orthopaedic Nurses. Ms. Schmit’s team works to ensure these and other evidence-based guidelines are being followed in their total joint ERAS protocols. Second, SCA Health’s own outcomes metrics have helped track effectiveness and eliminate variance, which has standardized the approaches in every ERAS protocol. Third, SCA has shaped detailed checklists, handoffs, competencies and other implementation tools to direct each step in an ERAS pathway.

Breaking down a pathway

A successful ERAS program requires regimented protocols that must be followed, documented and embraced by every team member working with the patient through each step of surgery, says Ms. Schmit. “One slip in protocol, such as a long-acting preoperative opioid being ordered by a particular surgeon unfamiliar with the protocols prior to surgery, could potentially derail the entire pathway. This is why standardization, education and communication of the rationale behind it are so important to success.”

• Select the right patients. Only appropriate patients for total joint surgery in the ASC setting are selected, and the dedicated medical criteria includes the patients’ psycho-social history. “We want to set patients up for success from the start,” says Ms. Schmit. “If they don’t have resources available to help them after surgery or aren’t motivated to go home the day of surgery, they aren’t an ideal candidate.”

• Optimize patient health. The surgeon introduces the preoperative ERAS pathway to the patients and their caregivers as soon as the procedure is scheduled. This provides clear expectations regarding their discharge and allows them to immediately start to prepare accordingly. The patient is referred for preoperative medical clearance from their primary physicians and specialists as necessary.

PATHWAY PRECAUTION One slip in protocol, such as a long-acting preoperative opioid being ordered by a particular surgeon unfamiliar with the protocols prior to surgery, could potentially derail the entire pathway.  |  Rock ‘N’ Roll Randy

• Preparing for surgery. Patients are enrolled in Total Joint Bootcamp two to four weeks before their procedure, which can be attended in-person or virtually. An SCA nurse trained in current best practices and ERAS protocols teaches the class. The curriculum includes going over the details of the surgery, anesthesia, physical therapy goals and the expected recovery trajectory. This is also when ERAS patients learn about the expectations for postoperative pain management and what they will bring home, including a patient medication tracker.

A nurse from the total joint program oversees the process and uses a standardized checklist to confirm every step is taken and to document the information gleaned for the entire care team’s reference. For example, the nurse coordinator will document the procedural details, caregiver contact information, education received by patient/caregiver and confirmation that the patient is cleared for surgery.

• Assessing pre-op health for post-op care. On the day of surgery, an assessment is conducted by the preoperative nurse and the nurse coordinator to confirm the patient’s baseline health status for factors such as their medical history, past surgeries, current medications, skin integrity and dietary adherence with only clear liquids up until two hours prior to surgery. The pre-op nurse uses a lower extremity assessment form to document the patient’s baseline strength, circulation and sensation in the operative extremity so the post-op nurse can easily access the data. The patient also undergoes nasal decolonization and preoperative bathing with chlorhexidine wipes. Pre-warming is next, followed by placement of a nerve block.

The preoperative education process includes establishing the patient’s baseline pain number, as well as a discussion of what pain control medications will be administered. A pre-op nurse instructs them on how to use the patient medication tracker tool. “This post-op mobility and pain management information is reiterated after surgery as well, but we’ve found patients learn better and retain more if this education is done prior to surgery,” says Ms. Schmit. When all pre-admission activities are checked off, documented and confirmed by the care team, the handoff to surgery takes place.

• A minimally invasive approach. Surgeons avoid drains and administer a non-narcotic local infiltration for analgesia. The anesthesia team is encouraged to use neuraxial anesthesia, peripheral nerve blocks and opioid-sparing analgesia whenever possible.

“We work closely with anesthesia teams and surgeons to ensure narcotics are avoided through the surgery because they are traditionally used to giving IV narcotics in non-ERAS care,” says Ms. Schmit.” Further work with anesthesia is also important for aligning preoperative nerve block medications with postoperative ERAS protocols for pain management. For example, they currently encourage bupivacaine for adductor canal blocks in total knee arthroplasty because it provides long-acting analgesia to aid the patient in avoiding narcotic use at home during the time when post-op pain usually peaks.

• Standardize order sets throughout. “Our ultimate goal with ERAS protocols during surgery and really throughout every point of contact with the patient is to take out variance whenever and wherever possible,” says Ms. Schmit.

By reviewing ERAS patient outcomes data, SCA leaders learned that variance in any element of care is the most likely cause for a patient’s delayed postoperative recovery. This can include modifications that an individual anesthesia care provider might make to these standardized protocols, such as the dosing and timing of medications that can significantly affect recovery outcomes. Close coordination between clinical leadership, surgeons and the anesthesia team aligns anesthesia protocols that are a key element to early and safe ambulation of the patient.

• Early ambulation. Avoiding IV narcotics with alternatives such as ketorolac and/or acetaminophen combined with early administration of oral narcotic pain medicine readies patients for movement, rather than making them sleepy and potentially nauseous.

The SCA team has a variety of assessments to determine when patients are ready to ambulate. It also uses fall risk protocols and has minimum staff levels to assist patients immediately after surgery.

BEST PRACTICES

Sneak peek at AORN’s ERAS Guideline

ERAS protocols are a beneficial approach for most surgical patients in every procedural setting, because they aim to minimize the physiological stress response to surgery.

AORN is slated to publish its long-awaited Guideline for Enhanced Recovery After Surgery this November. “The hallmark of any ERAS program is to be very standardized, while also looking to individual patient factors that can be addressed within the pathway to optimize their recovery,” says guideline author Lisa Spruce, DNP, CNOR, CNS-CP, FAAN, senior director of AORN’s evidence-based perioperative practice.

Here are six recommended actions from the new guideline:

Designate a dedicated ERAS nurse coordinator. This role is pivotal to lead implementation, guide protocols in daily clinical practice and oversee outcomes data to support ongoing program improvements.

Use comprehensive preoperative risk assessments for every patient. Be sure to use assessment calculators for cardiac, pulmonary, venous thromboembolism and postoperative PONV risks.

Begin surgical optimization weeks before a procedure. Assessments for functional health status, such as cardiopulmonary exercise testing and lifestyle habits, can identify areas that can be improved, such as nutrition, physical fitness and stopping behaviors like smoking.

Refine patient education on best fasting practices prior to surgery. Patients should be encouraged to eat a light meal six hours prior to surgery and continue clear liquids up to two hours before surgery.

Collaborate with surgeons and anesthesia professionals to implement a multimodal pain management protocol. This team approach can target effective pain control that minimizes the adverse effects associated with narcotic pain medications.

Assess and treat PONV using multimodal strategies. Effective PONV prophylaxis aims to reduce this major obstacle to early ambulation through a combined approach that can include pharmacologic therapy, avoiding fluid overload, limiting preoperative fasting and avoiding opioid use.

Visit aornguidelines.org to review AORN guidelines, follow new releases and subscribe to get monthly updates, including when the new ERAS guideline is released.

—Carina Stanton

Measure competencies to improve

A physical therapist trains the SCA care team on safe mobility and ambulation techniques at an in-service session. These in-services, along with standardized training checklists, reference tools and related competencies, are required to be completed by all teammates who will be caring for patients. A tracking tool for staff is used to train new employees about the ERAS protocols and provides role-specific standardized training that includes education on key ERAS protocols such as nerve blocks, patient education and post-op mobility.

Leverage data

SCA Health uses an internal, total joint-specific outcome dashboard to compare and analyze patient outcomes and identify any variance in the ERAS pathways to learn which protocol isn’t being followed. For example, if an anesthesia provider inadvertently uses opioids throughout the case, that can lead to increased length of stay. This tool can provide insight into why a provider wasn’t informed about the ERAS protocol and to compare the outcomes to those in which the pathways were followed correctly. “Once you have these data captured, physicians are more open to conversations that bring practices back in line with standardized ERAS protocols,” says Ms. Schmit. OSM