Enhanced Recovery Programs in Cardiac Surgery

History of Quality Improvement in Cardiac Surgery

Prior to the adoption of enhanced recovery, there had been a robust history of multidisciplinary quality improvement initiatives for cardiac surgery patients. The initial “fast-track” initiatives, which are a common comparator for modern ERAS programs, were initially explored by a diverse group of surgeons, anesthesiologists, and intensivists in the 1990s, and represent an important turning point in the modernization of cardiac surgical perioperative care. In general, a fast-track approach involved limiting the traditional use of a high-dose opioid/benzodiazepine-based anesthetic (meant to provide improved hemodynamic stability) with a balanced technique: lower doses of opioids, increased use of volatile anesthetics, avoidance of long-acting hypnotics, and a goal to extubate patients early in their postoperative course. The net effects were a significant reduction in mechanical ventilation times and intensive care unit (ICU) length of stay (LOS). These results, as well as confirmation of absence of harm (such as reintubation or readmission), reduced hospital LOS, and cost savings have been reproduced in multiple subsequent studies and are key metrics of quality in the Society of Thoracic Surgeons (STS) database. ^{, ,} Although “fast-track” is typically associated with interventions aimed at reducing postoperative intubation time, it is often overlooked that the original Engelman protocol also included a bundled approach consisting of patient education, antiemetic prophylaxis, mobilization, and augmented medium-term follow-up.

Beyond “fast-track,” cardiac anesthesiologists and surgeons have contributed to numerous quality improvement efforts. Risk stratification models, such as the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and STS Adult Cardiac Surgery Risk Score (see Chapter 1 ), allow for the identification of high-risk patients, facilitate informed decision-making on appropriate therapeutic options, and direct resources to those who will benefit most. Large multinational outcome repositories, such as the European Association for Cardio-Thoracic Surgery (EACTS), STS, and the International Registry of Acute Aortic Dissection (IRAD) databases promote measuring and reporting of key outcomes, as well tracking inter- and intrainstitutional performance. Multidisciplinary collaboration, fostered through international societies, has led to the publication of several best practice guidelines in areas such as patient blood management, temperature management during cardiopulmonary bypass (CPB), and postoperative atrial fibrillation. Finally, the adoption of enhanced recovery concepts was facilitated by already established efforts to standardize the application of care bundles and cardiac surgical clinical pathways. ^,

Principles of Enhanced Recovery Programs

ERPs have commonly been described as evidence-based, bundled perioperative interventions to lessen surgical insult, hasten recovery, and prevent unintended health care-associated conditions ( Boxes 29.1 and 29.2 ). While this is true, the concept of ERPs is far more expansive than perioperative care protocols, as one recent review illustrates. Core principles of ERPs also include:

• The Multidisciplinary Team—Care for the surgical patient has become increasingly specialized and in order to both capture the necessary expertise as well as establish appropriate consensus; a fundamental aspect of ERPs is the creation of a multidisciplinary team ( Table 29.1 ). This includes subspecialty physicians (i.e., surgeons, anesthesiologists, pain specialists), nursing, specialized support staff (i.e., respiratory therapy, nutrition, physical therapy), and administrators. An essential component of the multidisciplinary team is the patient, as well. Patient and provider engagement is necessary to ensure program success. Shared decision-making, a key component of patient-centered health care, incorporates the patient as part of their own care team to work with clinicians and other providers to identify treatments and establish a care plan to meet the goals associated with the surgical intervention.

  TABLE 29.1

  List of Potential Members When Building an ERP Team

  Role	Team Member
  Physician	Anesthesiologist Cardiologist Cardiothoracic surgeon Critical care physician Family physician Geriatrician Physiatrist
  Nonphysician care provider	Advanced medical practitioners Dietician Nursing Perfusionist Pharmacist Physiotherapist Preadmission clinic nurses Psychologist Respiratory therapist Social worker
  Administration	Clinical educators Hospital administration Information technology Operating room managers Ward managers
  Patient advocates	Family members Former patients (cardiac) Former patients (noncardiac) Other care providers Patient advocacy groups
  Supplementary expertise	Communications Data analysis Human resources Organizational change Public relations/media Quality improvement Social media

  If not a formal part of the ERP leadership team, these listed groups would also be likely stakeholders whose consultation and input will facilitate the design, implementation, and sustainability of a successful program.

  ERP , Enhanced recovery program.

• Multimodal Care—Fundamental to ERPs is the notion that care programs leverage the additive, if not synergistic, application of phase-specific, multimodal interventions. As a result, surgical, anesthetic, and nursing components are applied across the perioperative spectrum (i.e., preoperative, intraoperative, and postoperative phases) from the time of surgical consideration until full postoperative recovery. A classic example involves the use of numerous medications and techniques for perioperative pain management, which leverages multiple mechanisms of pain relief, medication administration (i.e., oral vs intravenous), and dosing (i.e., scheduled vs as needed) to achieve desired effects. ^, These same principles are extended to numerous other areas including postoperative nausea prevention, optimal nutrition, and early ambulation.

• A Scientific, Consensus Derived, Evidence-based Protocol—A cornerstone to quality improvement initiatives is the adoption of interventions associated with improved outcomes. Evidence-based, consensus guidelines, such as those provided by major perioperative societies provide an appraisal of the literature, where available, or leverage expert opinion to establish the optimal approach to perioperative management. These guidelines serve as the basis for local program protocols, which reduce undesired variation in health care delivery. More uniform practice allows for institutions to both provide consistent and predictable care as well as to better monitor progress and ensure additional program improvement.

• Change Management, Implementation, and Audit—Beyond establishing the care team and identifying the broad intervention framework, ERPs rely upon additional strategies to conceptualize program elements, motivate participants, and monitor progress. Described as adaptive components, in contrast to the more technical aspects (i.e., protocols, interventions), these include multifaceted provider and patient education, strategies to ensure administrative buy-in, thoughtful implementation approaches (discussed later), and program auditing procedures. ^, Adaptive components are, perhaps, more essential to program success than technical components, yet the literature devoted to the topic is far less mature. It is in this area that ERPs probably exact their greatest influence as compared to more traditional perioperative care.

BOX 29.1

Key Principles of Enhanced Recovery Protocols

• Evidence-based/data-driven

• Leverages the impact of bundles

• Encompasses full perioperative journey

• Comprehensive in scope

• Aims for standardization of care

• Seeks accumulation of marginal gains

• Patient-centered

• Collaboration between all health care providers

• Incorporates audit as a feedback tool

BOX 29.2

Principles of Enhanced Recovery Programs

• Reduce perioperative physiologic stress and facilitate a return to postoperative patient recovery.

• Standardized application of evidence-based best practices within an enhanced recovery protocol.

• Accumulation of marginal gains through bundled care.

• Collaboration between multiple medical disciplines and nonmedical stakeholders.

• Patient-centered health care including shared decision-making and patient advocacy.

• Comprehensive approach, spanning all aspects of perioperative care and all phases of the surgical journey.

Multidisciplinary teams, multimodal care, evidence-based protocols, and adaptive strategies for implementation and program sustainment are basic principles of modern perioperative care that underpin all ERP programs, particularly those associated with cardiac surgery.

Enhanced Recovery After Cardiac Surgery Society Guidelines

The ERAS Cardiac was established in 2018. Based on the recommendations of the Institute of Medicine (IOM) for developing clinical practice guidelines, a multidisciplinary group of experts was assembled to formulate key questions, perform a systematic review of existing literature, appraise available evidence, and complete a Delphi process in order to obtain consensus on recommendations for inclusion in the Guidelines for Perioperative Care in Cardiac Surgery. Each recommendation was then graded for class of recommendation (COR; strength) and level of evidence (LOE; quality), following the framework described by the American College of Cardiology (ACC), American Heart Association (AHA), The American Association for Thoracic Surgery (AATS), and the STS guiding the development and grading clinical practice documents. ^, The resulting guidelines for Enhanced Recovery After Cardiac Surgery are composed of 22 recommendations, covering the spectrum of the perioperative period, based on the best available current evidence ( Table 29.2 ).

Elements for Cardiac Surgery-Enhanced Recovery Programs

An ERP is fundamentally built upon a selection of elements, or interventions, which will be bundled and applied in a consistent fashion during the perioperative period. The selection of elements will depend on several factors: prioritization of identified areas in most need of improvement, feasibility, resources available, administrative leadership support, impact on existing workflow, inter group dynamics of the stakeholders involved, and maturity level of the program itself. The published ERAS Cardiac Guidelines provide an excellent starting point, but should not be considered an exhaustive list of all possible elements. Some elements align with areas of established expertise within the cardiac anesthesiology profession, such as multimodal analgesia, regional anesthesia, postoperative nausea and vomiting (PONV) prophylaxis, hemodynamic monitoring and management, NPO considerations, postoperative extubation strategies, and postoperative cognitive function. While many of these are addressed in other chapters within this textbook, others are not as universally familiar to anesthesiologists, and are summarized in the following section.