In determining clinical effectiveness, UAB Medicine relies on a thorough analysis of patient demographics, outcome and satisfaction metrics, and other information gathered across numerous disciplines.
That’s certainly true for the enhanced recovery after surgery (ERAS) pathway, which is designed to reduce post-operative complications, shorten length of stay, and hasten a patient’s return to normal functions. Outcome data suggest that ERAS is effective in improving patient experience at UAB. However, that data may be enhanced by feedback from the patients themselves, as a UAB surgical care team observed this past summer.
UAB Medicine patient Johnny Kline, diagnosed with bladder cancer in early 2016 and referred some months later to Jeffrey Nix, MD, for treatment involving a cystectomy and urinary diversion, returned to UAB in August to share his experience with his care team. The group met at the West Pavilion Conference Center for a celebration of Kline’s excellent outcomes (complete with cake and refreshments), but more significantly, the event allowed many of the 50-plus clinical and non-clinical staff members along Kline’s particular ERAS path to hear firsthand about the results of their efforts.
“UAB was too good,” Kline says. “I don’t have any problems or concerns you can learn from to improve the process, because it went too well. Dr. Nix warned me that I might be recovering in the hospital for almost two weeks; I went home on the fourth day. That new pain medication gave me no problems, just like we hoped. Through this entire surgery there was someone right there beside me asking how I was feeling or telling me what to expect, and always in plenty of detail. I was never alone, never in the dark about what was going on.”
Associate Chief Medical Officer Ben Taylor, MD, who directs UAB’s clinical effectiveness program, UAB Care, notes the value of Kline’s feedback in assessing the success of ERAS.
“The most appropriate way possible to recognize all that our teams do is having our patients here to share their experiences,” Dr. Taylor says. “It reminds us why we are all here in the first place: to take one patient, start to finish, and ensure that all procedures and elements of care line up for the best possible outcome. Input from patients guides us to do more of what works and less of what doesn’t.”
This setting also offers members of the team who engage with patients at the beginning of the ERAS pathway a chance to hear about the results of their work from a patient they might otherwise not see again. In Kline’s case, his poignant and at times emotional talk with the group reveals the morale-boosting component of sharing best-practices success stories, and in some measure reflects the “family” aspect of care that Dr. Nix emphasizes in his practice. Foremost, however, patient feedback is an additional element of cascading best practices to frontline staff.
“We anticipated that implementing ERAS pathways would have a positive impact on our patients and the care we provide at UAB,” Dr. Nix says. “Having Mr. Kline come back to share his story with our team was a tremendous opportunity to connect back to why we take process improvement so serious. This will serve as further motivation for us to continue to improve our practices going forward.”
The Appeal of ERAS
The ERAS pathway, which began at UAB in 2015 with colorectal surgery, is being applied in other disciplines and procedures throughout UAB Medicine. The results from these initial efforts demonstrated the value of ERAS, and the ERAS project for colorectal surgery received a first place UAB Health System Innovation Award for 2016, as part of a competition designed to encourage creative thinking, improve workflow, and disseminate best practices across UAB Health System entities and affiliates. That effort was led by colorectal surgeon Daniel Chu, MD, and anesthesiologist Jeffrey Simmons, MD, in close collaboration with the UAB Care team and many others.
Since implementing ERAS for colorectal surgery, the overall post-operative length of stay (LOS) was reduced to a median of 3 days, and previously observed disparities in LOS among minority patients were eliminated.
“The success of ERAS in colorectal surgery was a result of identifying, positioning, and empowering the right people to make change,” Dr. Simmons says.
The ERAS project is innovative in several ways, according to Dr. Chu.
“First, our project leveraged the infrastructure and processes of the UAB Care program to create truly multidisciplinary, team-based, and sustainable partnerships across UAB,” Dr. Chu says. “This project enlisted champions from all walks of surgical care, not only surgeons and anesthesiologists but also nurses of all specialties, HSIS programmers, residents, nutritionists, social workers, data analysts, UAB Care, etc. Many of these newly discovered relationships are now being utilized to develop other ERAS and cross-disciplinary projects such as readmission reduction programs. Second, this project was able to reduce disparities in LOS with ERAS. This finding is novel, as we show that minority patients benefit tremendously from ERAS. As a tertiary referral hospital serving a geographically wide, racially diverse population, reducing disparities is particularly relevant to our institution, and this work puts us at the forefront of recent National Institutes of Health initiatives on targeting surgical disparities. Third, our project demonstrated that change is possible. Barriers to ERAS implementation are well-documented, but with a coordinated, sustained, and multipronged approach, an entire continuum of care can be optimized to achieve potentially even better outcomes.”