The ERAS dilemma; from guidelines to pathways

By Corrina Kane, Senior Director of Marketing and Dr. Gajan Srikanthan, Director Clinical Pathways, Lumeon

We spent an enlightening few days at the 7th ERAS World Congress meeting in Liverpool, UK, from May 1-3. Organized by the Enhanced Recovery After Surgery (ERAS®) Society, the ERAS Congress hosted a global audience with strong representation from multidisciplinary teams and a focus on improving outcomes for surgical patients.

One of the central riddles of the conference — and ERAS in general — is why a process aimed at optimizing outcomes of surgical interventions should be called “enhanced” as opposed to just “standard operating procedure.” It is clear that there is sufficient evidence to insist that this is the way care should be delivered everywhere, for everyone.

In a similar way, there is sufficient evidence to assert that care pathway management (CPM) such as that facilitated by Lumeon should be SOP in healthcare. Employing technology to ensure best practice clinical pathways, care team coordination and patient engagement techniques ensure that patients are properly prepared for, and followed-up-on after surgery in the medium-to-long-term, seems just as obviously beneficial as enhanced recovery protocols immediately prior to and post-surgery.

Perhaps that’s why there seems to be great synergy between CPM and ERAS.

In many of the discussions at the Lumeon booth, experts expressed concern with pre-operative readiness — reporting patients arriving the day before or the day of surgery inadequately prepared. Prehabilitation is extremely important, and the question was even posed whether in some cases surgery should be delayed to optimize the patient’s readiness. Nutritional and frailty assessment need to be more prevalent in the preassessment period to enable the identification of the correct optimization strategy for the patient well ahead of surgical intervention – starting with diagnosis in primary care.

Practitioners who stopped by the Lumeon booth also reported frustrations with difficulties in contacting and capturing data on patients after they are discharged post-surgery. Even under an ERAS protocol that demands regular follow-ups with patients, this is typically a laborious manual process involving nurses calling patients a day, a week, and a month after discharge.

Experts’ and practitioners’ concerns about prehabilitation and post-operative care and assessment strengthened our view that pre-surgery patient readiness and post-acute follow-up are areas where Lumeon CPM can have a high impact. Our ability to orchestrate and automate a digital prehabilitation plan in order to optimally prepare patients physiologically and psychologically for surgery not only impacts enhanced recovery and positive outcomes but also reduces cancellations. Post-acute follow-up allows for automated engagement and data collection personalized to a patient’s care plan and preferences, preventing readmissions and removing administrative burden from ERAS nurses.

Despite these obvious collaborative possibilities, there was surprisingly little discussion during the conference about how technology can be used as an enabler for ERAS. Most references were to medical devices, and those that did touch on software were references to a vague “patient app”. This indicates to us that practitioners are aware that digital engagement has the potential to play a role in operative processes, but are not fully engaged in exactly how technology could be used within a joined-up initiative to actually orchestrate the longitudinal patient pathway.

ERAS guidelines are a great example of a coherent clinical knowledge base that can be transformed into a meaningful digital pathway. Visio documents and excel spreadsheets are not the way forward. These legacy applications represent a missed opportunity to drive the adoption of evidence-based guidelines that truly improve outcomes for patients.

Practitioners working on ERAS need to look at the logistics of how this new standard of care will be delivered, who will deliver the care, and its impact on clinical quality and cost. The operational model needs to be defined, agreed, assured, and shared, and the discussion of the role of technology to optimize productivity, quality, and the patient experience should be an inherent part of this process. 

At this point, standardized implementation of ERAS is very rare. Clinician inertia in the case of both surgeons and nursing staff is a major obstacle to consistent implementation of ERAS protocols. CPM can have a huge impact in terms of operationalizing ERAS and embedding it into workflows to ensure these programs are standardized.

Mayo Clinic Center for Innovation advises those working to implement new systems in healthcare to “think big, start small, move fast.” This is the key to successful roll-out across a system, and it applies well to both CPM and ERAS.

It’s important for those implementing these systems to understand them in the larger context of patients’ complex care journeys within a fragmented medical system. Implementation can start with one specialty or institution at a time and expand from there, as rapidly as possible until these systems become the new normal — the standard operating procedure for high-quality care delivered at scale.