At a recent state wide quality meeting, I was introduced to the concept of ERAS, or enhanced recovery after surgery. ERAS is not a new concept, however, it is just starting to make its way into the cardiac surgery community. The concept of ERAS was developed by a study group of surgeons in Europe in 2001. The focus of this group was the quality, rather than the speed, of recovery after surgery. This group developed a model which stressed several key points: a multi-faceted approach to deal with delays in recovery and perioperative complications, an evidence-based approach to care protocols, and the use of frequent, interactive audit of these processes.
In 2010, the ERAS Society was formed. The goals of this society are to focus progress through research and education, and to develop models for the creation and adoption of best perioperative practices. The first surgical sub-specialty to champion ERAS was colorectal, followed closely behind by several other specialties. Cardiac surgery has been late to the game, but at an ERAS session held during the annual AATS meeting in April 2018, an expert consensus statement in cardiac surgery was presented. This is likely the jumpstart that our community needed to get on board.
ERAS Cardiac Surgery Society is an international working group that was put together to develop evidence based best practices in peri-operative care in cardiac surgery. The group focused its research on meta-analyses, randomized controlled trials, and large prospective cohort studies which provided recommendations regarding care of cardiac surgery patients. In the end, they came up with 23 consensus recommendations. In order to break this list down, they followed a recommendation and level of evidence grid that was originally developed by the American College of Cardiology (ACC) and the American Heart Association (AHA). The original grid was developed to help guide clinical strategies, as well as all aspects of patient care. In 2017, recognizing that a similar grid could be used to guide the development of clinical practice guidelines in their journals, the AATS/STS published a position statement including an updated version of this grid in the Journal of Thoracic and Cardiovascular Surgery. This same grid is used to assign a class of recommendation, and level of evidence to each consensus statement in the ERAS cardiac surgery document. They are also color coded for easy readability, with green being the strongest level of recommendation, and red being points that are not recommended.
If you are like me, you may wonder why such a framework should be implemented in your practice when you are already faced with a large number of practice-based guidelines. After examining the literature surrounding ERAS, I’d like to share these two important points. First, a study by K Lassen, et al has demonstrated that change in clinical practice takes approximately 15 years to adopt after clear evidence is available. Second, experts such as Ljungqvist, et al who have published a review on ERAS, have learned that healthcare practitioners, surgeons in particular, think that their outcomes are better than they actually are. Both of these statements show that we are likely not giving our patients the best, and most cutting-edge care, even if we think we are. Learning this made my institution look at our practices and evaluate whether our protocols are in line with the ERAS cardiac surgery recommendations. We have also taken it a step further, to start developing our own ERAS-type document, based on the expert recommendations. I invite you to re-examine your practice’s current guidelines, and to look over the recommendations which can be found in the paper, “Enhanced Recovery After Cardiac Surgery (ERAS): An Expert Consensus Statement in Cardiac Surgery” by Daniel T. Engelman, et al. I have also included a few other sources I used here, that further explain the concept of ERAS.
“The American Association for Thoracic Surgery/Society of Thoracic Surgeons position statement on developing clinical practice documents” by F Bakaeen, MD et al, published in The Journal of Thoracic and Cardiovascular Surgery, Volume 153, Number 4
“Enhanced Recovery After Surgery: A Review” by O Ljungqvist, MD et al, published in online January 11, 2017 by JAMA Surgery
“The Evolution and Future of ACC/AHA Clinical Practice Guidelines: A 30-year Journey” by The ACC/AHA Task Force Members, published in the Journal of the American College of Cardiology, Volume 64, No. 13, 2014