Practical Initiatives Improve Outcomes, Shorten Stays

Physician-researchers offer practical, common-sense, easy-to-implement actions to improve outcomes, shorten hospital stays, and lessen the amount of opioids needed to control pain post-discharge.

Research presented this week at the American Society of Anesthesiologists PRACTICE MANAGEMENT 2018 meeting found that anesthesiologists can take a lead role in improving the patient experience -- from the decision to have surgery through discharge and beyond -- which can improve outcomes and reduce costs.

Colorectal and bariatric surgery patients benefited from an enhanced recovery after surgery (ERAS) program, left the hospital sooner and required fewer opioids to control pain, according to new research from Providence Anesthesiology Associates in Charlotte, NC.

PAA compared the results of 621 patients undergoing colorectal or bariatric surgery who participated in an ERAS program to historical data prior to the implementation of the ERAS.

Colorectal patients in the ERAS group stayed in the hospital 2 days compared to 4.5 days for non-ERAS patients. Bariatric patients in the ERAS group stayed 1 day vs. 2.15 for non-ERAS patients. Patients in both ERAS groups used significantly fewer opioids after surgery than those in the non-ERAS groups and had shorter stays in the post anesthesia care unit. Costs were reduced by 20% per case among the colorectal surgery ERAS patients compared to non-ERAS patients.

The ERAS program included preoperative patient education beginning in the surgeon's office and more extensively at the preadmission testing clinic, carb loading the night before surgery and three hours before the procedure, administering preoperative Alvimopan to restore bowel function after surgery, and employing pain methods other than opioids including transversus abdominal plane blocks to reduce or eliminate opioids after surgery.

"Our results demonstrate the benefits of physician anesthesiologists and surgeons working collaboratively to lower costs and improve our patients' outcomes," said Vicki Morton, DNP, director of clinical and quality outcomes at PAA.

Another study from the University of Pittsburgh Medical Center study found that pre-surgical consultation with pain medicine specialist eases anxiety about post-surgical pain management for some chronic pain and substance abuse patients.

The study reviewed 12 spinal fusion patients who consulted with an anesthesiologist pain specialist before surgery. The patients either had a history of substance abuse and were on outpatient addiction maintenance therapy, had a history of high opioid use before surgery, or specifically requested a pain clinic consultation.

Each met with the physician anesthesiologist, who consulted with the surgeon and patient to formulate a plan for the most appropriate pain management after surgery.

The patients reported they were less stressed about surgery, less anxious during the perioperative period and more satisfied with pain control after surgery.

"Some of these patients refuse to leave the hospital after surgery until they feel they are on the right pain regimen, and therefore stay longer," said Trent Emerick, MD, director of quality improvement and innovation, Chronic Pain Division, in the Department of Anesthesiology at the UPMC. "We believe that by working to address these issues before surgery we can decrease costs while improving satisfaction."

Researchers at Beaumont Health in Royal Oaks, MI, believe that evaluating older patients for frailty should be part of standard anesthesia pre-surgical screening. They recommended using a short screening questionnaire, such as Fried's Frailty criteria, because frailty can be an independent predictor of postoperative complications.

Patients who are identified as frail before surgery should be optimized before undergoing the procedure through nutrition, strength training, improving balance and mobility, counseling and medications, the researchers said.

"A healthy 80-year-old is not the same as a healthy 30-year-old, but they often are assessed for surgery in the same way," said Laura Lepczyk, DO, a clinical anesthesia resident at Beaumont.

"Further, some 80-year-olds are strong and vibrant and others are weak," she said. "A frailty assessment before surgery can help providers determine whether a patient is strong enough for surgery and if not, help determine if the patient's health can be optimized to enable the procedure."