New protocols for enhanced recovery, especially non-narcotic anesthesia, promise to cut health care costs and prevent the spread of the opioid epidemic.
Health care is a hot-button issue for the nation, and no one is more concerned than practitioners. “The politics and dynamics of health care are putting pressure on providers to decrease cost,” says Bruce Weiner, a certified registered nurse anesthetist (CRNA) and president of the American Association of Nurse Anesthetists (AANA). “Health care currently consumes almost 18 percent of the gross domestic product and continues to rise.”
Facilities everywhere are looking to cut costs and help patients live healthier, more productive lives. New protocols for enhanced recovery after surgery (ERAS) are already popular in Europe and have recently gained traction in the United States. As part of the ERAS movement, anesthesia experts such as CRNAs are playing a critical role in attaining successful outcomes while reducing and even eliminating the use of narcotics.
Formalizing the surgery process
Historically, pre-, post- and intraoperative care models have varied across facilities and practitioners, resulting in diversity of patient outcomes, difficulty tracking and preventing surgical complications and increased costs.
“For every complication, there’s an almost exponential increase in length of stay,” says Weiner. “One complication can add 2 ½ days, two complications can add five days and three can add up to 11.”
ERAS guidelines are a multidisciplinary approach to care involving collaboration and accountability between every member of the health care team as well as the patient. Minimizing stress in each stage of surgery helps patients recover faster, and precision anesthesia is playing a critical role.
The pathways of pain
Opioids have long been a ubiquitous method of pain relief. The problem is that they’re also inefficient, providing a blanket effect when local relief is all that’s needed.
“We don’t want to just give patients narcotics, which limits [their] mobility, makes them nauseous and decreases their appetite,” says Lynn Reede, CRNA, senior director of professional practice for the AANA. “And we don’t want unused opioids in their medicine cabinet for family members to find.”
New developments mean that narcotics can now be used solely as a last resort.
“Opioid-sparing approaches are an emerging trend,” says Garry Brydges, CRNA, president-elect of the AANA. “There’s a battery of non-opioid agents CRNAs can now use in a multi-modal approach to manage pain.”
Breakthroughs in non-narcotic medications, such as intravenous ibuprofen, and improvements in the strength and duration of topical anesthetics are helping to precisely target pain while getting patients up on their feet faster.
The future of enhanced recovery
While CRNAs are vital to ERAS, so are patients. ERAS is a holistic system in which patients’ involvement in their own care is key to achieving optimal outcomes.
“Studies have shown that when patients are engaged and know what to expect they are more satisfied with their pain relief since they are able to return to their daily life more quickly,” says Reede. “That’s a big change.”
Starting before surgery and lasting 30-90 days post-op, keeping patients informed not only decreases stress but allows the necessary accountability for ERAS to succeed. “Patients play a critical role as monitors of how well ERAS protocols are being followed,” says Brydges.
The American College of Surgeons, in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, recently launched the Safety Program for ERAS and is recruiting 750 hospitals to participate. This quality improvement project will provide participating hospitals with support and access to experts to implement ERAS protocols.
The payoff from ERAS will be a safer, more efficient health care system, improved patient satisfaction and a more prosperous nation.
