Post-Surgery Complication Rates Cut In Study

Nine thousand surgical patients being treated at Kaiser Permanente’s 20 Northern California medical centers had a one-third relative reduction in postoperative complication rates and a 21% reduction in opioid prescribing rates according to a new study.

The study also showed higher rates of home discharge versus discharge to skilled nursing facilities among hip fracture patients.

Called the Kaiser Permanente ERAS (Enhanced Recovery After Surgery) program, it focuses on improving pain management, mobility, nutrition and patient engagement. Designed and led by a multidisciplinary team of clinicians, performance improvement staff and patient education teams, the program focuses on improving pain management, mobility, nutrition and patient engagement.

“In my 24 years as a surgeon, this has been the biggest change in our clinical practice,” said co-author Efren Rosas, M.D.

“For decades, surgeries were guided by commonly held principles including no food after midnight the night before surgery, strong opioids for pain management and bed rest for recovery.”

“The elements of an ERAS program—alternative medications for pain control, avoiding prolonged fasting and encouraging walking—have been shown to reduce complications like blood clots, muscle atrophy, nausea, confusion, delirium and infection.”

Pain management involves opioid-sparing interventions using pain-relief alternatives. Patients are encouraged to begin walking within 12 hours of surgery and maintain a daily goal of walking at least 21 feet within the first three days of surgery.

Efforts to reduce prolonged pre-surgical fasting include the use of a high-carbohydrate beverage within two to four hours before surgery. Post-operative nutrition is provided within 12 hours after surgery.

Program implementation started in 2014 and was completed over the course of one year. A total of 5,002 emergent hip fracture repair patients were included in the study, as were 1,523 control patients for other types of emergency orthopedic surgery.

ERAS patients demonstrated significant gains.

The rate of early ambulation increased 18% among hip fracture patients. Similarly, the use of early nutrition increased 12% in hip fracture patients. The total dose of opioids also decreased significantly. Hospital length of stay decreased significantly and the researchers reported a one-third reduction in relative post-operative complication rates.

“This study demonstrates the effectiveness of a systems-level approach to an enhanced recovery program implementation, even across widely divergent target populations,” said senior author Stephen Parodi, M.D., associate executive director of The Permanente Medical Group. “While prior studies have had limited ability to evaluate program implementation at scale in real-world settings, we were able to evaluate care patterns in over 16,000 surgical patients over a two-year period. We were able to demonstrate the feasibility of large-scale ERAS program implementation over a relatively short interval because of the collaboration of thousands of clinicians.”