Implementing the ERAS Protocol With Surgical Patients

• ERAS or Enhanced Recovery After Surgery was an initiative started to improve patient outcomes with surgery. 
• ERAS begins with pre-operative education between patient and nurse, reviewing all the dos and don’ts before and after surgery, expectations, and pain management. 
• Let’s breakdown the nurse’s role in the ERAS protocol! 

ERAS stands for “Enhanced Recovery After Surgery” and is a new initiative to improve patient outcomes during the intraoperative timeframe. ERAS protocol began at the end of the twentieth century with evidence based research to guide protocols before, during, and after surgery to decrease surgical complications and speed recovery.  

Although it has been researched and discussed for decades, many nurses who don’t work in the OR setting may not have heard of it. Postoperative morbidity has always been a concern to surgeons, nurses, and of course family members, so identifying causative factors that contribute to poor outcomes has been widely researched. The best patient outcomes are measured by a short hospital stay and absence of postoperative dysfunction.  

Factors that have contributed to poor patient outcomes include poor anticipatory guidance for the patient, so they don’t know what to expect before, during, or after surgery, dehydration, and poor bowel function from fasting the traditional eight to twelve hours, poor pain control, poor nutritional support, and bedrest due to uncontrolled pain for a prolonged time after surgery. Once these contributory factors were identified, measures have been taken to improve each step in the surgical journey of a patient.  

ERAS protocol begins in the preoperative stage where a patient is educated about the surgery and expectations after surgery including IV fluids, medications, and even extra tubes and dressings the patient may receive.  

Of course, full disclosure of benefits and the purpose of the surgery must come from the physician/surgeon first. The role of the nurse is to support this education and notify the physician if there is still confusion by the patient or family.  

How Does ERAS Protocol Help Patients?

The goal of the ERAS protocol is to help patients avoid the cascade of negative physical and psychological responses due to surgery. Any surgery can create physical and emotional stress, which in turn creates increased pain, immobility of the bowels and a possible paralytic ileus, dehydration, increased cardiac demand in efforts to compensate for dehydration, and respiratory complications.  

Preventing those complications begins before the first surgical knife has made its first cut. Educating patients about what to expect from surgery can help to alleviate stress and fear.

Introducing the surgeon and anesthesiologist to the patient in the preop area has a calming effect on patients as they see their medical providers as real people, and visa versa. Medical staff needs to recognize the patient as a person and not just a number on the caseload for the day. 

ERAS Protocol Components

Some new changes in the protocol are to allow the patient to eat carbohydrates up to two hours before surgery instead of the traditional 8-12 hour fast, earlier consumption of food after surgery, and earlier walking after surgery.  

Guidelines were changed after recognizing the detrimental dehydration and constipation from a prolonged fast from food or water. Electrolyte and nutritional deficiencies are also addressed in the preoperative area instead of waiting to do so in the medical-surgical unit.  

Preoperative carbohydrate loading is now part of the protocol, which acknowledges the role of nutrition on wound healing and the prevention of physiological hyperglycemic stress response and insulin resistance.  

Providing nutritional support may be given IV, NG, enteral, or through TPN. Carbohydrate loading may also decrease protein breakdown seen in gluconeogenesis when carbohydrates are limited.  

Some of the earliest research regarding nutrition, bowel preparation and fluid management came from numerous studies of colonoscopies and colostomies. Although dietary restrictions have loosened, avoidance of cigarettes and alcohol up to 30 days before surgery is still advised as in the past.  

Avoiding deep vein thrombosis is still a priority and the use of sequential compression devices and low molecular weight heparin subcutaneously is still part of the protocol. The use of oral beta blockers and alpha 2 agonists up to 1 week before surgery has gained favor as it decreases the stress response seen before and after surgery. Both are also known to decrease perceived pain, and the need for postoperative opioids.   

Intraoperative use of laparoscopic surgery, when possible, promotes earlier ambulation, decreased surgical site infection, and less pain for the patient.  

A single dose of a broad-spectrum antibiotic before the first knife incision and a second antibiotic infusion if the surgery extends beyond 4 hours has also shown improved post-surgical outcomes.  

Using intraoperative anesthetics that have a lower ½ life help to decrease the sense of the post-surgical hangover and ability for earlier ambulation.  

Helping to control perioperative nausea and vomiting (PONV) is also a focus that significantly can affect postoperative stress and recovery. Interestingly, the use of nasogastric tubes and drainage tubes have fallen out of favor as they have not been shown to improve paralytic ileus or post-surgical drainage from abdominal surgery.  

In the post-surgical time period, earlier feeding and ambulation have shown decreased mortality and morbidity by avoiding sepsis, dehydration, and stress related complications. Urinary catheters are to be removed as quickly as possible to prevent CAUTI infections.  

Nursing Role in ERAS Protocol

Nurses need to know what ERAS protocol is and what their role is in their respective unit or department.  

For those in any perioperative setting such as preop, the OR, PACU, or a post-operative medical-surgical unit, the ERAS protocol directly affects your actions and tasks. Preoperative nurses must coordinate and communicate with the physician/surgeon, anesthesiologist and be meticulous about completing the pre-op checklist.  

By helping with each of these tasks outlined in the protocol in a timely manner, post-surgical complications and all added expenses have been reduced by 40% . 

ERAS protocol is not just the responsibility of the surgeon or anesthesiologist, but the entire nursing staff that will come in contact with the patient. Each medical staff plays a role in improving the patient outcomes through the ERAS protocol.  

Resources for You and Your Patients

Each hospital will have a particular manner to communicate and promote the ERAS protocol. Many are familiar with the surgical timeout that occurs before the first surgical incision and that is part of the culture of safety and focus on promoting improved patient outcomes with the ERAS protocol.

If you are not familiar with ERAS protocol and you work in a surgical area, contact your unit director or administrators to help them become better informed and compliant with evidence based research and guidelines.  

The Bottom Line on ERAS Protocol

Knowing about research that guides better patient outcomes is a responsibility of all healthcare professionals. Knowing about and following ERAS protocols is crucial if you work in a surgical setting before, during, or after surgery.  

We all want the best outcome for our patients and having the research that creates a guideline and protocol for daily activities in our work is extremely helpful. Better patient outcomes ultimately lead to better job satisfaction for you, better financial health for the hospital, and of course a healthier community of people where you live.  

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