Enhancing recovery

The world-class cardiac surgical program within the Libin Cardiovascular doesn’t just happen. It’s the result of a commitment to innovation and a willingness to question accepted practice by the entire care team.

Now that commitment is being formalized with a new Cardiac ERAS® (Enhanced Recovery After Surgery) program recently initiated within the Institute, which is amongst the first-of-its-kind in Canada. Led by a team of researcher-clinicians within the Institute, the project aims to improve the experience and shorten recovery time for cardiac surgery patients in Calgary by questioning all aspects of care and making small improvements that can add up to big gains.

Dr. Alex Gregory, MD, is a lead of the program and says the multi-phased project brings together everyone involved in the patient experience, from pre- to post-surgery care.

“It is a whole team approach and a great platform to get people who don’t always talk, talking,” he said. “Everyone has a say in how we can improve things. It elevates every single person that participates in patient care to the same level.”

ERAS isn’t a new concept. It began in Europe in the early 2000s when a group of general surgeons got together and asked the question “why are we doing what we are doing?”

What they realized is that some of their activities within the surgical room and in after-care were based on tradition, rather than evidence. They began making small changes, such as allowing patients to eat before surgeries and treating pain differently, that ultimately resulted in a better experience for patients, as well as reduced complications and costs.

Since then, ERAS initiatives—and guidelines— have become popular globally in many areas of surgical practice.

Cardiac surgical programs have recently begun to embrace the ERAS approach.  There have been several recent publications on the impact of implementing a cardiac ERAS program, although none from Canada – until now.

“To my knowledge, we are one of the first in Canada to undertake a formal Cardiac ERAS program,” says Gregory.

The Libin team has completed Phase I of its ERAS program and is gathering data to publish its findings. They looked at things like if patients were being extubated within a standard length of time, that they had good pain control following their surgery, and whether they were able to return home sooner.

The team created a web-based app that provided a checklist for providing patient care post-surgery. The app, used by staff in the Cardiovascular Intensive Care Unit (CVICU) at the Foothills Medical Centre, allowed researchers to keep track of what was happening in the unit.

Using this software, the team measured 200 data points in 185 patients—ranging from opioid use, to length of stay, to patient-reported pain levels—to allow them to assess whether their evidence-based protocols were occurring for each patient, and, if not, why. It was all done to improve overall patient experience.

“We wanted to know if something wasn’t being doing, was there a reason for it,” says Gregory, noting the software also acted as a prompt, helping the care team think through why they are doing what they are doing.

According to Kari France, unit manager of the CVICU, many of the protocols—such as early mobilization of patients post surgery—were already in place.

“We are at the forefront of science-based care, and we were already doing a number of things on the cardiac ERAS protocol,” she says, noting the biggest change was using having nursing staff use the software to track care.

That said, both France and CVICU nurse educator Chris Coltman are in favour of the ERAS initiative.

“It will be a way for us to adopt the latest and greatest innovations to improve care… that is exciting for me,” says Coltman, noting the potential benefits for patients include a decreased length of stay in hospital and fewer complications.

Now that phase one is complete, the team is looking forward to phase two of the initiative, which will assess a broader range of interventions including changes in the intensive care unit; standardizing pre-habilitation for patients, which involves getting patients as healthy as possible through improving their nutrition, exercise regime and mental health; and barriers to patient compliance.

It’s exciting for Gregory, who believes the Calgary team is a leader in this area.

“Calgary is an ideal centre to design and implement these types of quality improvement initiatives,” he says. “We are nimble, patient-based and we don’t put up barriers when it comes to doing what is right for patients.”