Cutting Average Length of Stay to 4 Hours
“In the lumbar decompression study we found the median length of stay was just over 4 hours. There were no admissions to the hospital, although 4 patients required extended stay—3 of them for pain control. Importantly, we did not observe any complications or readmissions within 30 days of surgery.
And what happened when HSS used its ERAS in anterior cervical surgery?
Dr. Albert told OTW, “We had 34 patients cared for under the pathway, 26 of whom were discharged on the day of surgery. The median length of stay was 16 hours/38 minutes. Extended observation was required in 8 patients due to pain or for respiratory monitoring. We were very pleased that the overall pathway compliance was 82.2%.”
Eliminate the Need for Opioids in Spine Surgery
And, says Dr. Albert, the opioid issue is paramount when it comes to planning and implementing an ERAS protocol. In fact, he envisions spine patients leaving the hospital having never seen an opioid.
“Interestingly, over 37% of the lumbar decompression cohort was identified as opioid tolerant on the day of surgery. Although opioid tolerance is typically associated with prolonged length of stay and more overall complications, we did not find any effect of opioid use on time-to-discharge or other complications.”
“We believe an ERAS strategy that includes multimodal analgesia, postoperative nausea and vomiting (PONV) prophylaxis, short surgical duration and minimally invasive techniques can mitigate or eliminate the need for opioids.”
“Based on our findings, we are creating protocols and pathways that will allow patients to recover faster after surgery and with less pain, nausea, etc. We have already found that patients are ambulatory faster and more alert when they receive less total perioperative opioid. This is especially important for the opiate naive patient.”
“Based on our initial findings, we designed an opioid-free protocol for lumbar microdiscectomy. We are currently analyzing data from 20 patients who have received zero pre- and intraoperative opioids. Not only do these patients have acceptable pain scores in the PACU [post anesthesia care unit], but they are literally setting records for how fast they are ready to leave the recovery room—as little as 3 hours after surgery.”
Albert’s Three Goals
Dr. Albert has three basic goals for the ERAS program.
“We now have a service-specific study underway whose primary goal is to assess the average opioid medication they are being given (how many pills) and how many they take.”
“The second goal is to examine service-specific guidelines, i.e., since instituting guidelines number of pills saved in a year ranged from 2800 (carpal tunnel) to 19,600 (spinal decompression).”
“Our third goal is to use ERAS to create multimodal pain relief (preoperative gabapentin, dual antiemetic therapy, IV Tylenol, etc.).”
