Updated May 21, 2020

Global safety standards ensure less pain, fewer complications

Thirty years ago, patients undergoing hip or knee replacement usually stayed two weeks in the hospital. Today, most go home within 24 hours. And they do it with less pain, fewer complications and a shorter hospital stay than most patients — and doctors — ever dreamed possible.

“It’s almost an outpatient surgery for the bulk of our patients,” said VCU Health orthopedic surgeon Stephen Kates, M.D. “The return to function is amazing.”

As if to prove Kates’ point, artificial knee recipient Frank Elliott, 74, of Woodland Heights, Va., at four hours post-surgery was stepping down the hallway holding onto his walker. His physical therapist, Heidi Campbell, urged him to slow down. “I could’ve walked farther,” Elliott said with a smile, pleased with his progress. And he did. Elliott, in fact, walked out the door the very next day — the hospital door — and was home in time for lunch and a visit with his grandkids.

Frank Elliott , 74, walks down the hallway at VCU Medical Center just hours after knee replacement surgery.

ERAS protocols aid Elliott’s rapid recovery

Patient safety and recovery have always been a priority at VCU Health. But since beginning the rollout of Enhanced Recovery After Surgery (ERAS) protocols in 2017, infection rates have decreased, readmission rates have gone down, and length of hospital stay, for some, is barely a day. Patient satisfaction scores are at an all-time high.

What is ERAS?

ERAS refers to the global standardization of best practices before, during and after surgery to improve patient outcomes. VCU Health applies these standards across all specialties for scheduled surgeries.

A major goal: Get patients as healthy as possible before surgery

Under ERAS, the patient’s care team of surgeons, nurses and other medical specialists identify and treat the patient’s underlying health conditions to ensure he or she is as healthy as possible before the procedure. Prior practice was to be ready for any complications that could occur as a result of these conditions — but not postpone surgery until the conditions were controlled.

“We're being more proactive now,” said Paula Spencer, director of the Office of Clinical Effectiveness at VCU Health System and an ERAS expert.

The care team, for instance, helps patients with diabetes control their blood sugar before they have surgery. The team provides immuno-nutritional support to those with cancer and other conditions affecting appetite to help them build strength to tolerate their procedure. Overweight patients lose weight, smokers quit smoking and patients with heart conditions or sleep apnea better manage their conditions.

“If a patient has anemia, instead of deciding we may need extra blood on hand for transfusion, we intervene before surgery by providing treatment, such as IV iron,” Spencer said. “The IV iron builds up the iron in their blood supply, making sure they have less chance of requiring transfusion during the operation.”

 “It's very unusual to need a transfusion after surgery now,” Dr. Kates concurred. “It's very unusual to have a blood clot after surgery, and a lot of the problems we previously were very worried about are much more uncommon.”

Dr. Kates, chair of the Department of Orthopaedic Surgery in the VCU School of Medicine, serves as a national advisor on ERAS.

Patients share responsibility for recovery

Before having their surgery, VCU Health patients attend a Preoperative Assessment Communication Education (PACE) Clinic. The focus of the clinic is to:

• Assess patient readiness for surgery
• Address key risk factors, such as:
• Anemia/risk for blood transfusion
• Diabetes/high blood sugar
• Poor nutrition
• Chronic pain and opioid use
• Create a pre-surgical action plan for the patient to follow

Susan Stine, scheduled for bilateral hip replacement, blows into a spirometer to assess her lung function at the VCU Health PACE clinic.

As part of the clinic, patients receive a five-day supply of body wash, mouthwash, nasal swabs and other products to reduce their risk of wound infection. Orthopedic patients, like Frank Elliott and Susan Stine, in for joint replacement surgery, attend a special preoperative clinic for instructions on how and when to use the products, exercises to strengthen their muscles and tips on modifying their homes to make it easier for them to get around safely.

After surgery, nurses will remove IV drips and drainage tubes and get Elliott, Stine and  other patients up and walking soon after they waken. Patients eat, drink, sit and get dressed with minimal assistance. Independence is encouraged.

“We empower patients to make their own recovery, and we are finding that patients very much prefer this,” said Michael Scott, M.D., an ERAS founding father and former VCU director of critical care anesthesiology. Dr. Scott currently serves as an ERAS consultant to VCU Health. “Because we are not doing all these things for them, it actually accelerates recovery, and people get home faster,” he said.

Just hours out of surgery, Frank Elliott moves his right knee up and down several times without any pain. 

Less pain, fewer opioids

With ERAS, patients enter the operating room healthier — their pre-existing conditions addressed and under control. Lifestyle modifications, such as losing weight and quitting cigarettes, speed the healing process and increase pain tolerance. Pain medication is given before surgery so less is needed afterwards. With fewer surgical complications, patients feel less pain, decreasing their need for addictive opioid medications. 

“We have worked aggressively to reduce the need for opioid pain medicine after the surgery,” Dr. Kates remarked. Prior to ERAS, patients commonly received opioids before surgery, he said. “Those are a thing of the past.”

Patients undergoing total knee replacement now receive a spinal epidural and a peripheral nerve block before surgery, administered to the leg.  These agents numb sensory nerves, reducing post-surgical pain.

“In many cases, this eliminates the need for opioids,” Dr. Kates said.  “We instead use medications like Celebrex, Tylenol and Neurontin to help relieve pain and inflammation. “

By modifying small elements before, during and after surgery, through ERAS, “VCU Health has achieved one of the lowest surgical site infection rates in the country,” Spencer said. “We’ve reduced the number of opioids prescribed and achieved our goal of getting patients better, faster.

ERAS promotes holistic health care

Patients tend to think of surgeons as focused solely on the operation, Dr. Kates remarked. While that perception may have been true to some extent, that’s no longer the case, he said. “ERAS has made us more complete physicians, not just technicians. It’s just better medical care.”

For more information on VCU Health orthopedics care, please visit VCU Health Orthopaedics.