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E7: Enhanced Recovery After Surgery

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Today, we’ll be diving into the relatively new field of Enhanced Recovery After Surgery, or ERAS. The mindful curation of a patient’s recovery process after surgery is one of the most proactive steps a hospital system can take in preventing opioid dependence in its patients.


Dr. Izquierdo grew up in Illinois and completed his undergraduate degree at The University of Akron as part of a combined B.S./MD program. He attended medical school at Northeastern Ohio Medical University. His surgical internship was completed at Loyola University Medical Center in Chicago.

Dr. Izquierdo started Anesthesia residency at The MetroHealth System in 2011 and graduated in 2014. His last year was spent as Chief Resident. From that point on, he remained a staff anesthesiologist. He continues to practice General Anesthesiology, and as of July 2020 is also The Director of Obstetric Anesthesiology. In addition to being the anesthesiology lead for Enhanced Recovery After Surgery (ERAS), Dr. Izquierdo is an Associate Director of both Informatics (EPIC systems) and Quality for the anesthesia department. These roles have put him in position to help develop the Enhanced Recovery After Cesarean Deliveries (ERAC) program to facilitate recovery after c-sections.


Dr. Brook Watts joined The MetroHealth System executive leadership team in January, 2018 as Vice President and Chief Quality Officer. In this capacity, she is responsible for quality, safety, and patient experience throughout The MetroHealth System. She is Professor of Medicine, Case Western Reserve University, and is board-certified in Internal Medicine and Clinical Informatics.

Dr. Watts completed her M.D. from The University of Alabama, her Internal Medicine residency and chief residency at The University of Michigan, advanced training in quality improvement through the Veterans Affairs Quality Scholars Fellowship, and a master’s degree in Health Policy from Case Western Reserve University.

She was formerly Chief Quality Officer at the Louis Stokes Cleveland Veterans Affairs Medical Center and the Senior Advisor for Health Informatics for the VA National Office. She is a member of the editorial board for the Joint Commission Journal on Quality and Patient Safety, has served as principal investigator on numerous grants, and has authored more than 30 peer-reviewed publications in quality and safety.

She participates in a variety of community activities, including the Board of Trustees of MedWish, a non-profit which repurposes medical supplies to provide humanitarian aid around the world. She is also the proud “Chief Operating Officer” of the Watts-Stephany family, which, along with her physician-husband, includes managing the many sports activities and engagements of 3 children ages 13, 12, and 10 (and a dog!).

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

Today, we’ll be diving into the relatively new field of Enhanced Recovery After Surgery, or ERAS. The mindful curation of a patient’s recovery process after surgery is one of the most proactive steps a hospital system can take in preventing opioid dependence in its patients.

Dr. Marcos Izquierdo, an anesthesiologist at MetroHealth, helped implement the ERAS program at MetroHealth. He says that this multidisciplinary approach has existed for about twenty years already.

MI: It started in Europe and the concept slowly made its way over to the US and considering it's such a big project for each hospital, it's taken some time to implement it, various hospitals. But it's really a process that puts the patient at the center of the experience and challenges a lot of old dogmas and philosophies with surgical recovery.

At its core, ERAS exists to push patients to be more involved in their care, starting with education.

MI: Enhancing and optimizing nutrition preop and making sure that all of their expectations are aligned with ours. … And then afterwards, get them moving and get their diet started and get them out of bed as quickly as possible. And all of this is focused on trying to keep a balance, trying to maintain as close to a normal physiologic state or keep the patient as close to where they are normally. And it's been shown to improve outcomes after surgery.

Dr. Brook Watts of internal medicine at MetroHealth is also a significant advocate for and participant in the ERAS program.

BW: We all know that surgical procedures can be painful and we certainly want our patients to feel like they've had the best experience possible. So we've been working to establish some of these best practices. So one of the first things we did was to join up a national collaborative focusing on enhanced recovery after surgery programs for certain groups of patients. And this starts from the very beginning and it means helping patients to understand what's going to happen around the time of surgery because it's no surprise that if things are uncertain or unknown, that patient's experience of going through it will be heightened or heightened in a negative way, right?

If you know what to expect and you know what to do about it, or what's going to be done about it, and you feel like you have a degree of control, it's certainly a lot easier to face those kinds of challenges like pain.

Dr. Watts says that a lot of ERAS best practices run in tandem with many traditional, universally-utilized methods for presurgical preparation.

BW: I'm sure everybody's heard, nothing to eat or drink after midnight, right?

So it turns out that, that is a one size fits all that doesn't make sense. And it took sort of reflecting on again, what it means to be going through a surgical process. So it turns out that having people be caffeine deprived and dehydrated, and pretty stressed out and grumpy, because they hadn't had anything to eat or drink might not be a good thing. Go figure.

She says that while the rule of not eating any solid foods after midnight the day before your surgery still applies, clear liquids are a different story.

BW: Having clear liquids up to three hours before your surgery is a very acceptable practice for most patients, not all patients, but most patients. And this becomes particularly important because our surgeons obviously operate throughout the day. And if you're that afternoon case, you're used to having that caffeine in the morning or something to drink. There's really something very different about sitting home and being able to sip on tea, clear liquid for most of the morning, then sort of waiting in that terrible holding pattern of nothing to eat or to eat or drink and having that caffeine headache.

And another example would be mobilization or getting people up, right? And I think one of the things there was a sense at some point that, and it was old school that bed rest was a good thing and it turns out there's just about hardly anything that bed rest is a good thing for. And it's a best practice, for example, now for orthopedic surgery patients who are getting joint surgery to have their first physical therapy session the day of their procedure, right?

And it makes a lot of sense. And the more we get people back to feeling like themselves, the more we sort of move around so that our breathing is normal, and our bowels are normal, and starting to get people really just feeling like themselves. It turns out that, that's better for physical recovery. And of course for emotional recovery as well.

We need to work through the experiences of the individual patient to make sure that we're really meeting all the needs.

Dr. Watts says that a lot of these changes are, frankly…


BW: I hate to say it, but I think it really comes back to common sense. And that we need to do what we call, which I love, co-production of healthcare which means that or really recognizes that the patient is the person experiencing the disease state and the recovery. And that if that experience is in central, then we can't be successful in getting to the outcomes that we're looking for. So we have to co-produce the healthcare with patients.

It seems so silly that we wouldn't think about, okay, what works for you, right? What is the right thing for you in your situation and what are those options that we can give you to help you manage your pain that are right for you? And I think that the moment for me, and this is something that we're still working towards, is really reflecting on the things that we all do at home to make ourselves feel better. Whether it's we've had a bad day or we are having pain, right?

We know how to self comfort. And it always struck me that when people are in the hospital and going through these particularly acute settings that we weren't providing potentially access to those basic comforts that people use to make themselves feel better.

Dr. Watts shared that she was struck by the lack of basic comforts provided for those in the hospital.

BW: One of the smaller things that we were able to do here, which I'm really proud of, is we did move towards a room service menu. And what that means is that you, as the patient, you're not subject to picking things up what we've put on the menu for the day. There's a set menu. And if you really want to order chicken soup every day, that's okay, you can do that. But I think there's something to be said for that. Or if you want to eat breakfast is available all day. So if pancakes is the only thing that sits on your stomach right now, then it's okay to eat pancakes for dinner. You do not have to have our yucky hospital meatloaf. Although, I heard meatloaf is quite good. It may not be my first choice.

Dr. Izquierdo agrees that individually, a lot of the elements practiced in ERAS are not revolutionary.

MI: But what enhanced recovery does is brings all the services together at the same table and work together to be more consistent in these practices with as many patients as we can. That's everybody from the nurses in the surgery clinic, the surgeons, some of the physician assistants and then nutrition, physical therapy, the perioperative nurses and then the nurses on the recovery floor, so the surgical floors, who will be taking care of patients afterwards.

In addition to some of these more “common sense” practices in ERAS, a big part of the program involves educating patients on what their options for managing post-op pain will be. This is where the goals of the Office of Opioid Safety and the ERAS program intersect.

MI: One of the main goals of the Office of Opioid Safety is prevention of the development of this disease, the disease being opioid addiction or abuse. In enhanced recovery, that's one of the main factors. It's called a multimodal or opioid-sparing anesthesia where we minimize the exposure to opioids. It doesn't mean we're not going to treat somebody's pain with opioids. It just means that there's a lot of other options and medications that we can use qne anesthetic techniques to minimize exposure to opioids.

BW: For many patients we can use non-narcotic approaches to pain relief that may be very helpful. And the way I describe this to people is all those things that you would do at home to make yourself feel better when you're uncomfortable, we want to be able to offer you those sorts of things in the hospital as well as the first thought, right? So is that an ice pack? Is that a heat pack? Is that pillows for repositioning? Is that taking a hot shower? Is that particular foods that might make you feel better? But those things should really be first and foremost on our list to try to offer to patients rather than jumping right to pills and specifically pain pills for discomfort that can be expected around times of surgery.

The second thing is thinking about other kinds of pain relief. I think it's easy to jump to thinking that narcotics are the choice. And I think in some ways patients have come to accept that. But we also know that often things like anti-inflammatories, or as we talked about poor direct treatment like ice, may provide more relief and better relief without side effects and narcotics. So again, really discussing those sorts of things for our patients so they understand the options and can make some informed choices.

Dr. Izquerido says that he believes it’s key for different hospital departments to share their data and work together to create the best possible outcomes for patients.

MI: So that patients are educated coming in to surgery about how we're going to manage their pain, set the expectations that there will be some pain after surgery and opioids aren't the only answer. And again, I think part of that is understanding that there is a risk of ongoing opioid misuse for all patients coming to surgery, whether you have a history of addiction or not.

All patients coming to surgery, just by the fact that they're having surgery and getting opioids perioperatively, during surgery, after surgery, puts them at risk of developing a disorder or an issue with opioids.

Decreasing opioids is one goal of the Enhanced Recovery Program. The Institute of Healthcare Improvement define quality and care as a triple aim, so three pieces. One is improving patient outcomes. One is improving the patient experience and then doing all that at a lower cost of care. If you compare that to buying a car, you can get a better car. You can get a better buying experience where you're not getting harassed by the salesman. And then at the same time, pay a lower price for the car. I think everybody will agree that that would be an excellent outcome in the car buying experience.

And then in addition to that, I'll say that the opioid outcomes is just one part of it. Actually, like I mentioned before, these concepts started more than 20 years ago, which was before the opioid epidemic. It was more initially about improving safety, decreasing the side effects of opioid medications. And this started as they realized that these medications that we have, can all work synergistically. They can work together and have a better effect. And not only have a better effect for pain control, but reducing the side effects of each individual medication

All of this started and then obviously, with the opioid epidemic, it then became time to make a move with enhanced recovery, I think. It was an opportunity to get ahead and just as one piece of all of the different measures to reduce opioids in the community. So it was a great time to work collaboratively with everybody, to meet the same goals. We were able to do that and at the same time improving some of these patient outcomes.

Dr. Watts says that first and foremost, doctors need to make sure that they’re giving patients the correct amount of opioids for their individual situation and condition so that they aren’t burdened with the extra pills. BUT until that happens, it’s important that there are accessible ways to dispose of those extras.

BW: I think it's all becoming much more apparent to all of us that giving people opportunities to do that easily and safely is really important. And I've been really pleased to see, I think as others have been, how many communities have stepped up with options for safe disposal. So I think it's just that reminder to people that leaving these things sitting around in cabinets for years on end isn't the best practice. And that we have safe ways to help get rid of pills if there do happen to be some extra.

So, I mean, again, I think it's having options. It never did make sense, right?

So in essence, we very simply change the defaults and electronic health record working very closely with our informatics colleagues. This is the best practice and something that we would encourage any health system to do that hasn't approached it. It's a systems fix, right?

So it's not dependent on someone's individual behavior. Change the number, and the default, and the electronic health record, so that the automatic isn't airing towards a larger number of pills. Pretty simple and works really well.

Moving people away from that automatic reflex of prescribing opioids in the peri surgical period and our providers to reducing those has had a dramatic reduction in the amount of opioid usage.

Dr. Watts says that the reality is, we all have pain, all the time, and we all have our own set of coping techniques for that pain.

BW: And so the more we can use those as a part of the foundation and then supplement obviously with other alternatives, such as pills that are needed under certain circumstances, that makes sense. But to think that the pills were the first option all the time for everybody, that wasn't common sense. And I'm really grateful that we've had the opportunity to have the conversations about what it really means holistically to deal with discomfort.

I think this is really taking the evidence and putting it into a holistic place of quality, safety, and experience. And it's a good reminder. And I think the whole conversation about opioids is a good reminder that we have to constantly question the way we do things and the why and the way we do things. And I think many of the things that we do around the time of surgery, where we were doing just because it was the way we always did them.

Next time on OnePath…

We talk about the office of opioid safety’s education efforts.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.

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The Team

Libbey Pelaia

Libbey Pelaia (host) is an educator within the Office of Opioid Safety and has a demonstrated history of leading initiatives within the healthcare, research, and higher education sectors.

Hannah Rae Leach

Producer & Engineer
Hannah Rae Leach (producer and engineer) is a Cleveland-based audio producer, writer, musician, and newly-minted advocate for opioid safety.

Joan Papp, MD FACEP

Joan Papp, MD FACEP is the founder and Medical Director of the Office of Opioid Safety at MetroHealth Medical Center.

Karolyn Tibayan

Karolyn Tibayan is the Director of the Office of Opioid Safety at MetroHealth Medical Center.

Sean Rule-Hoffman

Mix Engineer
Sean Rule-Hoffman (mix engineer) earned a degree in Music Technology with a minor in Electronic Media and Film from Capital University in Columbus, Ohio.

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