ERAS and Urogynecologic Surgery: New Pathways and Successes

Urogynecologic surgeries are complex, multidisciplinary affairs that require close collaboration to achieve optimal patient outcomes and to improve upon the surgical paradigm of bladder and pelvic reconstructive procedures. Numerous ERAS efforts have been and are being devised and tested across the entire UPMC system to improve the patient experience during surgical admissions.

Halina M. Zyczynski, MD, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, division director of Urogynecology and Pelvic Reconstructive Surgery, and medical director of the Women’s Center for Bladder and Pelvic Health at UPMC Magee-Womens Hospital, is leading ERAS efforts for urogynecologic surgery. 

Dr. Zyczynski explains the history and implementation, and some of the successes realized during the first year of the new ERAS pathway at UPMC Magee. The impact on the patient’s surgical experience under ERAS were recently published in the American Journal of Obstetrics and Gynecology in a paper titled “Implementation of a Urogynecology-Specific Enhanced Recovery After Surgery (ERAS) Pathway.”¹ Additional findings from an ongoing quality improvement project were shared at the 2018 American Urogynecologic Society (AUS) meeting on October 13.

Q: ERAS has existed for many decades, first originating in the world of colorectal and GI surgery. In recent years, ERAS has begun to permeate many other surgical disciplines as the evidence base for its efficacy builds. When did this ERAS initiative begin at UPMC Magee, and what were the goals for the ERAS protocol in urogynecologic surgery?

A: We launched our urogynecologic surgery ERAS protocol in February 2017 after a year of planning by a multidisciplinary team of UPMC Magee experts from gynecologic surgery, anesthesiology, nursing, and pharmacy services. Our protocol is one of several designed specifically for women having gynecologic surgery. The urogynecology ERAS protocol is customized for women pursuing vaginal and minimally invasive surgery for pelvic organ prolapse. It is based on the core principles of ERAS introduced by Drs. Esper and Holder-Murray, the UPMC champions of ERAS, and further refined to be gender-specific and individualized to the pelvic surgery needs and the metabolism of older women.

The common goals of ERAS protocols are quicker recovery after surgery through patient preparedness, medical optimization, and optimal pain management. When we launched ERAS on our service, we made a concerted effort to track clinical outcomes in a quality improvement project. We compared the various aspects of the patient experience before and after the implementation of ERAS at UPMC Magee. We are particularly protective of our vulnerable older patients and specifically wanted to learn whether or not ERAS benefits were comparable in women across all age groups. To our knowledge, ours is the first study of the impact of age on ERAS outcomes.

Q: What are some of the specific elements of the ERAS protocol that you implemented in order to meet your goals of an earlier recovery?

A: First and foremost is the gender-specificity of our protocol to better align with the unique needs of women, and specifically older women because a high percentage of our cases are in women over the age of 65. Like many ERAS protocols, we focus heavily on patient preparedness for surgery. This includes education and the establishment of clear expectations for the surgical experience. We strive to optimize patient health before the procedure through nutrition guidance, daily exercise, weight loss, and, if applicable, cessation of smoking. We counsel women to avoid presurgery fasting and aggressive bowel preps. They are instructed to drink generous amounts of electrolyte-rich beverages, such as Gatorade®, or clear fluids up to three hours before surgery. Pain and nausea prevention is started before surgery and includes several nonnarcotic medications. These and other anesthetics aim to reduce the administration of opioids. Early fluid intake in the recovery room facilitates the return of normal bowel function and discontinuation of IV fluids. Early ambulation targets the prevention of blood clots or deep vein thrombosis.

Q: You’ve published your initial findings from the study recently in AJOG. Can you summarize the key learnings and outcomes you were able to uncover?

A: To begin with, we found that compared to patients under the prior standard of care, those who experienced surgery under the new ERAS paradigm had a 13.8-hour shorter hospital stay. The duration of surgery did not change. Instead, the reduced time of recovery from anesthesia enabled early discharges. We consider the ability to safely go home on the day of surgery to be the ultimate reflection of a successful “early” recovery. Under ERAS, the proportion of patients who were discharged to home on the same-day of surgery increased from 25.9 percent (pre-ERAS) to 91.7 percent. Importantly, we did not observe an increase in the 30-day postoperative complication rate, though there were a few more hospital readmissions that we are studying further.

Q: You also were interested in whether older women would benefit as much as younger women from ERAS. What has your analysis of the data uncovered so far concerning age?

A: We have a diverse mix in our urogynecology patients. Their average age is 66 years with more than 25 percent of women over the age of 75 years, which compels us to regularly consider the special needs of community-dwelling, functional women in their late 80s and early 90s. Our goal is to send them home better than when they arrived for surgery. In addition to considering the multiple medical comorbidities of older women, we are cognizant of their vulnerability to delirium and postoperative cognitive dysfunction from anesthesia and opioid pain medications. For these and other reasons, we were very pleased to learn that the benefits of ERAS were experienced by women of all ages on our service. We found that like their younger counterparts, the length of stay amongst the oldest group of women decreased by 58 percent — from 25 hours to 9.7 hours. Their opioid consumption decreased by 92 percent which is comparable to the 88 percent reduction seen in the youngest cohort. This remarkable reduction equates to older women on average receiving only 8.0 mg of morphine equivalence under the ERAS protocol compared to 82.5 mg morphine equivalents before ERAS.

Lastly, we learned that a third of our ERAS patients in each age group experienced opioid-free anesthesia after their small initial dose of extended-release morphine that is part of our multi-modal pain management approach in the pre-op unit.

On a side note, our analyses identified the characteristics of women who required higher than average amounts of opioid medication for pain relief. They were the youngest women, those who are under treatment for chronic pain, and those with a history of depression. These findings will influence our prescriptions of postoperative pain medication.

Q: What are patients telling you about their experiences?

A: To learn what patients thought of their surgical experience, we initiated telephone calls to patients the day after they were discharged to home. For the majority who were discharged on the same-day of surgery, the calls were made within 24-hours of surgery. Our standardized survey revealed that 93.5 percent reported their surgical experience as very good or excellent.

Q: Where are you headed next with ERAS at UPMC Magee?

A: We have been able to extend our ERAS protocol from UPMC Magee to our surgical services at UPMC Passavant and the Magee-Womens Hospital of UPMC Hamot with comparable success. By doing so, we demonstrated the transferability of the pathway in all its complexity to other sites. This is reassuring given that we strive to provide a comparable patient experience at all sites of service in the UPMC women’s health service line. Additionally, we need to get the word out to women that they should not suffer from their prolapse because of fear of surgery. We know that some women have been told they are “too old” to have their prolapse repaired. Others defer care because they are wary of being hospitalized for fear of acquiring delirium or infections. When I share the findings of our study with patients and their families, they are very relieved and reassured that under the new ERAS clinical pathway, even our oldest patients can expect to have a safe, short admission with a very high likelihood of sleeping in their own beds the night of their surgery. It is an extraordinary shift in the patient experience that we look forward to building upon in the years to come.

References and Further Reading

¹ Carter-Brooks CM, Du AL, Ruppert KM, Romanova AL, Zyczynski HM. Implementation of a Urogynecology-Specific Enhanced Recovery After Surgery (ERAS) Pathway. Am J Obstet Gynecol. 2018 Jun 18. Epub ahead of print.