NAPA Helps Launch the First U.S. ERAS Cardiac Program, Producing Outstanding Clinical and Operational Outcomes

Overview »

Enhanced Recovery After Surgery (ERAS®) programs promote patient safety and faster post-surgical recovery. The first standardized ERAS protocol was developed in Europe for colorectal surgery in 1997. ERAS pathways for other specialties followed, but due to the complexities of heart and vascular surgery, ERAS cardiac programs had been unsuccessful—until a NAPA anesthesiologist, a cardiac surgeon, and a nurse educator at WakeMed Heart & Vascular, the cardiac practice at the not-for-profit regional WakeMed health system serving Raleigh, North Carolina, made it their mission to develop the first ERAS cardiac program in the U.S.

NAPA anesthesia leadership and clinical expertise helped transform cardiac care at WakeMed Health & Hospitals by spearheading an evidence-based ERAS cardiac program that produces superior clinical and operational outcomes. While enabling safer surgeries for cardiac patients, the new ERAS Cardiac also saved WakeMed’s Raleigh Campus hospital nearly $2 million in year one. This groundbreaking program demonstrates how NAPA adds value to its healthcare partners, and how small changes in procedures can have a big impact.

Situation »

William Bradford, MD, was chief of NAPA’s cardiac anesthesia team at WakeMed when clinicians were inspired by nurse educator Gina McConnell, RN, BSN, to create an interdisciplinary ERAS pathway for cardiac surgeries. Collaborating with cardiovascular surgeon Judson Williams, MD, plus WakeMed’s pharmacy and nursing departments, Dr. Bradford deployed the anesthesia team’s expertise to lead in 16 months of research, integrating feedback from NAPA’s physicians and certified registered nurse anesthetists (CRNAs), as well as their perioperative colleagues. After defining a pathway comprising 20 specific components, from pre-op education through post-op patient discharge, Dr. Bradford and Ms. McConnell delivered robust staff education that secured 100% acceptance of the program: every cardiac surgeon and anesthesiologist agreed to follow the perioperative pathway.

Solution »

Dr. Bradford found that key interventions coupled with education positioned the patient for better surgical success. Armed with data from other ERAS programs and the Society of Thoracic Surgeons (STS), the team pursued strategies that effectively decreased mortality, 30-day readmissions, postoperative renal failure, and deep sternal wound infections, among other improved patient outcomes.

A comparison of pre- and post-ERAS cohorts over the 18-month study period showed that the ERAS cardiac program produced downward trends in both intensive care unit (ICU) and hospital length of stay (LOS), opioid use, GI complications, the rate of reintubation and time on a ventilator, and the ICU readmission rate. These findings were reported in “One-year Results from the First U.S.-based ERAS Cardiac Program,” co-authored by Dr. Bradford and published in the Journal of Thoracic and Cardiovascular Surgery in 2019.1

When Dr. Bradford relocated to another NAPA partner hospital, he passed the ERAS baton to NAPA anesthesiologist Parker Gaddy, MD, who continues to evolve the program with innovations such as using ketamine intraoperatively, and multimodal alternatives to opioids for treating small increases in heart rate and blood pressure. Dr. Gaddy notes that besides increasing patient satisfaction scores, the collaborative culture and trust that is embedded in the ERAS cardiac program has significantly improved medical staff satisfaction.

Results »

Since implementing ERAS Cardiac, the hospital has received international acclaim for its clinical success and better financial performance, derived from associated results such as reducing post-op LOS by 1.2 days. Compounding the savings realized with fewer patient-bed days, ERAS Cardiac operational efficiencies also allow for increased case volume. In 2021 an additional cardiac surgeon was added to manage more cases.

In July 2021, CMS announced that WakeMed Heart & Vascular ranked first place nationally in Quality Outcomes for Open Heart Bypass Surgery, with the lowest U.S. mortality rate reported in 30-day risk-standardized mortality measures for coronary artery bypass graft (CABG) procedures. CMS also noted that WakeMed and Cleveland Clinic tied for the lowest mortality rate (1.4%) among nearly 1,000 hospitals reporting nationwide (the national average for risk-adjusted mortality scores is 2.9%).2, 3

The WakeMed program was also recognized as the first ERAS Cardiac Center of Excellence and earned the hospital the highest possible three-star STS ratings for CABG surgery, aortic valve surgery, and mitral valve replacement/repair.

While improving patient safety is the primary driver behind any ERAS program, the financial benefits that accrue to hospitals from reduced LOS, complications, readmissions, and opioid use can have a tremendous impact on the bottom line. Adding to the initial and ongoing multi-million-dollar savings, ERAS Cardiac enabled the hospital to reduce insurance payments for its cardiothoracic ICU (CTICU) by approximately $5 million. As strong hospital partners pioneering ERAS in cardiac and other service lines, NAPA’s anesthesia-driven, value-based approach promotes safer patient care and a stronger hospital balance sheet.



1. J Thorac Cardiovasc Surg 2019;157:1881-8

2. 30-day Risk-Standardized Mortality Measures for Coronary Artery Bypass Graft procedures nationally reported outcomes listing announced August 30, 2021 by Centers for Medicare & Medicaid Services (CMS) for reporting period July 1, 2017 to December 1, 2019; this rate includes mortality during hospitalization and after discharge of Medicare patients.

3. CMS reported that WakeMed and Cleveland Clinic had a 1.4% risk-adjusted mortality score, the lowest among all hospitals reporting nationwide; the national average for risk-adjusted mortality scores is 2.9%.

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