Putting enhanced recovery protocols into practice

Proper preparation and recovery are cornerstones in the evolution of surgical care.

The U.S. healthcare system must improve its approach to enhanced recovery protocols because of the way reimbursement models are shifting. Pay-for-performance drives shared savings and measurably better results. These benefits will be captured only by surgical providers that can fully optimize their operations.

Enhanced recovery techniques can be applied before, during and after hospital procedures with impressive results. Research has shown that by consistently applying enhanced recovery techniques the cost of care can be dramatically reduced, delivering better clinical outcomes more quickly. This research has also demonstrated that for every $1 invested in enhanced recovery techniques, almost $4 of savings can be recouped. In one example for colorectal surgery, the average savings per patient equated to $1,800. Hospital length of stay, complications and readmissions were also reduced by 30 to 50 percent.

Not only does enhanced recovery reduce the cost of care, it also improves patient satisfaction and wellbeing, and can even lead to improvements in societal issues like the opioid crisis. For example, hospitals and physicians are now under pressure to prevent opioid misuse and addiction, especially with regard to post-surgical care. There are often not enough resources available at patient discharge to adequately communicate complex medication dosing instructions and rigourously monitor and follow-up as the patient returns home. Enhanced recovery protocols have been used successfully to reduce post-discharge opioid use.

Though its benefit are clear, enhanced recovery protocols are often time consuming and complex to implement, traditionally requiring providers to augment their staffing levels at great additional cost. To be effective, they also need to be personalized to individual patient needs and further extend beyond the hospital into the patient home, primary care and rehabilitation services.

Essentially, these protocols must reflect evidence-based best practices and be integrated into operational processes that enable the care team to do the right thing at the right time. When combined with automated patient and care team communications, enhanced recovery protocols help ensure that patients are in sync and engaged with the care team, better prepared for surgery and understand how to recover quickly.

Patients need to receive relevant and personalized guidance, while being motivated to help ensure adherence to recovery advice. Topics include gradual exercise, hydration, smoking cessation, alcohol reduction, balanced nutrition, weight control and medications management. Prescription guidelines can also be embedded into pathways to assure compliance with protocols.

What are the obstacles for enhanced recovery?

U.S. healthcare struggles with enhanced recovery protocols for several reasons. First, different organizations interpret the guidelines in different ways – there is no standardization across the board. Second, the guidelines are retrospective and use static checklists instead of being properly embedded into clinical workflow. Third, providers must augment staff to manage the additional cognitive load in the absence of an automated system to assist, guide and task them along the way.

To handle these protocols, organizations often feel pushed into hiring more and more resources trained in enhanced recovery protocols. A recent study found that the role of an enhanced recovery nurse requires them to be typically skilled in pathway development and implementation, data collection/audit, staff education and project management, as well as patient support and education throughout the pathway – this is both a difficult skillset to hire for and an expensive one.

Poor communication also hinders proper enhanced recovery implementation and adherence. Everyone in the care team is in a different place in the hospital setting or care environment. Along with hospital staff members, there are those involved with follow-up care, such as providers in nursing facilities or long-term care facilities, nutritionists and even therapists. How do you coordinate and make sure people have a common plan that is well communicated?

Guidelines often stop at the point of discharge, whereas many activities required for accelerated, complete recovery happen at home or in another care setting. Enhanced recovery must include more than just the activities required for patients to recover to the point of being discharged from the hospital.

Engaging the needs of different patients is another crucial aspect to enhanced recovery. These protocols are really about addressing a patient’s clinical risk, so need to be adapted to the individual. What level of severity or acuity does the patient have? What complications do they have? Are they a diabetic? What preferences and limitations need to be take into consideration?

All of these factors need to be dealt with as part of enhanced recovery protocols. As a provider, how do you do that? How do you gather that information up front to make sure you’re delivering the most appropriate protocol for that individual?

Using automated pathways to overcome enhanced recovery barriers

Currently, enhanced recovery is stalling because it’s so labor intensive. Hospitals too often take guidelines and convert them into static, internal checklists, without considering how to place the patient at the center of this process, from first referral to final recovery. To operationalize enhanced recovery, we must start with the patient and consider their entire journey.

The first elements of enhanced recovery protocols can be quickly implemented as a flow, bringing together care team members and patients around a personalized, digital care plan. From this baseline, providers can then evolve and refine as they go, while gathering data to compare results and improve.

With this data, care operations is becoming a science. We now have the opportunity to design care into a digital process, in a similar way to how you might think about Amazon designing an eCommerce experience or Expedia designing an online booking experience. To date, we have not had sufficient data, research and evidence to analyze the effectiveness of new operational practices – this is about to change.

There has been about a 60 percent compliance rate with enhanced recovery protocols in those health systems that have started to adopt them. While that doesn’t seem bad, adoption should be as high as 90 percent for maximum impact. How do you find ways to engage all of your patient population all of the time? And how do you adapt to the needs of different individuals, focusing resources in realtime on those most at risk, while fast tracking those who are recovering quickly?

New and innovative technology categories like Care Pathway Management are already helping hospitals to efficiently scale enhanced recovery techniques by allowing teams to manage and monitor an adaptive digital recovery plan, which can be made up of many tasks and activities, and tailored to every patient. Ultimately, Care Pathway Management puts the patient back at the center of care delivery operations.

We’ve seen the airline industry have success with this approach, implementing technology for a seamless flight experience for all stakeholders – whatever their individual needs, engaging all parties, to deliver excellent experiences while minimizing cancellations and lost revenue. Healthcare now needs to create its own enhanced recovery flight path, one that helps the care team stay on track during their busy schedule, doing the right thing at the right time.

By Rick Halton, Vice President of Product and Marketing, Lumeon

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