Personal Perspective: ERAS – Ongoing Quality Improvement Changes to Surgical Care

“Personal Perspectives” provide a space for practitioners and patients to offer their personal views about any aspect of enhanced recovery. “Personal Perspectives” do not necessarily reflect the views of the ERAS Collaborative in general. If you would like to contribute your personal perspective, please contact the Project Manager

ERAS – Ongoing Quality Improvement Changes to Surgical Care

By Deborah Bachand, RN, BA; formerly Manager of Quality Improvements for Surgical Services at Island Health and Member of BC Enhanced Recovery Collaborative Advisory Panel

Change.  I love words, and I’ll bet that many of you are tired of that one. The Oxford English Dictionary tells us it is an old word with Celtic origins; that it can be used as a noun, and a verb both with and without direct objects, that an altered form is also an acceptable adjective.

I have seen a lot of change in my 40 plus years of nursing – mostly good and mostly beneficial to people – our patients. Some changes I have disagreed with.

I disagreed with the move to the BSN program, which purports to train bedside nurses with limited access to the bedsides of real patients. I disagreed with the ‘primary care’ nursing model, which broke down the bonds of teamwork and in my opinion made a hard job harder. But I came around. And then I recently sat in on a local forum where our university community met with the nursing professional standards body to discuss what to do about nurses coming out of the current BSN programs, none of whom at that table considered ‘practice ready’. And most of us are aware of, or have been embroiled in the conflict between health authority administrators, staff, managers and nursing unions over the change back to team nursing – aka CDMR – Care Delivery Model Redesign.

Change is difficult but as someone once said: Change is inevitable – resistance is futile. We can’t undo the changes to university degree nursing or the changes brought about by resource stresses in health care but we can change the way we deliver care to ensure that patients are getting the best we can provide based on statistical evidence, carefully measure outcomes, and by being attentive to the needs of our patients and their desire to get back to life as they knew if before they heard the words “you will need surgery”.

By now you may all be wondering what this has to do with ERAS. Reflect for a moment on ERAS as the new change for surgical care – spreadable, sustainable. Think about how we can never go back to the way things were.

When I started nursing in 1969, surgical care was very different. We schooled patients to understand they would be sick, immobile, inactive, and just downright miserable for several weeks.  We told them to expect pain as part of the deal. We told them to expect to lose weight, lose wages, lose their appetite, lose their dignity – and at that time, with what we knew then, all of that was true.

When I first learned about the principles of ERAS I was skeptical.  Hydrate patients with carbo-loading drinks just before surgery? Surely they will all aspirate and end up in ICU. Do surgery on someone without bowel prep?  Everyone will get septic from a bowel infection. Have patients chew gum in PACU? Of course they will choke. Feed and mobilize on post-operative day one? Bowel obstructions, vomiting, nausea, falls from weakness, increased pain – here we come. How is this describing care that is better for patients? Easier for caregivers?  And yet it is.

We have evidence to show that our former way of starving, purging, dehydrating, and immobilizing patients, even tying them down with Foley catheters, and naso-gastric tubes was doing more harm than good.  None of us are here to harm patients so we must embrace the current known scientific evidence and look for signs that it is working.

Spread your success stories and work to figure out how the failures could be prevented or their harm decreased. If you are connected to social media, work to spread the benefits of surgical change with your colleagues and friends. Understand that while we want to sustain the notion that we must change as the science behind what we do changes – no one is suggesting that the principles of ERAS as we currently know them will not change.  They will. As we learn more, develop new technologies to deliver care, and measure process and outcomes, even the ERAS program I am familiar with will change. Since I first learned about it in 2009 – it already has.

Coincidentally, I have just finished reading two books, and also watched a film in which the issues of change were tackled.  They are: The World Without Us, by Alan Weisman; Flight Behavior, by Barbara Kingsolver; and the film was Selma – the story of Martin Luther King’s fight to change the voting laws for black Americans nation-wide. In all three, the final message remains clear. Change can be seen as a wheel – with the focus in the middle. In our case, the focus is surgical patients.  For Alan Weisman it is the earth we inhabit.  Barbara Kingsolver’s novel was a complex undertaking, which tackled climatology and interdependent relationships.  In the movie Selma – the focus was a huge segment of the American population suffering under prejudice. In all of the works above, the changes required strong, committed leadership. Change needs determined leaders armed with facts and vision to make things better.  Don’t wait for leadership to come from your educator, your manager or your clinical leaders.  Don’t wait to be told by physicians or administrators.  Get the facts. Act. Lead. Change is inevitable – resistance is futile.

deborah bachand

 

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