Nothing by mouth? Challenge that dogma

"No food or drink after midnight." For decades that order, written "NPO" (nil per os) on the patient's chart, has been a standard instruction to all patients undergoing surgery. Pre-op fasting was deemed essential to prevent stomach regurgitation and aspiration into the lungs while under general anesthetic. If the patient was found to have consumed anything, the surgery would be cancelled.

Research evidence suggests, however, that the risk of aspirating is low and fasting puts most patients into a semi-starved, insulin-resistant state that slows healing and delays the return of gut function. Instead, research shows that carb-loading before surgery may lead to faster healing and better patient outcomes.

"Surgery is very taxing on the body — the energy needed to heal is like running a marathon. People going into a marathon don't fast, they carb-load so they have the energy stores to get through it," explains Dr. Ron Collins, a Kelowna anesthesiologist. Collins is one of the lead physicians on a new province-wide collaborative project, underway at 10 BC hospitals, to implement new surgical care pathways, such as pre-op carb-loading.   

Under the project, patients scheduled for colorectal surgery will be given a high-calorie, glucose drink at 12 hours and then three hours before the operation. But carb-loading is just one of some 20 specific new protocols — many that challenge surgical dogma —  that will be implemented before, during and after surgery and documented to assess the impact.

Called  Enhanced Recovery After Surgery (ERAS), the protocols all aim to improve healing, reduce surgical complications, and speed recovery time. The new processes will be studied pre-and-post implementation at the 10 hospitals to examine whether they improve patient outcomes and shorten hospital stays.

"Colorectal surgery is just the first step. This whole ERAS movement is going to completely redesign the way we administer surgical services across BC and Canada," said Collins.

ERAS protocols originated out of Scandinavia in the 1990s, then moved to the UK National Health Service. Putting the full suite of ERAS protocols in place has been found to cut patient complication rates by 50 per cent and cut length of hospital stay by at least 30 per cent. Similar results have been found in pilot projects in Canada. Collins led a pilot project in Kelowna between December 2011 and 2012 implementing ERAS protocols for 67 patients undergoing colorectal surgery. During the pilot,  patient length of stays in the hospital fell from an average of 12 days down to 4, not only improving patient outcomes with fewer complications, but also halving the cost of each colorectal surgical case from $16,000 to $8,000.

Results of  the Kelowna pilot were immediate.

Results of  the Kelowna pilot were immediate.

"It became clear, very quickly, that this was very dramatic. It was having a huge impact on the complication rate and on people’s ability to get up, to start eating and drinking and to go home sooner," said  Collins.

Surgeons in the project are keen to implement the changes, notes Dr. Tom Wallace, a general surgeon at Kamloops Royal Inland Hospital who is part of the project. "Even to have everybody in the same room talking about the issues is a step forward.  In the past we've been in silos:  I do my surgery, he gives his anesthetic, and nursing does the post-op care.  We don’t recognize the linkages between those things, the fact that I may do excellent surgery, but the patient has a bad outcome because of something else in the process of care," says Wallace.

Pre-op changes include patient education and counselling, carbohydrate and fluid loading, prophylactic antibiotics, and minimal or no bowel preparation (such as no enemas.) During surgery, steps include keeping the patient warm rather than cold, proper hydration (with an emphasis on not giving TOO much fluid) and using short-acting anesthetics or epidurals. After surgery, the steps include stimulating the digestive tract to get it moving again by having patients chew gum as soon as possible, early feeding, early removal of a catheter, the use of non-opioid pain killers, and getting the patient up on their feet as soon as possible.

Changing decades-old processes in health care has been compared to attempting to change a 747 engine in flight. Therefore the project model is a "structured collaborative" a change model pioneered by the U.S. Institute for Healthcare Improvement to address that challenge. Under the model, local Action Teams (the 10 hospitals) commit to implement certain steps of the ERAS pathways which each team feels it can take on. They document and monitor the change. Then they come together in learning sessions with all the other sites to share challenges and successes and learn from each other. After the learning session they go back to their sites for the next action period and try to implement more changes.

"When you implement a change of this sort, it just can't be one or two people, the whole team has to change, the entire infrastructure has to change," says Collins.

Take, for example, doing away with fasting and introducing a high calorie "Carb load" glucose drink at 12 hours and then three hours before the surgery. Sounds simple, right? But here are all the changes that one action spurs in a hospital system, explains Wallace:

  •  the team has to decide what the specific glucose solution will be and who the vendor will be;
  •  the administration has to purchase it in enough quantities to cover the surgical case load;
  • since it lasts only 30 days and must be refrigerated, the glucose supply needs storage and inventory management;
  • since it comes in large containers, someone has to decant the right amount for each patient;it needs a plan and documentation for which individual surgical patients it is appropriate for;
  • it needs to get it delivered to the bedside of the right patient;
  • someone has to ensure the patient drinks it and marks it on the chart;
  •  since there is a concern about potential diabetic patients, every patient's blood glucose will now be tested and documented just before surgery;
  • the anesthetist on the case has to know about the new carb loading protocol for this patient, so the surgery is not cancelled because he or she assumes an NPO order is in place.

"It is incredibly complex, and that is for putting in place just one of the 20 processes!" says Dr. Wallace.

Here is another question: who buys the gum for the post-surgical chew? For now, it looks like as part of the patient education, patients will be asked to bring their favourite brand to the hospital prior to surgery.

The ERAS collaborative is funded by the Specialist Services Committee, a joint committee of the Doctors of BC and the provincial government. Overseeing the project is the ERAS Advisory Panel, which includes representatives in surgery, anesthesiology, and nursing from all regional health authorities, as well as members from the BC Patient Safety and Quality Council and complementary initiatives. The project's 10 hospitals are in Terrace, Kelowna, Kamloops, Campbell River, Nanaimo and five in the Lower Mainland.

If the results are good, ERAS protocols will eventually spread to other surgical procedures and more BC locations.

For more information on ERAS protocols see erassociety.org. For some really cool videos on optimal fluid management during surgery (one of the specific ERAS steps) see "Consequences of fluid overload in the gut."  

-30-