Thank you for tuning in to the Becker's Healthcare Podcast.
We'd like to thank the sponsor of this episode, Edwards Life Sciences.
This is Laura Dedo with the Becker's Healthcare Podcast.
I'm thrilled today to be joined by Dr. Daniel Engelman,
president of the ERA ERAS Cardiac Society and Medical Director of Cardiac
surgical Critical Care in patient services and professor of surgery at the
University of Massachusetts, Chan Medical School, Baystate,
and Dr. Michael Grant,
vice president of the era R Eras Cardiac Society and Associate Professor of
Anesthesiology and Critical Care Medicine at Johns Hopkins Medicine. Dr.
Engleman. Dr. Grant, thank you so much for joining us on the podcast today.
Thank you for inviting us to join you.
Fantastic. Well, I'm excited for our discussion.
I know there's gonna be a lot of important information we go over,
but before we dive into the broader discussion,
I would love to hear from you both a little bit more about your backgrounds and
really how your careers have evolved up until this point. So, Dr. Engleman,
can we start with you?
Sure. Well, I am a cardiac surgeon. I trained in cardiac surgery.
I spent most of my time in the operating room in the first 17 years of my
career. And my father, however,
was an academic cardiac surgeon and he was publishing on fast track recovery
following cardiac surgery.
And he did a lot of publications talking about the speed at which you could
get patients healed and back home to their baseline state using a combination of
medications and protocols. And that intrigued me, but I started thinking, well,
it's not all about the speed. Perhaps we need to just tighten up our protocols.
And that's when I kind of stumbled across enhanced recovery after surgery.
And ever since 2017,
I worked with a group of multidisciplinary experts to start the International
Enhanced Recovery after Surgery Cardiac Society in which we standardized
evidence-based best practice. Uh, Mike, your thoughts?
Yeah, so, um, you know, I was lucky enough that Dan reached out to me, um,
shortly after he realized the society. Um,
and at the time my particular interest was both in kind of the area of systems
engineering, you know,
how you think about constructing smart systems around patient care, um,
but also patient safety and quality. Uh,
and so it ended up being a really nice marriage of being able to kind of bring
those, that background plus my clinical background in anesthesia. Again,
kinda a nice synergy with the surgical side. So I brought that background, uh,
to the board as well. And you know, we've created a, a,
a board of other executive, uh,
members that are from a host of different disciplines, and I'm sure we'll,
we'll dive into that as well. Um, and so the last couple of years we've, um,
been working in collaboration to see the society moving forward.
That's amazing to hear. And you know,
really an outstanding society and organization to support some important work to
be done. Now,
I was wondering if you could tell us a little bit about the quality improvement
programs that you have at both your organizations.
How do you optimize patient care? And Dr. Engleman, can we start with you?
Sure. So historically cardiac surgeons felt that if you did a good operation,
the patients would do well, that all the magic happened in the operating room.
But it turns out that isn't really true.
That maybe up to 75% of the preventable morbidity and mortality that
occurs following cardiac surgery actually occurred outside of the operating
room, either from a patient that wasn't preoperatively optimized or
postoperatively could have been treated in a different way in the intensive care
unit or, uh, on the telemetry floor or even after discharge.
So there's a lot of important work that needed to be done outside of the
operating room. Uh,
and that's where we started getting into dividing it into phases of care where
we divided up into preoperative optimizing patients intraoperatively,
what could we do, working with our anesthesia colleagues and our, our, um,
perfusionist colleagues, and then postoperatively,
which is where I would say most of our work has occurred.
And we could delve into each of those areas separately. Uh, Mike?
Yeah, I mean, you know, one of the things I think that's worth mentioning is,
you know, we have a lot of literature.
It's been published over the course of decades and decades, um,
and in some ways that literature has provided us the keys to kind of how to
manage patients,
but actually kind of unfurling that literature and understanding where all those
data should be incorporated into your clinical care has been a challenge. Um,
they actually say that oftentimes the translation of primary literature to the
bedside can take as much as, um, 15 to 20 years to actually realize.
And so a big part of the effort that I think we've been excited about is
establishing best practice around the care of the cardiac surgical patient by
using largely literature that we already have at our disposal,
but also helping to generate new literature and do it at a pace that allows us
to bring it to the bedside more quickly.
And so that's a lot of this is us standardizing best practice and then applying
it, um, in implementation science format to help the clinician.
So if we want to delve into maybe some pre-op elements,
is that what you're thinking we should start, perhaps?
Yeah, I mean, absolutely.
I think that would be fantastic and just really helpful to look at all those
different areas you mentioned, um, and,
and dive one bit deeper to think through what's gonna be very critical in those
spaces as well as the best opportunities to grow and develop and,
and get better.
Sure.
So patients who are non-emergent where you have a little bit of time to work up,
these patients probably can be optimized in about five different domains.
Now, every hospital isn't going to do every domain,
but at least it's worth thinking about these domains.
And the domains would include, uh,
alcohol and cigarette cessation in those patients that have a little bit of
time.
Patients do better if they stop smoking and drinking before a cardiac surgery,
uh, anemia optimization. So those patients that are anemic,
you can either replete them through iron through, uh, epogen,
uh, through all types of different, um, means in which you can, uh,
get their anemia under control to prevent the blood transfusion postoperatively.
Patients who are frail,
you can work on their strength and exercise them based on their
critical anatomy or whether they need valve surgery.
But there is a way to get patients better prepared, uh, physically, uh,
before their surgery. Uh,
there's an entire bundle surrounding SSI prevention, surgical site,
infection prevention, nutrition,
malnourished patients can be optimized preoperatively, um,
education surrounding opioid use. What am I missing there, Mike?
Yeah, I mean, I think those are the, those are the big ticket items, you know,
these individual pillars. You know,
one of the pieces that you allude to Dan that I think is really appropriate is,
um, we have often, especially in the United States,
thought that time to surgery was the real key. You identify an issue,
get 'em into the operating room. The moment you're in the operating room,
you can actually get to the heart of why those patients, um,
were infirm to begin with. Well, you know,
it turns out that there's actually this, I think,
appropriate period of time where you may choose to, you know,
paradoxically delay that surgical encounter in order to optimize patients.
And that's a real paradigm shift,
but that's kind of a hallmark of what that preoperative optimization period
would require.
And we call it prehabilitation instead of standard rehab, it's rehab.
That's the pneumonic.
Absolutely.
That's fascinating and just so helpful to understand and consider for those who
do have time and are able to go through those processes and really optimize
themselves for the surgical procedures.
So then what happens for those patients once they're ready for surgery and,
and then the recovery, um, time periods, you know,
what strategies have most successful for improving patient care in the or?
And then the ICU.
Mike, you wanna take a stab at this?
Yeah, so, so you know, the operating room, um, there are obviously some,
some large bucket items. So, you know,
we think an awful lot about how you manage hemodynamics. Well,
the way that you think about vasopressors and fluid administration,
there is a entire period of time where you're on a cardiopulmonary bypass
machine and there are strategies to optimize organ perfusion while you're on
that machine. Um,
things that we probably don't use as ubiquitously as we should. Again,
that's a big set of best practices around perfusion based care. Um,
we have to think about obviously how we administer opioids,
how we administer pain medications in general,
using balanced anesthetics that compliment your, um, pain management techniques,
how we ventilate patients. Um, so, you know,
obviously in the operating room there are strategies to reduce some of the risk
to lung injury that are associated with positive pressure ventilation.
And the list can kind of go on and on and on.
What we really try to avoid is diving into some of the more technical aspects of
the surgery itself,
because there are entire societies devoted to how to do a specific
kind of surgery.
This is more about how do we optimize the care that's surrounding that surgical
encounter, um,
and using best practices in the operating room to facilitate that surgery.
That really is helpful to know and, and definitely I,
I love that kind of mindset of continuing to try to get better use best
practices and, and really those the technical aspects of,
of surgery getting better. Um, and then too, you know, from your perspective,
when you're looking at all of these things,
how do you best share best practices between colleagues? Um,
whether it's within the organization or, or just broadly,
what have you seen worked really well once you kind of gather the data and,
and see that there's a change that made a big difference?
Well, I think your, your classic mechanism in academics has been publication.
Um,
and one of the advantages of that is that that's something that gets around to
kind of at the society level. And, you know,
people who are really into the academic side of this have exposures to that
literature.
What we have found is that those aren't always the people who are making the
decisions, and that's not how you get it out to all of the masses.
And so we spend a lot of time, um, doing things like being able to create, um,
ready-made turnkey order sets that can translate some of those, um,
elements of literature to kind of a bundled application to take to the bedside.
Uh, we think a lot about how we can, um, lecture,
especially on a societal level or in some of the kinda local hospitals to be
able to, um, you know, disseminate that information.
A lot of this is word of mouth and networking,
so you get to know your colleagues very well in these various areas and that
helps with some, um, dissemination. Um,
and so there it's a multi-pronged approach that really requires a,
a lot of different avenues to get the word out.
Yes, we, um,
wrote initial guidelines in 2019 that were published in JAMA Surgery,
and now we are, um,
updating those which will be published in the Annals of Thoracic Surgery as an
expert consensus document. And that should come out in January. But, uh,
as Mike alluded to, just publishing generalized guidelines of,
well, it's important to prevent acute kidney injury,
doesn't exactly tell the bedside practitioners, how do I do that?
Just tell me some of the metrics you're gonna use and physically,
what do I do for my patient?
And that's why we think that these turnkey order sets that we're
now publishing, which translate not just our expert consensus work,
but the world's expert consensus work into an actionable bedside document is
very useful. So we have written one on acute kidney injury.
We have one coming out now on patient blood management,
how to decide when to transfuse patients and prevent them from getting
transfused unnecessarily.
We're going to be publishing them soon on surgical site infection,
on atrial fibrillation prevention and treatment, uh,
which medications you should hold prior to surgery to prevent untoward uh,
effects of these medications, which should be held pre-op.
Well,
that absolutely sounds like they would be extremely beneficial tools to have and
really be able to implement for organizations. And, you know, I'm wondering, um,
especially for those that maybe have not had much experience with the enhanced
surgical recovery programs, what has been your experience implementing them?
How do you really do that, um,
on the people level to make sure that all the clinicians and care providers are
on the same page and understanding the information, the data,
and the different things that you're trying to do,
as well as what have the results been?
So, yeah, so I mean, the bundle of postoperative things,
which is very extensive, would include things like, um, reducing opioids,
getting patients mobilized earlier, paying attention to their nutritional needs,
uh, getting them, uh, off the ventilator as soon as possible.
All of these elements we like to think of as aggregations of
marginal gains,
little tiny improvements in each of these different areas come together and
reduce length of stay, get patients home instead of to rehab hospitals,
which is where they want to be, uh, get them to be less likely to be readmitted,
which is, uh, very costly and also very unfortunate to the patients.
It's improves patient satisfaction.
The education that's associated with all of these things, uh,
absolutely resonates with our patients and with hospital administration because
it lowers healthcare costs by reducing hospital stays and
postoperative complications, which increases patient value,
which we think is, uh, absolutely essential. Uh,
and besides it's just the best thing to do for patients.
Right? Yeah, I mean, I think to feed off that a little bit, you know,
every single thing that we've mentioned is not,
it's not controlled by an individual,
it's controlled by a whole team of individuals and they're from a variety of
different backgrounds. And so anytime you try to do something of this scale,
I mean, we're talking about individual phases of care,
we're talking about multi-pronged approaches to each of those individual facets
that's gonna require you to have a team of individuals that are responsible for
those care elements. And so I think a, again,
a hallmark of kind of the enhanced recovery concept is that you have to develop
a multidisciplinary, um, executive team. You know, you have to have, uh,
members from all different disciplines,
whether it's anesthesia and surgery and nursing and your perfusionists, but, um,
uh, a host of other, um, areas of expertise, things like pharmacists, um,
you're a respiratory therapist, your physical therapists,
these are vital aspects of the care elements that you're trying to employ.
And I'll be honest with you, as a, you know,
routine anesthesiologist in the operating room, I'm just simply not, um,
experienced or expertise enough in those various areas.
We never hope to try to take all of that on as an individual.
And that has really been what, um,
kind of surgery has been asking of surgeons for decades. Um,
and that's not really fair to the surgeon.
So what enhanced recovery really does is it says, listen,
I'm not asking one individual to be an expert in all of these areas.
I want this team of experts to come together and coalesce around a single
unified, um, we'll call it a care package that goes to the patient.
I love that. It,
it seems like that would paint a really clear picture of what you're trying to
do and what you're looking for and be an exciting thing for them to work on
together to really have a better, uh,
grasp of what patients are needing and how to coordinate their care in a really,
um, effective way.
Yeah, and you know,
the other piece to mention here is that enhanced recovery also shifts some of
the priority away from how you want to do the job
around the patient to actually having the patient be involved as a
kind of driver in their own care. Um,
so one of the pieces that Dan alluded to initially was this idea of patient
education and patient engagement. Enhanced recovery asks the patient,
what do you want your life to look like after this surgical encounter
and how will this surgical encounter get you there?
So you're engaging that patient to give them a more formal education base.
You're gonna give them expectations around things like how yet surgical
encounter's gonna look.
It's a roadmap of sorts of what surgery is gonna entail for them.
And then it asks us to follow that patient from the decision to make, uh, uh,
to,
to actually engage in the surgical encounter all the way through full recovery
at the end. And that may be days after surgery, it may be weeks after surgery,
it may be quite a long time after surgery.
And the idea behind all of this is the patient remains the focus,
the very center and the driving force behind that care plan.
Laura, one thing I'd like to point out is, you know, it seems like a lot,
I mean,
we've talked about all these different elements and it may be overwhelming for a
hospital or a practitioner to, to delve into this.
And if you want to get started,
the first thing you need to do is look at your metrics,
pull up the SDS database on your particular program,
and look for areas of low hanging fruit areas in which you are not performing
as well as you think you can. And just work on that one, delve into that one,
work on early extubation, early mobility, um,
blood utilization, acute kidney injury, one area, and get a small win.
Get everybody behind it, get a small win, and it will feed on itself.
And next thing you know,
they'll be wanting to pull in a couple more areas for improvement and track it.
See, hey, look, now we're getting our patients off the ventilator, uh,
in six hours. It used to take eight hours.
We're getting all of our patients out of bed the morning after surgery.
It used to take two days.
This will empower the team and you can celebrate the wins and the patients will
appreciate it.
I love that, that that's really great advice. And you know, I'm wondering too,
um, as we wrap up here,
is there any other advice that you have for clinical leaders to make sure
they're making the most of UAS?
Yeah, I mean, I think, I think there's, uh,
an incredible opportunity for you to look at your deficiency and to begin to
track it immediately.
So if you get the sense that you're really suffering from this, we'll call it,
we'll, we'll call it one item that you really need to, you know,
get a big victory on to kind of sell it to your administration.
Let's say surgical site infection rates, for example.
Use that as the mechanism by which you're gonna start thinking about program
elements. But you have to audit that, okay,
so not only are you gonna audit the degree of surgical site infection over time,
but you're gonna look at the individual elements that you think inform that and
predict that. And these are process care elements.
So am I doing things like surgical scrubs?
Am I giving antibiotics appropriately ahead of time, et cetera, et cetera.
And you're gonna track not only kind of your adherence to those individual
elements, but then the overall outcomes as well.
And that that auditing then feeds back to your individual team members.
If you don't have that kind of closed cycle communication around those elements,
you're, you're gonna be doing things well intendedly,
but maybe a little haphazardly. Um,
and you certainly won't see the needle moving.
So I think my biggest take home for this would be identify the measure you are
trying to improve upon and actually measure it. Which,
which sounds a little perfunctory, but it's incredibly necessary.
Thank you, Dr. Grant, that that's really great advice and certainly, um,
very helpful for our audience to think about as they're looking at what can be
really beneficial for them as they're using ERA AS in the future. Dr. Engleman,
do you have anything else to add?
I do. So if any programs or practitioners want more information,
if they actually want to get these order sets or even programmatic guidance of
how to start an era AS program and how to look at bundles of care and example
orders and example checklists and PowerPoints,
it's all available on our website, which is e eras cardiac.org,
one word Eres, C-A-R-D-I-A-C, eres cardiac.org.
And for a small annual fee of $50 or something,
they could have unlimited access for that year to all these materials.
They can ask us questions, engage with us.
We have a monthly practitioner meetings,
which are live Zoom events where we get an expert at one of these domains to
speak and then open the floor for questions.
So there's lots and lots of interaction and room to improve.
'cause we wanna learn from practitioners, we don't know what's right,
we just know we need to standardize evidence-based best practice for our
patients.
Fantastic. I love it, Dr. Uncommon. Dr. Graham,
thank you so much for being here today.
This has been such a fun and interesting conversation and I look forward to
connecting with you both again soon. Thanks.
For much for having us.
Thank the.
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