.svg)
Surgical site infections. Central line-associated bloodstream infections. Ventilator-associated pneumonia. These are just a few examples of the hospital-acquired conditions (HACs) affecting millions of patients every year in the United States, and each one comes with a considerable financial burden for hospitals — and patients. When a single incident can incur additional healthcare costs of up to $94,879, not to mention the increased morbidity and mortality rates, HACs put an enormous burden on already-strained hospital budgets. And much of that burden is avoidable; between 35% to 55% of healthcare-associated infections (HAIs), a major category of HAC, are preventable when using evidence-based protocols. That preventability is exactly why HACs also affect Medicare and Medicaid reimbursements and hospital ratings. The more preventable an event is, the more payers and regulators hold hospitals accountable for it.
To address the inconsistencies in care that lead to HACs, an international group of surgeons and healthcare experts created ERAS, or Enhanced Recovery After Surgery. ERAS is an “evidence-based approach that incorporates the entire care team, including the patient, to develop protocols that reduce postoperative complications and decrease length of hospital stay.” In other words, ERAS serves as a set of best practices to prevent costly hospital-acquired conditions — but it’s up to hospital administrators and care teams to ensure they’re being implemented.
What is Enhanced Recovery After Surgery?
In 1997, Danish surgeon and Professor of Surgery at Copenhagen University Henrik Kehlet proposed “that while minor changes in perioperative practice have no significant impact alone, incorporating multiple changes could drastically improve outcomes.” Four years later, members of “leading surgical groups” met in Sweden to further develop Kehlet’s theory. This meeting was known as the ERAS Study Group.
The group realized “There was also a great discrepancy between the actual practices and what was already known to be best practice” due to the use of outdated traditions. Over the next decade, the study group evolved into the ERAS Society and sought to move medical practices away from tradition toward a more evidence-based approach to medicine. The group continued to meet, conduct research, collect data, and publish their findings; the first ERAS Implementation program took place in Sweden in 2010.
Since then, the ERAS Society has established proven guidelines for anesthesiology, emergency surgery, intensive care, and nearly two dozen additional specialties. These guidelines require the cooperation of patients, doctors, nurses, and other members of the care team to enforce. The results are promising: ERAS has been shown to reduce patients’ lengths of hospital stays and healthcare costs, making a strong business case for its implementation.
How ERAS improves outcomes
While specific protocols vary by specialty, ERAS provides guidelines for patients and care teams to follow before, during, and after surgery. All of these guidelines stress “preoperative education” that includes patients; for example, a colorectal patient would be advised to increase exercise and stop smoking one month before surgery.
In many cases, ERAS stresses a minimally invasive intrasurgical approach and also provides guidance on the use of NG tubes, vasopressors, fluids, and anesthesia. Post-surgery, the ERAS Society recommends early mobilization across all specialties and provides additional catheter, medication, and diet instructions.
According to a 2023 study, “The development of Enhanced Recovery After Surgery (ERAS) has brought about substantial transformations in perioperative care, substituting conventional methods with a patient-centric, evidence-based strategy.” These transformations include “diminished postoperative complications, abbreviated hospital stays, heightened patient satisfaction, and healthcare cost reductions.”
For a closer look at those healthcare cost reductions, we can use hospital-acquired pressure injuries as an example. ERAS protocols include interventions that directly impact HAPIs, among other hospital-acquired conditions. If each preventable pressure ulcer costs the hospital $14,506 with a baseline compliance rate for prevention strategies at 65%, improving that compliance rate to 88% could save hospitals over a million dollars annually.
The compliance increase from 65% to 88% isn’t hypothetical, by the way; it’s exactly what happened when MetroHealth solved its information overload with C8 Health.
Increasing compliance with ERAS and other data-backed protocols is where the real challenge lies. Hospital-acquired conditions generally aren’t the result of a lack of available guidelines or carelessness. Steps get missed at the point of care because, as MetroHealth Medical Director of Perioperative Services Dr. Luis Tollinche put it, information is stored in a “well-intentioned but fragmented ecosystem” — and clinicians often rely on memory instead of new protocols.
It’s not hard to imagine what that ecosystem looks like in practice. It’s a nurse halfway through their shift desperately trying to recall the latest protocol email when the data is three folders deep, in a drive nobody’s touched since last quarter. It’s a surgical team that has one set of guidelines and a post-operative care team that has a conflicting set. When data is spread throughout cloud drives, emails, and PDFs, clinicians default to the information that’s freshest in their memories while updating guidelines are forgotten or lost in the system.
Increasing ERAS compliance through Quality Improvement
Johns Hopkins has a name for the type of “structured, systematic approach” needed to overhaul data storage and increase ERAS compliance: Quality Improvement (QI). While this change won’t happen overnight, QI allows clinicians to determine how and why their teams are falling short, address the issue directly, and implement rapid, meaningful changes to day-to-day routines.
At its core, ERAS is a multidisciplinary QI project. The same Quality Improvement framework used in avoiding adverse drug reactions, reducing unnecessary Cesarean deliveries, and preventing central line-associated bloodstream infections can also be used to increase ERAS compliance throughout your healthcare system:
- Define the opportunity for improvement: Increasing ERAS compliance means improving patient care and cutting down on preventable costs.
- Assess your current performance: Collect data and determine the current rate of ERAS compliance. Once you know your starting point, you can identify the goal — for example, MetroHealth went from 65% to 88% compliance with the help of C8 Health.
- Identify why the problem is occurring: What’s happening at the point of care? Are members of the care team unfamiliar with ERAS, or do they just not know how to access the most recent guidance?
- Design and test an improvement approach: To improve compliance among the anesthesiology department at MetroHealth, Dr. Tollinche determined that a “centralized clinical knowledge management approach” could reduce the “cognitive and logistical friction” contributing to hospital-acquired conditions.
- Evaluate the results: Calculate your new ERAS compliance rate and determine whether your first round of QI changes was successful.
- Refine, sustain, or expand the results: Even if you don’t meet your compliance goal the first time, there’s still room for improvement. Collect feedback from clinicians to identify points of friction in the process and refine your method as needed.
In addition to the healthcare and financial benefits, hospitals that successfully implement Enhanced Recovery After Surgery protocols are recognized by the Association of periOperative Registered Nurses (AORN) and the ERAS Society. Among the currently recognized Centers of Excellence in the United States are C8 Health customers The Mayo Clinic of Phoenix, Arizona and Brigham and Women’s Hospital of Boston.
Targeting HACs with C8 Health
You can’t increase ERAS compliance without a shared playbook for the entire care team. C8 Health unifies all approved protocols and guidance in one place, so clinicians spend less time hunting for the right answer and more time acting on it. Instead of digging through shared drives and emails, a nurse can pull up the current protocol from their phone in seconds. Department leaders can see where compliance is slipping before it turns into a HAC.
By putting the latest evidence in front of clinicians at the point of care, department leaders close the gap between what's known and what actually gets done at the bedside. For C8 Health partners, that translates to an annual savings of $550,000. Reach out to set up a free demo.
At MetroHealth, 87% of respondents agreed or strongly agreed that the C8 Health app was easy to learn, while 86% thought it improved delivery of services. Learn more about the results of the mHealth App Usability Questionnaire here.
HACs rarely travel alone. If pressure injuries or surgical site infections are part of your compliance picture too, the same evidence-based approach applies to both. Check out Implementing SSI Prevention Measures for Improved Patient Outcomes and Pressure Ulcer Interventions: Implementing Evidence-Based Practices for HAPIs.
