A Backus Hospital surgical practice has reduced opioid use, shortened post-op hospital stays

Norwich — A year into a program designed to help patients recover from surgery faster, William W. Backus Hospital doctors have found that opioid use among colorectal surgery patients dropped by half and patients are spending on average two fewer days in the hospital.

Backus parent company Hartford HealthCare has been rolling out the use of Enhanced Recovery After Surgery — a set of procedures for patients and doctors developed in European hospitals around 2001 — throughout the company's six Connecticut hospitals as ERAS has become common in the United States over the past several years.

"The traditional way of scheduling a patient for surgery has been ... they come to the doctor, they get the diagnosis that they need surgery ... and there is a level of communication between the doctor who is going to perform the surgery and the patient, but usually it's just limited to that particular office visit," said Dr. Sergio Casillas, a colorectal surgeon and Backus' chief of general surgery.

In February 2017, Casillas and nurses who treat patients undergoing colorectal surgery started telling patients to prepare for operations weeks beforehand by exercising more, eating healthier and smoking less. During surgery, doctors avoid long-acting opioid pain medicine and instead focus on using short-acting anesthetics or nerve blockers. After their surgery, patients are encouraged to walk around, avoid opioid medications, if possible, and eat a low-fiber diet.

Casillas' patients now meet for at least 30 minutes before their surgery with APRN Claudette Faucher-Charles, who demonstrates lung-strengthening exercises, recommends diet and lifestyle changes that can make their bodies more resilient to surgery and counsels them to try pain medications like Tylenol before asking for opioid painkillers, which can slow their intestines' recovery and comes with a risk of addiction.

"It's the communication aspect, and having someone to talk to," said Thomas Bradham, a Mystic man who was diagnosed with a four-inch malignant tumor on his colon in January. "Learning what the surgery was going to entail ... and the fact that they prepare your body both physically and mentally for entering the surgery ... was (different) from any other surgery I've had."

Before Casillas performed surgery to remove part of his bowel, Bradham started eating a low-fiber diet, upped his exercise and started using a breathing device to improve his lung capacity. 

Patients like Bradham would traditionally spend up to a week in the hospital on bed rest, restricting their food intake and moving as little as possible, Casillas said.

But the enhanced recovery program encourages nurses to put patients back on a normal diet, avoid opioid drugs if they're not in too much pain and start moving their bodies and walking as soon as possible.

"I was up the next day walking around," Bradham said.

Over the first year of the program, Faucher-Charles collected data on 109 of Casillas' patients who underwent surgery for colon cancer and other intestinal conditions and compared them to patients that Casillas operated on before the program began.

More than three times the number of patients were able to recover from surgery without the use of opioid medications at all, and average hospital stays were two days shorter. The rate of complications like intestinal obstruction, collapsed lungs and leaks from the surgical attachment of the intestines went down from almost 35 percent to 2.7 percent. More than 97 percent of patients' guts were functioning again two days after their surgery, compared to 47.7 percent in the previous year.

Casillas used robotic technology to operate on more patients during this period, which is less invasive than traditional surgery and could account in part for the improved recovery times, Faucher-Charles said.

But she attributed the improvements mostly to the work of the nurses and hospital staff who have accomodated the new procedures into their routines. 

"It's a big culture change," she said.

Lawrence + Memorial Hospital Chair of Surgery Paul Bourguignon said L+M colorectal surgery staff started using the enhanced recovery protocol several years ago and have expanded it in the past several months to general surgery patients.

He said it formalizes things surgeons have been telling their patients before surgery individually — like the importance of eating healthy food before a surgery and smoking less.

"I've been telling people that forever," he said. "We've been doing it independently in our own offices (but) now we're talking about it amongst each other. I think it's been kind of a revelation for all of us."

Bourguignon said anecdotal evidence is showing L+M colorectal patients have also benefited from the formalized enhanced recovery system known at ERAS with less opioid use, shorter hospital stays and fewer complications.

The ERAS system will eventually be used in specialities across the hospital, he said.

"Everybody wants to do ERAS now, they're all chomping at the bit," he said.

In Hartford HealthCare hospitals like Backus, ERAS will soon be a standard practice in gynecological and spine surgeries, Faucher-Charles said.



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