White Coat, Black Art·DR. BRIAN'S BLOG

Hospitals helping patients recover faster from surgery

Chewing gum following surgery helps patients get out of hospital sooner. Seriously.
A holistic approach involving family doctors, nurses, surgeons, anesthesiologists, and other health care professionals before surgery right through recovery aims to help patients get back to normal functioning as soon as possible. (MAD.vertise/Shutterstock)

Roughly a million Canadians a year undergo surgery. On average, they spend a week in hospital. That's according to the Canadian Institute for Health Information. An article published today in the Canadian Medical Association Journal is offering a new approach to shorten hospital stays and reduce complications.  

The new approach is called enhanced recovery after surgery or ERAS. It's an evidence-based program that hastens recovery from surgery while improving outcomes. A Danish surgeon named Henrik Kehlet originated the concept around 20 years ago. Back then, the average hospital stay after colon surgery was between five and 10 days. In 1999, Kehlet published a study in which he cut the length of stay to just two days. Since then, surgical hospital stays have been shortened for a growing number of operations.

The ERAS approach begins with preoperative counseling. Patients are encouraged to stop smoking and drinking alcohol four weeks prior to surgery because doing so improves surgical outcomes such as lower complication rates and better quality of life. The surgeries include colorectal surgeries, gynecologic and urologic surgeries and partial liver removals. 

There is dietary advice as well. You've been hearing a lot about carbs being bad for you. In this model, studies have shown that carbohydrate loading prior to surgery increases sensitivity to insulin, reduces post-operative inflammation and improves outcomes.

Anemia is corrected by doctors to optimize oxygen-carrying capacity. To prevent surgical infections, antibiotics are given an hour prior to and sometimes during surgery. Blood thinners are given to patients to prevent blood clots. 

The approach following surgery has been changed up as well. The traditional advice to keep surgical patients in bed for days and to not feed them until the return of normal bowel function have been tossed aside. Patients who start eating within the first 24 hours have better outcomes. They begin with clear fluids and if tolerated advance quickly to solid food. High-protein diets are preferred.

Studies have shown that patients who chew gum postoperatively enjoy a quicker return to normal bowel function.

Patients are encouraged to start strolling around the wards within the first 24 hours following surgery. On the first day, they should be up for a minimum of two hours; after that, they're encouraged to walk at least six hours per day.

Expect resistance

The ERAS approach has grown in acceptance across Canada. The principles have been adopted by the Canadian Patient Safety Institute. A number of Canadian surgical care teams have climbed on board. They include Alberta Health Services, Eastern Health in Newfoundland and Labrador, McGill University Health Centre, the University of Toronto's Best Practices in Surgery, the Winnipeg Regional Health Authority as well as BC's Patient Safety & Quality Council and the Doctors of British Columbia.

But there are challenges to making enhanced recovery more widespread. A hospital that wants to start doing this needs to assemble a team of motivated champions from surgery, anesthesia, nursing, physiotherapy and nutrition. Hospital staff need training on the principles of enhanced recovery.

ERAS is so different from the traditional way of doing that the people involved in training should expect resistance from front-line workers. The program works better when the patient's family doctor is brought into the plan prior to surgery.

And it works best when the patient and trusted family members are brought into the process early on. That way, the patient is motivated to follow the plan, and is more likely to enjoy its benefits.

About the Author

Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter. As host of CBC Radio’s White Coat, Black Art, he uses his proven knack for making sense of medical bafflegab to show listeners what really goes on at hospitals and clinics. He is the author of The Night Shift and The Power of Kindness: Why Empathy is Essential in Everyday Life.

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