Julie Crowell, BSN, RN, helps patient James Mitchell sit up in a chair as part of the Cardiac Surgery ERAS pathway.

Many cardiac surgery patients at the Brigham are benefiting from an Enhanced Recovery After Surgery (ERAS) pathway that accelerates recovery, with participants up and walking within 24 hours of surgery.

“ERAS is a way to enable our patients to fast-track their recovery and discharge home,” said Andris Soble, BSN, RN, of the Cardiac Surgery Intensive Care Unit. “Seeing the success of patients when we implemented early mobility and ambulation, combined with the use of different pain management options, encouraged nurses to buy into the process early on.”

Early ambulation is one of the interventions of the ERAS pathway created by the Cardiac Surgery division for patients undergoing coronary artery bypass grafting, isolated aortic valve replacement and mitral valve repair or replacement surgery.

The pathway, which comprises pre-operative, intra-operative and post-operative interventions, was developed with the input of the multidisciplinary team, including surgeons, anesthesiologists, perfusionists, nurses, therapists and others.

Culture Change in the ICU

Previously, patients undergoing open heart surgery stayed in bed for 48 hours post-operatively. “As long as patients are stable, we wanted to change our mindset and see if they ambulate early,” said cardiac surgeon Tsuyoshi Kaneko, MD.

After witnessing the success of patients on the protocol, nurses took the program a step further. “They are even urging early ambulation for patients who aren’t on the ERAS protocol because they know it’s good for them,” said Kaneko. “It’s been a culture change within the ICU.”

Dirk Varelmann, MD, cardiac anesthesiologist, noted that getting out of bed earlier is also good for patients’ mindset. “Being able to walk around the unit creates some feeling of success for the patients that they are recovering,” he said.

To date, more than 100 patients have participated in the pathway. In addition to early ambulation, interventions include offering pre-operative patient education, providing a carbohydrate-rich drink to patients prior to surgery, minimizing the use of opioids and implementing a multimodal pain management strategy that keeps patients comfortable without side effects, such as constipation and drowsiness.

Maria Bentain-Melanson, MSN, RN, nursing director of the Cardiac Surgery ICU, said that the engagement of nurses has been vital to patients’ success post-operatively. “Nurses were receptive to these changes and interventions in care when the concept of ERAS was introduced, and they contributed ideas to ensure the pathway is followed in the ICU,” she said.

These include helping to create a patient care checklist for those on the ERAS protocol to ensure each intervention is completed on time. “Nurses also helped us improve identification of ERAS patients by putting a sign on their doors and the patient whiteboard so all care team members are immediately aware,” said Bentain-Melanson.

Looking Forward

Based on the success of patients within the protocol, the Cardiac Surgery team has also broadened its inclusion criteria to focus on more complex patients, including those undergoing double valve surgeries and aortic surgery.

In the spring, Cardiac Surgery nurses won first prize with a poster reflecting the multidisciplinary team’s success with the ERAS protocol during the 2019 American Association of Thoracic Surgery’s annual meeting. The team plans to continue studying and improving the protocol, with an eye toward examining cost benefits and improved outcomes.

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