World-Renowned Expert at UH Co-authors Statement on Perioperative Care in Cardiac Surgery

Innovations in Cardiovascular Medicine & Surgery | June 2024

Rakesh Arora, MD, PhD

Rakesh Arora, MD, PhD, Director of Perioperative and Cardiac Critical Care and Director of Cardiac Surgery Research at University Hospitals Harrington Heart & Vascular Institute, is part of an international panel of experts who coauthored the recently released Joint Consensus of the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society and The Society of Thoracic Surgeons (STS). Other distinguished specialists who contributed to the document represent healthcare institutions across the U.S., Canada, Europe and South America.

Published in the April 2024 Annals of Thoracic Surgery, the Joint Consensus expands on the 2019 statement aimed at advancing evidence-based, interdisciplinary care pathways that improve patient safety and optimize surgical protocols from preoperative preparation through the recovery period.

“There has been significant interest in the document from 2019 onward,” says Dr. Arora, recently named the Alan H. Markowitz, MD, Chair for Cardiac Surgery at University Hospitals and Clinical Professor at Case Western Reserve University School of Medicine. “With the latest version, we have additional participation and partnership from the ERAS International Society and the Society of Thoracic Surgery, really reframing what perioperative care should look like for the cardiac surgery patient.”

A world leader in perioperative care and cardiac surgery management, Dr. Arora is spending the year traveling around the country and internationally to present the ERAS consensus statement, which includes a grading system of the level of evidence underpinning each recommendation. “The three pillars we want to ensure are delivering excellent clinical care, continuing academic medical research and training the next generation of clinicians to provide the highest levels of perioperative management.”

The 2024 update gives specific focus to patient engagement and shared decision-making. “In order to impact clinical outcomes important to both patients and healthcare systems, it is crucial that we ensure the surgical care journey is patient-centric and well-documented through ongoing quality assessments and metrics,” Dr. Arora says. The latest ERAS guidelines draw on previous data and theories to inform multimodal approaches that promote smooth care transitions and support an unidirectional patient flow to seamlessly return people to a good quality of life.

Dr. Arora explains that the current statement places additional emphasis on the preoperative phase. “Identifying patients with higher vulnerabilities and providing opportunities for optimization during that presurgical period helps foster a positive transition through the phases of care to minimize complications or readmissions,” he says. “We are still in the early stages of understanding the long-term potential of ERAS, but the overall subtext of what we are trying to accomplish is to aggregate marginal gains that target patient safety and benefit healthcare resource utilization.”

QR Code: ERAS Turnkey Order Set (TKO) Multimodal Analgesia.

QR Code: ERAS Surgical Site Infection Prevention.

ERAS implementation at UH

“Dr. Heather McFarland and the ERAS team here at University Hospitals have sought to apply enhancing recovery pathways across thirteen service lines,” Dr. Arora says. “The work that has been undertaken at UH has resulted in a meaningful difference in terms of patient quality outcomes, length-of-stay reductions and addressing opioid utilization, among other quality measures.”

The system’s cardiac ERAS program has been evolving over the past six or seven years. “We are currently in the process of revising a really well-crafted perioperative manual that was started before my time by Dr. Marc Pelletier, Dr. Greg Rushing and other members of our team,” Dr. Arora says. “We will be incorporating some of the newest best practices for enhancing recovery and implementing dedicated care pathways throughout the system that encompass the entire patient experience.”

That includes the creation of turnkey order sets that bundle perioperative best practices into an accessible format that can be easily accessed through the patient’s electronic medical record (EMR). “As we continue to grow our program and reframe the way people look at ERAS, we hope to highlight that best practices in perioperative care not only empower patients but also directly relate to safety and efficiency,” he says.

Next Steps

Dr. Arora is looking ahead to how tools such as AI, biomarkers and dashboards can provide real-time data acquisition to alert care providers more immediately when patients experience a negative status change. “There will always be a bit of a gap before even the very best clinicians are able to perceive subtle patient declines,” he says. “Bringing newer technologies online will provide additional lead time to address complications and provide an added layer of benefit to our cardiac surgery patients.”

For more information on ERAS and perioperative care protocols, contact Dr. Arora at Rakesh.Arora@UHhospitals.org.

Contributing Expert:
Rakesh Arora, MD, PhD
Director, Perioperative and Cardiac Critical Care, and Director, Cardiac Surgery Research
University Hospitals Harrington Heart & Vascular Institute
Alan H. Markowitz, MD, Chair for Cardiac Surgery, University Hospitals
Clinical Professor, Case Western Reserve University School of Medicine