Dr. Nagaraj Palankar, Consultant-Surgical Gastroenterology, a renowned consultant in surgical gastroenterology at Manipal Hospitals, introduced ERAS, an evidence-based protocol designed to improve surgical outcomes, reduce complications, and accelerate recovery. Initially developed for colorectal surgery, ERAS has expanded to gynecological, oncological, orthopedic, and hepatobiliary surgeries, demonstrating significant success.
Core Elements of ERAS
ERAS covers preoperative, intraoperative, and postoperative phases, with nurses playing a pivotal role:
- Preoperative Phase:
- Patient Education: Inform patients about the surgical process and recovery expectations.
- Nutritional Optimization: Correct anemia, electrolyte imbalances, and nutritional deficits to improve outcomes.
- Avoid Prolonged Fasting: Allow clear liquids (e.g., water, clear juices, or carbohydrate drinks) up to 2 hours before surgery and solids up to 6 hours, reducing patient stress and improving postoperative strength.
- Intraoperative Phase:
- Use minimally invasive techniques (e.g., laparoscopic or robotic surgery) for less stress and smaller incisions.
- Optimize fluid administration to avoid overload and maintain oxygen saturation.
- Employ regional analgesia (e.g., epidural or nerve blocks) to reduce opioid use.
- Maintain adequate temperature control to prevent hypothermia.
- Postoperative Phase:
- Prioritize pain management with non-opioid options and early recognition of breakthrough pain.
- Initiate early oral feeding (e.g., yogurt or soft diets) and stop IV fluids as soon as possible.
- Encourage early mobilization, such as sitting in a chair on the day of surgery or walking on the first postoperative day.
- Monitor for complications like nausea, vomiting, or distension, and escalate issues promptly.
Nurses are the backbone of ERAS, spending the most time with patients and driving protocol adherence. Their responsibilities include:
- Educating patients about fasting, surgery, and recovery.
- Administering carbohydrate preloading and monitoring tolerance to early oral feeding.
- Managing pain, removing tubes (e.g., nasogastric or urinary catheters) early, and mobilizing patients.
- Recognizing early warning signs (e.g., increased heart rate, fever, or vomiting) and escalating to the surgical or anesthesia team.
Dr. Palankar highlighted that ERAS significantly reduces hospital stays (e.g., from 7–10 days to 3–4 days for colorectal surgeries), lowers complication rates, improves pain management, and enhances patient satisfaction. Its success depends on the dedication of the nursing team and interdisciplinary collaboration.
Falls in healthcare settings are a significant concern, with global statistics estimating 700,000 to 1 million falls annually in the U.S. alone. Approximately one-third of these result in injuries, with 10% causing serious harm, leading to prolonged hospital stays, increased financial burdens, and even mortality. Dr. Varra Manikya Madhuri, a leading nursing educator at Manipal Hospitals, emphasized the nurse’s role in preventing falls to ensure patient safety and enhance recovery.
Falls are classified into five categories to better assess and address risks:
- Accidental Falls: Caused by environmental hazards like wet floors, clutter, or cords.
- Anticipated Physiological Falls: Linked to known risks such as impaired gait, balance issues, or cognitive impairments.
- Unanticipated Physiological Falls: Result from unexpected conditions like strokes, seizures, or extreme hypoglycemia.
- Behavioral (Intentional) Falls: Occur when patients with behavioral issues intentionally move to a lower level.
- Assisted Falls: Happen when a patient is assisted during a fall but still reaches an unintended surface.
To prevent falls, nurses must assess various risk factors, including:
- Age and Medical History: Older age and a history of falls increase risk.
- Sensory Impairments: Visual issues (e.g., glaucoma, blurred vision) or hearing loss.
- Musculoskeletal Issues: Muscle weakness, arthritis, or fractures.
- Genitourinary Issues: Incontinence of stool or urine.
- Neurological/Endocrine Conditions: Dizziness, delirium, or hypoglycemia.
- Medications: Diuretics, antihypertensives, or sedatives.
- Other Factors: Orthostatic hypotension, equipment attachments, or impaired mobility.
Prevention strategies are tailored to the patient’s risk level:
Low-Risk Patients:
- Orient patients to their surroundings.
- Ensure non-slip footwear and secure call bells, phones, and bed tables.
- Maintain beds in the lowest position with locked wheels and raised side rails.
- Conduct regular environmental rounds to eliminate hazards like wet floors.
Moderate-Risk Patients:
- Identify fall risk in medical records and during shift endorsements.
- Assist and supervise ambulation, conduct hourly safety checks, and offer regular bathroom assistance.
- Monitor for reversible causes like orthostatic hypotension or low blood sugar.
- Apply fall risk hand bands and educate patients and families.
High-Risk Patients:
- Implement all low and moderate interventions.
- Use high-risk stickers on charts and rooms, raise all side rails, and consider floor mattresses.
- Review medications and assess needs for physical therapy or 1:1 monitoring.
Dr. Varra Manikya Madhuri stressed that fall prevention must be balanced with patient mobilization to maintain strength and avoid complications of bed rest. It is interdisciplinary effort involving nurses, physicians, pharmacists, therapists, patients, and families. Customized care addressing each patient’s unique risk factors is essential to reducing fall incidents and enhancing recovery.
The Master Medics Program fosters global peer engagement through monthly webinars, virtual workshops, and cross-border collaborations, empowering nurses to enhance clinical competence and leadership. The session also addressed audience questions, such as
- Soda as a Clear Fluid: While technically a clear fluid, soda is discouraged due to bloating risks.
- Fasting Guidelines: Clear liquids are allowed up to 2 hours before surgery, except in cases like diabetic patients with delayed gastric emptying.
- Intraoperative Fluids: Fluid administration is optimized to avoid overload, with a maximum of ~100 ml/hour over 24 hours.
- Wound Healing: Abdominal wounds typically heal within 2–3 weeks, with sutures removed around day 7–10.
- Postoperative Complications: Increased heart rate may indicate inadequate pain relief, dehydration, bleeding, or sepsis, requiring rapid escalation.
Manipal Hospitals remains committed to advancing patient safety and care excellence through initiatives like the Master Medics Program. By sharing knowledge on fall prevention and ERAS, we aim to empower healthcare professionals and raise community awareness about best practices that save lives and improve outcomes. Stay engaged with our ongoing discussions and join us in building a safer, healthier future for all.
For more information about Manipal Hospitals’ initiatives, visit www.manipalhospitalsglobal.com.
