The Use of an Enhanced Recovery Bundle in Surgical Spine Patients to Reduce Opioid Requirements and Improve Patient Comfort

The number and cost of spine surgeries have increased over the past decade. Despite the evidence indicating that Enhanced Recovery After Surgery (ERAS) interventions decrease the stress response to surgery and improve patient outcomes, perioperative interventions for spine surgeries continue to vary across facilities nationwide. A multidisciplinary, evidence-based quality improvement (QI) project was implemented in a community-based acute care facility to address an identified gap in best practice. The Agency for Healthcare Research and Quality has determined ERAS protocols are the gold standard in perioperative care. Preexisting ERAS interventions did exist at the facility, but a complete ERAS protocol was not being utilized. Spine patients were receiving preoperative education, a consult with the pre-anesthesia testing clinic, a balanced anesthetic technique, antibiotics, and chlorhexidine gluconate wipes. A preoperative oral carbohydrate drink, and oral acetaminophen and gabapentin were added to make a complete ERAS bundle. This QI project found a statistically significant reduction in total morphine milligram equivalents required in the post-anesthesia recovery unit (PACU). Patients had improved comfort, which was not statistically significant in the PACU, with reduced need for postoperative nausea and vomiting medications. The length of stay in the PACU increased slightly but was not statistically significant. This QI ERAS bundle is evidence that the use of multimodal analgesia and oral carbohydrate combined with preexisting ERAS spine interventions reduce patients’ total amount of narcotics and improve their overall comfort. Individually, these interventions do not appear impactful, but patient outcomes are positively impacted when bundled.