St. David’s surgery recovery program reduces opioids, hospital stay

Marty Martinez, 52, loves golf. He plays at least 36 holes a week, usually Saturday and Sunday, sometimes Friday. He calls it “competitive golf,” a group of friends regularly playing for bragging rights.

Yet, when his hip pain got really bad, what he calls a 12 out of 10 on the pain scale, he finally agreed to do something about it and have hip replacement surgery April 12.

“I didn’t realize how bad it was,” he says of the pain. After the surgery, his pain was reduced to no more than a 2 out of 10 during recovery, he says, and people commented about how he looked so pain-free or so happy.

He had the surgery on a Thursday morning, went home the next day and didn’t need any pain medication by that Saturday morning.

Martinez took advantage of the new pain management program at St. David’s Medical Center called the Enhanced Surgical Recovery program. Martinez also works there as the facilities engineering operations manager,

Marty Martinez, the facilities engineering operations manager at St. David’s Medical Center, had a hip replacement this spring using new pain management techniques. St. David’s Health Care

“Our hospital is one of a handful of sites that piloted that program,” says Dr. Erick Allen, an anesthesiologist at St. David’s Medical Center, but it’s based on protocols and techniques that have been used in Europe, Allen says.

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The program, which began two years ago at St. David’s, has a few different components both before and after surgery. It is being used for gynecologic oncology and colorectal procedures as well as orthopedic operations such as on spines, hips, knees.

First staff works on educating the patient about being a willing partner in their own recovery and care to make sure they have buy-in and that the patient understands the procedure and the post-surgical care.

Then instead of fasting the morning of the surgery, patients are given clear liquids like apple juice, some sports drinks or even black coffee to drink up to two hours before the surgery. This makes sure they are not dehydrated. “It’s been demonstrated with clear liquids that those clear liquids are emptied from stomach within two hours,” Allen says. There isn’t the fear of these liquids getting into the lungs during anesthesia.

Doctors also attach patients to a fluid monitor to make sure they are not operating on a dehydrated or overhydrated patient.

Not fasting and better management of fluids means that patients are starting their recovery with energy reserves and better wound healing capabilities, less anxiety, better insulin management, Allen says.

Doctors also use many different medications for pain control instead of just opioids. Some of those medications are given before the surgery. They are using nonsteroidals like Motrin or Advil, as well as Tylenol and low-dose steroids. They also use gabapentinoids like Lyrica, as well as a ketamine lidocaine infusion. They also decrease the amount of gas anesthesia given and decrease the use of narcotics after the surgery.

They also pay attention to the pain at the incision point by doing using a nerve block or a pain medication pump while in the hospital.

Allen also says there has been an organized effort to reduce the strength of the narcotics used as well as the amount of refills allowed. It has been a challenge getting some patients who have been on narcotics for a long time before surgery comfortable post-surgery, but even those patients can use this protocol, Allen says.

The final key is that patients are up and moving and out of bed much sooner than before to avoid pneumonia, blood clots and other complications.

The feed-back has been “overwhelmingly positive,” Allen says. A big factor is shortening the length of stay. “If you can get people home quicker, in their own bed, it’s a huge satisfier. They can eat what they want on their schedule, with fewer drains and tubes.”

People, he says, are starting to request this technique from their surgeons.

“Five years from now this is going to be the expectations that patients have,” Allen says. “This is truly a better mousetrap. Patients are happier, there are few complications and it’s cheaper.”

The cost savings come in shortening the length of stay in the hospital for patients. Some additional resources, like help with patient education, more infusion pumps, more mixing of medications, and more help getting people out of bed, do happen, but the shorten stay in the hospital offsets those additional expenses.

Great Britain, Allen says, decided to go to this standard of care 10 to 15 years ago. “I do think we’re a little slow to get to this,” he says. “It will be the standard.”

All of the St. David’s HealthCare hospitals are moving to this standard if they haven’t already, Allen says.

“It was really impressive,” Martinez says. Within two weeks, he was putting again, and by three weeks. he was back on the golf course. “You can’t believe it.”