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Seeing the Potential in Postsurgical Enhanced Recovery Protocols

New program improves patient satisfaction, while decreasing length of stay, risk of complications for gynecology patients

Innovations in Obstetrics & Gynecology - Spring 2018

Sherif El-Nashar, MD


Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center; Associate Professor, Obstetrics and Gynecology, Case Western Reserve University School of Medicine

In September 2017, University Hospitals Cleveland Medical Center implemented an enhanced recovery program in its gynecology department.

First described in the colorectal surgery specialty, enhanced recovery protocols help hospitals achieve better pain management and reduce the use of narcotics – a concern that is only growing in importance as the U.S. opioid epidemic continues.

“Enhanced recovery protocols have become widely accepted as a standard of care to help patients recover faster and with less pain after surgery,” says Sherif El-Nashar, MD, PhD, a female pelvic medicine and reconstructive surgery specialist in the Department of Obstetrics and Gynecology at UH Cleveland Medical Center and Associate Professor of Obstetrics and Gynecology at Case Western Reserve University School of Medicine.

Dr. El-Nashar joined UH in 2015. Together, he and department colleague Megan Billow, DO, Co-Director, Sexual Medicine and Vulvovaginal Health Program, UH Cleveland Medical Center and Assistant Professor of Obstetrics and Gynecology at the School of Medicine, worked to bring an enhanced recovery initiative to UH.

The goal of the enhanced recovery program is to help patients prepare for surgeries, reduce the risk of complications, improve pain management and decrease length of stay. Important components of the program include:

  • Educating the patient about what to expect before, during and after surgery
  • Allowing the patient to meet the care team and ask questions
  • Helping the patient stay hydrated and nourished after surgery
  • Following a careful pain management protocol 
  • Following protocols to avoid complications, such as blood clots 
  • Preparing patients for discharge and follow-up care

The team in charge of implementing the enhanced recovery program began meeting regularly nine months before putting the protocols in place. Success demanded careful coordination among a multidisciplinary team that included surgeons, anesthesiologists and nurses.

“From the first day of planning, we knew that successful implementation of the enhanced recovery program would require a lot of effort from everyone and that the main player in the implementation would be our great nursing staff – starting from preoperative preparation to the PACU, and most important, on the postoperative floor,” Dr. El-Nashar says. “Our electronic medical record team also played a significant role to add the new protocol to EMR.”
Input from nurses, residents and other physicians was also critical to the process, he says. “Their feedback led to material and constructive changes in the final protocol,” Dr. El-Nashar notes.

Lastly, the enhanced recovery team integrated the program’s protocols into the hospital’s EHR. As a part of the EHR, the program could quickly become a seamless part of the workflow for surgeons, anesthesiologists and surgical nurses.

Though the enhanced recovery program has not yet been in place for a full year, the length of stay for gynecologic surgery patients at UH is already declining. Many patients are ready to go home within a day or two of surgery, rather than staying multiple days.

Together, the changes in pain management protocols and the increased communication between physicians, nurses and patients have done a lot to increase patient satisfaction and decrease length of stay, Dr. El-Nashar says.

“In the 1960s and 1970s, patients would stay at the hospital for four or five days after a hysterectomy,” he says. “Now, they can go home the same day or the day after. That is a big change.”

While the initial results of the enhanced recovery program are promising, Dr. El-Nashar and his team are continuing research trials to evaluate the program’s impact on patient satisfaction and length of stay. UH awarded the program’s multidisciplinary team a $50,000 innovation grant to continue looking into the effects of enhanced recovery protocols.

Continuing research will help UH physicians better understand the benefits of enhanced recovery protocols and find ways to improve the program.

“This initiative fits in with the core values of UH: patient care, research and education,” Dr. El-Nashar explains. “We are doing all that we can to make sure the patient understands the process and has access to the best available care.”

In addition to care team preparation, educating patients has been a key part of ensuring the program’s success, Dr. El-Nashar notes. “Patient education starts in the office setting,” he says.


Contact Dr. El-Nashar at