In the evolving landscape of cardiac surgery, enhanced recovery protocols are transforming how patients heal—making safety, efficiency, and long-term outcomes top priorities. Despite significant advances, challenges like surgical site infections (SSIs) and central line-associated bloodstream infections (CLABSIs) continue to complicate recovery. With hospitals under pressure to shorten stays and prevent readmissions, enhanced recovery after surgery (ERAS) protocols offer a roadmap to better care.
Systematic Evolution in Surgical Care
ERAS represents a paradigm shift in cardiac surgery, transitioning care from siloed interventions to a structured, multidisciplinary methodology that spans the entire perioperative period. Daniel Engelman, MD, of Baystate Medical Center, and Michael Grant, MD, of Johns Hopkins University, underscore the value of this transformation in fostering safety and efficiency. “ERAS is, at its core, the protocolization of key care elements across the entire perioperative arena which are evidenced to improve outcomes and avoid patient harm,” said Dr. Grant. What was once isolated to intraoperative 'fast track' strategies, first published by Richard Engelman, MD, 30 years ago1 has now evolved into a comprehensive model that integrates best practices across all phases of care.
Measurable Gains in Outcomes and Efficiency
Hospitals implementing ERAS protocols report significant improvements in patient recovery and institutional performance. “Patients are extubated sooner and mobilized earlier, often on the day of surgery, leading to reduced complications and shorter ICU and hospital stays,” said Dr. Engelman.
Beyond administrative metrics like reduced length of stay, ERAS has demonstrated decreases in postoperative complications, opioid usage, and healthcare resource u
tilization, while increasing patient satisfaction. These outcomes not only reflect enhanced care quality but also support broader goals in value-based healthcare.
“The most recognized shifts have been largely administrative, reducing mechanical ventilation time, ICU stays, and overall hospitalization,” said Dr. Grant. “But ERAS has also been shown to reduce postoperative complications and healthcare expenditures, while increasing satisfaction among both patients and providers.”
Targeting Infection Prevention
SSIs and CLABSIs remain persistent threats to recovery. Both experts emphasize structured prevention bundles as critical tools.
At Baystate, evidence-based practices, such as preoperative nasal decolonization, intraoperative glycemic control, and early central line removal, have been standardized through published order sets. “We’ve seen significant reductions in both SSI and CLABSI rates through bundled interventions and regular protocol compliance audits,” Dr. Engelman said. These efforts align with ERAS’s proactive approach to minimizing preventable harm.
Digital and Remote Monitoring
As ERAS protocols evolve, technology is playing an increasing role in optimizing postoperative care. According to Dr. Grant, many institutions are moving away from invasive monitoring and embracing digital tools, as data in this area continue to develop, and it remains a promising avenue for future research.
“We are increasingly gaining a better understanding of which patients benefit from less invasive monitoring, and which may be remotely monitored through phone applications or wearable devices,” he said. This shift supports earlier discharges while maintaining clinical oversight and enhances the ability to detect complications in real time, without the constraints of physical proximity.
Collaborative Culture: The Backbone of ERAS Success
A key ingredient in successful ERAS implementation is cohesive, multidisciplinary collaboration. Rather than relying on a single physician to direct care, ERAS protocols encourage distributed leadership and shared accountability. Dr. Grant emphasized the importance of regular communication, data-driven decision-making, feedback systems, and a culture of safety.
“The makeup of the team matters—including the multidisciplinary team of experts—as well as multiplatform leadership, with buy-in from the C-suite, at the service line level, and within medical directorship,” he said. “There needs to be a culture that allows all people along the service line to say something and have leadership support that culture.”
Dr. Engelman added, “Seamless teamwork and communication among all care providers is key; and having a dedicated ERAS coordinator to oversee protocol adherence, education, and data collection helps ensure continuity and accountability. This fosters a more resilient and responsive care environment, where every team member has a role in driving improvement.”
Learn more about how multidisciplinary teams aim to improve cardiac emergency outcomes.
Strategies that Accelerate Recovery
Several high-impact strategies underpin rapid recovery within ERAS programs. Dr. Engelman highlighted three: early mobilization, multimodal pain control, and nutritional optimization. “Encouraging mobility within hours of surgery not only lowers the risk of complications like thromboembolism and pneumonia, but also accelerates functional independence,” he explained.
Other strategies, such as opioid-sparing analgesia protocols and goal-directed fluid and hemodynamic management further enhance outcomes.
ERAS in a Value-Based Framework
With healthcare systems increasingly focused on cost control and outcomes, ERAS has become a valuable tool for enhancing efficiency and patient results.
Dr. Grant cited a 2019 study and a 2025 meta-analysis he co-authored showing ERAS outperforms traditional Fast Track cardiac surgery for reducing length of stay.
“When coupled with fewer complications and decreased readmissions, ERAS clearly translates to greater efficiency in care,” he said.
Looking Ahead: Personalization and Precision Medicine
Future directions for ERAS may involve blending protocolization with individualized care. Artificial intelligence, advanced analytics, and better risk stratification could allow teams to tailor protocols more precisely to each patient. “We will see less ‘blunt’ care element deployment and more precision-based medicine,” said Dr. Grant. This evolution could particularly benefit high-risk patients or those with complex conditions.
ERAS: A Dynamic Framework for Continuous Improvement
Enhanced recovery after surgery is redefining the future of cardiac surgery—not just in how care is delivered, but in how teams collaborate, how data are used, and how patients experience healing.
“ERAS should be considered more of a methodology and less as a protocol to be applied,” said Dr. Grant. “Its strength lies in its adaptability, grounded in evidence but constantly evolving.
As care teams embrace this model, enhanced recovery will continue to shape safer and faster patient care and recovery.
1. Engelman RM, Rousou JA, Flack JE, III, et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg. 1994;58(6):1742-1746.