Clinical Topics & News

Improving Veteran Adherence to Preadmission ERAS Protocol: Decreasing Avoidable Surgical Cancellations and Post-Operative Length of Stay (LOS)



Improve veteran adherence of preadmission enhanced recovery after surgery (ERAS) protocol.


NMVAHCS implemented the multidisciplinary Enhanced Recovery After Surgery (ERAS) protocol in 2018 to reduce postoperative morbidity and LOS utilizing evidence-based practice. Perioperative, intraoperative and postoperative practices were adopted, and well adhered. However, preadmission preparedness, the veteran’s responsibility, lacked adherence. Although detailed verbal and written instructions were provided, improvements were necessary. Patient related issues (PRI) regarding anticoagulation, drivers, anesthesia preop, COVID testing, and preparation often led to surgical cancellations.


ANNIE, an approved mobile application (app) utilizing Short Message Service (SMS) texts was identified to engage veterans. After facility and Office of Connected Care approval, an automated program was designed to text veteran’s preadmission instructions. Messages include 1-way reminders and 2-way messages providing automated instructions based on response. Veteran’s consent and enroll in the app 1 week prior to surgery and receive daily reminders for prehabilitation: daily exercise, arranging driver, and refraining from smoking, alcohol, illicit and herbal medications. Two-way messages verify anesthesia pre-op appointment and anticoagulation status. Reply messages provide information for scheduling or instructions regarding anticoagulation. Texts verify receipt and understanding of bowel preparation medications, COVID testing, “clears” diet, and assess for COVID symptoms. The day prior to admission, time sensitive reminders alert the veteran to each step of the Nichol’s preparation and carbohydrate drink consumption. Messages continue post-operatively assessing status, encouraging activity and pulmonary toilet. Messages also verify discharge education, receipt of stoma supplies, and surgical follow-up appointment.


Prior to ERAS the average LOS was 11 days, which was reduced to 9 days after initial protocol implementation. Veterans enrolled in the app averaged a LOS of 7 days: a cost savings of $31,865.00 per veteran and increased bed availability for other veterans awaiting surgery. In FY19, 69 avoidable PRI led to surgical cancellations. Cancellations decrease access to care and maintain avoidable facility costs averaging $30,270.00 per case. ERAS and enrollment in ANNIE decreased cancellations by 62% (26 cases) in FY20 and 70% (21 cases) in FY21.


Engaging veterans with SMS messages improves preadmission ERAS adherence: improving outcomes for the veteran and facility.

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