Understanding and Adherence to Early Mobilization in ERAS After Cardiac Surgery: The Patient Blind Spot

Abstract

To the Editor,

Perioperative care has been revolutionized by the use of Enhanced Recovery After Surgery (ERAS) protocols. It involves incorporation of evidence-based strategies into patient care, to help in speeding up the recovery, minimize complications and shorten hospital stays¹. Early mobilization among these methods is regarded as a cornerstone of ERAS, especially after cardiac surgery. It plays role in improving various body functions, e.g., in boosting pulmonary function, reducing delirium, and decreasing the ventilation time². Despite all of these benefits, practice of mobilization protocols at the bedside is consistently very poor. It may be primarily due to a “patient blind spot” which is referred to as a persistent gap in understanding and adherence that arises when patient-level barriers are not addressed.

It has been seen that the early ambulation in patients is hindered by a number of physical and psychological barriers. The fear of harming the sternum, pain due to surgery, dizziness, the presence of lines and drains around the body, and a lack of clarity regarding safety or necessity discourages the patient from early movement. Another factor, in many centres, the main focus of ERAS programs is on staff training and protocol design and very insufficient attention is paid to the patient perspectives, readiness, and their confidence. As a result, early mobilization becomes very difficult and a task prescribed by clinicians rather than a collaborative recovery behaviour. A great variation in adherence rates to early mobilization across institutions is observed which is explained well by this patient blind spot, even though the protocols seem standardized³.

​For addressing this gap, integration of strategies that pay pivotal attention to patient’s perspective into ERAS pathways is required. Firstly, mobilization counselling preoperatively should be done which includes visual demonstrations or short educational sessions to the patient. It should be clearly communicated to the patient that healing is promoted by the movement and the surgical site is not endangered by this⁴. Secondly, if the personalized mobility goals are set at the bedside e.g., sitting out of the bed two times on day one after surgery; walking 20 meters by day two etc, it will help in keeping the patient motivated and will also allow the tracking of progress in real-time⁵. Third, the coordination between the pain management e.g., giving pain-relieving medications and physiotherapy sessions should be considered. It helps in ensuring the comfort of the patient in mobilizing effectively when analgesia is optimal⁶. The integration of these elements into postoperative care plans and ​quality improvement audits will make sure that the early mobilization is transformed from a staff-driven directive to a goal actively pursued by patients.

In summary, collaboration of both behavioural efforts and physiological intervention is required to ensure early mobilization in patients. Adherence is likely to improve if the patient’s blind spot is addressed properly through education and synchronized care, as a result, outcomes of cardiac surgery will improve.