JACKSONVILLE — Just two hours before Jessica Arnold delivered her third child in a planned cesarean on Nov. 16, she finished off a 20-ounce bottle of Gatorade.
The fact that the staff at Passavant Area Hospital allowed and actually encouraged her to drink that close to surgery surprised her, but paved the way for what she later described as her easiest delivery.
"It made me feel a little bit more normal," Arnold, 40-year-old Jacksonville resident, told The State Journal-Register last week.
What used to be normal for most surgical patients — rigid in-hospital practices dealing with diet, pain-killing drugs and bed rest — is rapidly changing in Jacksonville, Springfield and across the country as part of a movement known as "enhanced recovery."
Based on a model developed in Europe in 2001, enhanced recovery is backed by research that says it makes patients feel better and actually promotes better results.
Enhanced-recovery programs relax rules that for decades have called for patients to refrain from drinking after midnight the day before a procedure. Instead, patients can enjoy moderate amounts of carbohydrate drinks up to two hours before a procedure without increasing the risk of aspiration during surgery.
After surgery, the programs allow patients to drink on their own, rather than receive IV fluids, and allow patients to resume normal diets only hours later rather than working their way up from liquid diets.
Rather than being told they won't have any pain after surgery and then given plenty of narcotics afterward to fulfill the promise, patients are told some post-operative pain is unavoidable.
They are given lighter pain-relief medicines, such as acetaminophen (Tylenol) or ibuprofen (Advil) afterward, or receive treatments such as nerve blocks.
All of those steps, proponents of enhanced recovery say, interrupt what can be a cascade of side effects, including the nausea and constipation often associated with narcotics.
Patients are exposed to lesser amounts of opioids overall — a positive trend amid a nationwide epidemic of overuse and abuse of legal and illegal opioids. But curbing the epidemic isn't why experts say the use of enhanced recovery is growing.
Experts add that patients tend to experience fewer complications because they are better-hydrated and have better blood flow when they are walking instead of lying in bed.
Along with fewer complications and shorter hospital stays, enhanced recovery usually results in patients reporting better pain control and more satisfaction with their hospital experience, according to Josh Newman, a nurse anesthetist and Passavant's anesthesia department manager.
"This is the best process that we could use for patients," Newman said.
First begun in 2016 at Passavant, enhanced-recovery practices now are used with hundreds of patients every year at the 131-bed Memorial Health System hospital.
Though not every Passavant patient may qualify, many who may benefit include those undergoing bowel procedures, mastectomies, hysterectomies, C-sections, and knee and shoulder replacements.
Randall Moore was involved with the first discussions about implementing enhanced recovery at Passavant while on staff there before he became chief executive officer of the American Association of Nurse Anesthetists in Park Ridge, Illinois.
Enhanced recovery amounts to "a seismic shift in surgical care and anesthesia care," he said.
Most U.S. hospitals are still in the early stages of adopting enhanced-recovery programs because the programs require involvement of so many different types of medical and health professionals who handle care before, during and after surgery, Moore said.
"It's very cool that Passavant Hospital was an early adopter of this," he said.
There was a big increase in hospitals adopting enhanced-recovery practices in 2017, Newman said.
"It's starting to become the standard of care," he said.
The restrictive rules often still in use in America are based on an "abundance of caution" and, in some cases, lack of clinical testing to prove that a more relaxed approach can yield better results, Newman said.
For example, fasting weakens the body, and so well-hydrated patients report less nausea from anesthesia and pain medication, he said.
Remaining in bed too long can lead to bed sores, infections at the site of surgery, pneumonia and blood clots, he said. Those complications can be avoided by encouraging patients to move around within hours of surgery.
Fewer complications mean less pain, and Newman said most patients experience less pain overall simply by being mobile sooner.
"One of the most influential interventions we can do is transitioning patients back to the normal activities of daily living," he said. "This means walking frequently, only using beds for sleeping, and resuming eating and drinking as fast as the patient can tolerate."
After putting enhanced recovery into place, Passavant documented a reduction of 16 percent in the time that knee-replacement patients remained in the hospital. The rate of nausea and vomiting for those patients dropped to 14 percent from 55 percent.
Lisa Buchanan, a registered nurse who is coordinator of enhanced recovery at Passavant, said many patients are ecstatic when they learn they can have fluids -- but not have dairy products -- up to a few hours before their elective procedures.
Because fewer patients are receiving opioid medications after surgery, they feel steadier on their feet and more willing to move around, she said.
Enhanced recovery has saved money for Passavant through shorter hospital stays, though the savings hasn't been tallied, Newman said.
At Memorial Medical Center in Springfield, enhanced recovery first was put into place in early 2017 for patients undergoing hysterectomies during robot-assisted surgeries.
Since then, the program has been expanded to include a majority of patients undergoing all types of inpatient and outpatient surgery at the 500-bed hospital, according to Jennifer Harris, administrator of perioperative services.
Enhanced-recovery practices are used for patients undergoing procedures that include gynecologic cancer surgery, colorectal surgery, robotic prostatectomies, and hernia and bariatric surgery, Harris said.
Elements of enhanced recovery also are incorporated in the hospital's JointWorks joint-replacement program, she said.
Results haven't been studied for all of the Memorial patients, but those undergoing gynecologic oncology surgery and robotic hysterectomies reported reduced pain levels, were up and out of bed sooner and had shorter hospital stays without experiencing an increase in readmissions, Harris said.
Dr. Nora MacZura, a gynecologic oncologist at the Springfield Clinic Center for Women's Health, said she was surprised at how well the program worked at improving pain control for her surgical patients.
"In general, most patients did very well," MacZura said. "They say, 'I never realized I would feel this good after surgery.'"
Without calling it enhanced recovery, HSHS St. John's Hospital has provided "all the elements" for several years "to improve patient satisfaction and decrease hospital length of stay," hospital spokeswoman Erica Johnson said.
Alternative forms of pain control help to minimize the use of opioids and avoid the drugs' adverse effects, she said.
"Our care team starts by educating patients before surgery about the importance of nutrition, smoking cessation and exercise in their recovery," Johnson said. "We even discuss their current level of pain and expectations for their pain after surgery.
"Our care team also has been very focused on early mobilization because we know that if we are able to get our patients up and moving soon after surgery, they will recover faster so they can be discharged and return home."
Jessica Arnold, a part-time preschool aide, said the extra encouragement she received from Passavant's staff to move around after the birth of her daughter, Lucy, made her feel better than after the 2015 birth of her daughter Nora, who also was delivered by planned C-section at Passavant.
Arnold said her husband, Bryan Arnold, noticed that she started picking up her newborn sooner after Lucy's delivery than after Nora's birth.
Arnold said she was able to avoid heavier pain medications after Lucy's birth, though Percocet -- a combination of oxycodone and acetaminophen -- was offered.
"The pain never got so bad that I had to take something stronger," she said. "I definitely felt like I was more ready to go home."