Enhanced Recovery after Surgery (ERAS): A new era of patient care Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC 11/20/2017

Conflicts of Interest The presenter has no conflicts of interest to disclose 11/20/2017

Objectives Upon completion of this session participants will be able to Share with healthcare teams the preoperative, intraoperative, and postoperative ERAS elements Verbalize the stakeholders / key roles needed to create a team for ERAS implementation State patient outcome measures, including the specific hospital reimbursement programs, potentially improved by consistent compliance with the ERAS elements 11/20/2017

What is Enhanced Recovery after Surgery (ERAS)? Evidence based, clinical best practices for surgical patient care acknowledged by multiple healthcare professional organizations & associations packaged as an implementation bundle Promotion of enhanced recovery protocols driven by Transition from acute care model of healthcare delivery to population health model Healthcare reimbursement Standardization of care Transition from acute care to population health – shift from clearance to optimization Healthcare reimbursement – insurers Standardization of care – evaluating processes 11/20/2017

Colorectal Enhanced Recovery (ERAS Society, 2014) 11/20/2017

Enhanced Recovery Phases / Elements Preoperative Patient education Patient optimization Carb loading & elimination of NPO Intraoperative Nausea / vomiting prophylaxis Opioid sparing, multi modal analgesia Intentional fluid use Postoperative Early food & exercise Multi modal analgesia Judicious IV fluid use Defined discharge criteria Patient teaching through progress audits (Marosky Thacker, 2016) 11/20/2017

Patient Centered Goals Elements Principles Patient education, specialty teaching Carbohydrate loading & elimination of NPO Multimodal analgesia Goal directed IV fluid therapy Perioperative nausea / vomiting prophylaxis Patient progress audits Patient engagement Euglycemic Sleeping, comfort, increasing mobility Euvolemic Eating / drinking, GI motility Patient satisfaction Evaluate your patient! Always wonder: Are the things we do or don’t do for this patient the right thing for this patient at this time? Consider each point of care from diagnosis to recovery Implement the evidence for best patient outcomes (Marosky Thacker, 2016) 11/20/2017

Program Planning Steps Define the population Identify the existing care processes / surgical care pathways / order sets Create process maps with the multi-disciplinary team Current state and future state Design or update the surgical care pathways / order sets 11/20/2017

Define the Population / Create the Team Anesthesia Nursing Pharmacy Advanced Practice Providers Quality / Process Improvement Physical Therapy Dietitians Educators Colorectal Surgery Head & Neck Surgery Breast Surgery Liver Surgery Gynecologic Surgery Neuro Surgery Ortho Surgery Urology Surgery Thoracic Surgery Spine Surgery (Gottumukkala, 2016) 11/20/2017

Workgroups and Structure: Example 1 Enhanced Recovery Steering Team Preoperative workgroup Implementing carb loading & elimination of NPO Patient education Intraoperative workgroup Goal Directed Fluid Therapy 11/20/2017

Workgroups and Structure: Example 2 Facility leadership Representatives from the multidisciplinary team Quality Statisticians Advanced Practice Providers Clinical Informatics Physical Therapy Nursing staff Educators Dietitians Education Order Sets Implement-ation Outcomes / Research 11/20/2017

Successful Implementation Strategies The program should be vetted by a key group of influential, culturally skillful early adopters Identify operational leaders who are passionate and committed Executive leadership support of the project team & the project plan Consistent communication of project goals and progress Regular, open performance feedback of compliance with the program plan How can you link incentives to participation with the project plan? Executive leadership support is most crucial in the initiating period. Performance feedback should be respectfully shared in a predetermined manner. Use crucial conversation skills and keep the team’s eyes on the goal. Rewards and accountability should be given as it is earned. 11/20/2017

Evaluating Compliance with the Elements Evaluate your facility EMR for ability to audit documentation & patient compliance with elements Explain which elements of patient care (process measures) relate to specific principles of enhanced recovery (outcome measures) Create a tool for visual data management Refresh data at routine intervals and share the groups progress 11/20/2017

Patient Outcome Measures Decreasing length of stay Decreasing readmissions CMS Medicare Acute Inpatient PPS Readmissions Reduction Program (HRRP) Decreasing surgical site infections CMS Medicare Acute Inpatient PPS Hospital-Acquired Condition Reduction Program (HACRP) CMS Hospital Value-Based Purchasing Decreasing surgical complications 11/20/2017

How Does Enhanced Recovery Impact Population Health? (WebMD, 2016) 11/20/2017

Summary Enhanced recovery is Patient centered Collaborative Expansive by principles of patient management, rather than element specific Uniquely implemented for each healthcare system and the population served 11/20/2017

Resources for Healthcare Professionals ERAS® Society http://erassociety.org American Society for Enhanced Recovery http://enhancedrecovery.org/index.php Do not search using the phrase ERAS – this stands for Electronic Residency Application System There are numerous peer reviewed published articles on enhanced recovery. 11/20/2017

References Brady, K.M., & Delaney, C.P. (2015). Successful Implementation of an Enhanced Recovery Pathway: The nurse’s role. AORN Journal, 102(5), 470-480. Calhoun, J.D. (2016, April). ERAS Implementation and the Coordinator’s Role. The 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine. Symposium presented at the meeting of American Society for Enhanced Recovery, Washington, D.C. ERAS Society. (2014). [on-line]. Retrieved from http://erassociety.org Gottumukkala, V. (2016, April). Setting up an Enhanced Recovery Program Elements, Buy-in, Hurdles, and Conflict Resolution. The 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine. Symposium presented at the meeting of American Society for Enhanced Recovery, Washington, D.C. Marosky Thacker, J. (2016, April). Enhanced recovery principles and practice. The 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine. Symposium presented at the meeting of American Society for Enhanced Recovery, Washington, D.C. WebMD. (2016). Tips to Get Ready for Surgery [on-line]. Retrieved from http://www.webmd.com/healthy-aging/all-about-surgery-16/slideshow-surgery-prep 11/20/2017

Contact Information Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC Quality Improvement Consultant, System Perioperative Services Indiana University Health (317) 963-1344 – office hhohenberger@iuhealth.org 11/20/2017