Implementation of an Enhanced Recovery Program (ERP) for Lower Extremity Bypass Adam W. Beck, M.D. Associate Professor of Surgery Division of Vascular Surgery and Endovascular Therapy University of Alabama at Birmingham June 12th, 2019

No relevant Disclosures

ERAS is not a new concept…1995 Dr. Henrik Kehlet MD, PhD Considered the founder of ERAS

How does eras work? Patients can drink up to 2hrs prior to surgery Regular diet night of surgery Mobilize Day of Surgery Minimize opioid use Minimize Intravenous Fluids Only get 1 set of labs

ERAS is not a new concept…1995 8 patients Laparoscopic approach Epidural analgesia Early oral nutrition Early mobilization 6 patients went home POD2 2 patients went home POD3 Average LOS after a colectomy at the time was 5-10 days Lancet

What is Eras? Reduce length of stay by up to 30-50%. Reduce post-operative complications up to 50%. Save up to $6,000 per patient for hospital stay. Significantly reduces or eliminates racial disparities in LOS, readmissions, and POCs. Reduces opioid use. Strict adherence associated with reduction in 5 year mortality by 42% in cancer patients.

How does eras work? Themes of ERAS “Perioperative care, not the actual operation, can dictate outcomes” Minimize stress and improve response to stress Patient centered approach Evidence based, “best practice” medicine Relies on multidisciplinary team approach

ErP vascular? Vascular surgery patients often: Multiple medical comorbidities Lower socioeconomic/educational level High risk for perioperative complications High risk for SSI High risk for unplanned readmissions Lower extremity bypass patients perhaps highest risk...good population for ERP? Excluded patients undergoing open surgical inflow procedures as well as trauma patients.

Implementation UAB Care team Care pathway transformation Many previous ERAS/ERP programs with various disciplines (use your institutional knowledge) Our team: vascular surgeons, anesthesiologists, rehabilitation physicians, physical therapists, wound care specialists, dieticians, pharmacists, pain management specialists, advanced practice providers, and nursing staff Physician champions: Vascular surgeon & Anesthesiologist Administrative support Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Lower Extremity Bypass ERP Goals Create and implement the ERP pathways for our lower extremity bypass population. Identify patients who undergo Lower Extremity Bypass and track goal project outcomes of: At least 80% use of ERP in eligible LEB patients Reduction of the observed to expected LOS index Reduction in percentage of 30-day all cause readmission Reduction in SSI rate Reduction of variable cost per case. It’s difficult to improve quality if we don’t define what quality is. In order to do that we must measure our outcomes, benchmark our outcomes and compare to other surgeons, and we must minimize variation in the way we do things.

UAB ERAS pathways Existing UAB ERAS pathways are based on ERAS society guidelines 2014- Colorectal 2015- Surgical Oncology 2016- Gynecology Oncology 2018- Vascular

Implementation Transformational process! Plan-Do-Check-Adjust (PDCA) methodology Requires collaboration of teammates Repeated re-evaluation of initiatives: Redesign Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

ERAS Implementation Leading Practice Guidelines Literature Review Leading Practice Guidelines Physician Champions Implementation Meetings Multidisciplinary Teams Pre-operative Intra-operative Post-operative ERAS Vascular ERAS Sustainment meetings

Preoperative phase Emphasis on patient education Early mobility Post-operative pain control Planned length of hospital stay

Smoking Cessation Protocol Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Fascia Iliaca/Sciatic Block Perioperative phase Chlorhexidine showers Preoperative hair clipping Non-opioid analgesia in preoperative holding area Placement of fascia iliaca block by Inpatient Pain Service (IPS) Fascia Iliaca/Sciatic Block Anesthesia of the anterior and medial thigh (femoral nerve) as well as the anterolateral thigh (lateral femoral cutaneous nerve) Able to be placed in patients receiving antiplatelet therapy Avoids use of an indwelling catheter which might limit early mobility

Intraoperative phase Anesthesiologists Goal directed fluid management Maintain normothermia Non-opioid pain adjuncts Lung protective ventilation Post-operative nausea prophylaxis Surgeons Skin closure protocol Separate instrument set for skin closure Changing of gowns/gloves, and changing of the overhead operative light handles Two wound closure methods Interrupted vicryl sutures with staples on the skin and a sterile occlusive dressing (OPSITE Post op, Smith & Nephew, London, UK) or Interrupted vicryl sutures with subcuticular moncryl and skin glue.

Postoperative phase Early mobilization Diet Tobacco cessation POD0- Edge of bed POD1- Out of bed, daily mobility milestones set by PT Diet Regular diet immediately after arrival to surgical floor Tobacco cessation Consult placed to UAB Tobacco Cessation team who visit the patient for bedside counseling typically on their second postoperative day

ERAS UAB Powerplan

Demographics Smoking Cessation Clinic Protocol: Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Process Metric Assessment Manual process audit Process metrics audited and measured: scheduling of the surgery as ERP completion of patient education diabetes patient optimization process multimodal medications regional block tobacco cessation process early diet early mobility. Automated monthly using Vizient (UHC) quality data Readmission, LOS, LOS index, SSI, %ERP enrolled, variable cost Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Team Compliance Smoking Cessation Clinic Protocol: Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Central Goals: Results to Date Baseline ERP P-value Eligible patients 189 57 ERAS % NA 69% Average LOS 11.1 ± 10.1 8.3 ± 8.4 0.056 Postop LOS 8.0 ± 7.5 6.1 ± 6.0 0.089 Observed:Expected LOS 1.8 ± 1.4 1.3 ± 0.7 <0.001 SSI % 5.8% 3.5% 0.499 Readmission % 21.6% 7.0% 0.012 Variable Cost/Case 18,777 ± 19,118 13,207 ± 9,930 0.004 Total Cost/Case 40,328 ± 37,820 29,865 ± 22,110 0.010 SSI Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: Follow up visit No Follow up Visit Current smoking status identified at intake Did the patient join any cessation programs? Have they used medication? If the patient did not quit, offer medication again and discuss importance again If successfully quit, make sure to discuss and praise success Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessation Acknowledge that quitting is hard, do not trivialize Explain why tobacco is addicting, how medication can help and how it works Help to choose a low stress quit date Recommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) Medication First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) Start Wellbutrin/NRT 7 days prior quit day Chantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date Discuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimen Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Length of Stay: Results to Date P=0.056 P=0.089

Cost per case: Results to Date

Successes Summary 68 patients have undergone through the ERP LEB pathway in the 10 months post implementation Improvement in observed to expected LOS: both total and post-operative Reduction in 30-day all cause readmission Reduction of surgical site infections Decrease of average cost per case

Ongoing Challenges Poor compliance in certain metrics PACT visit Celebrex administration (Anesthesia) Day of surgery mobility Ordering of Pre-OP PowerPlan Proper documentation of metrics (mobility) Long term maintenance of reached goals Patient participation (crucial to success)

Thank You