Enhanced Recovery After Surgery (ERAS) for Elective Colorectal Surgery at Vancouver General Hospital Quality Forum 2015 Good afternoon. My name is Andrea Bisaillon, Director for Surgery and co-presenting with me is Tracey Hong, a Quality and Patient Safety coordinator. Together we want to share with you our organization’s journey to improving patient outcomes through the implementation of the Enhanced Recovery After Surgery (ERAS) protocol for patient’s undergoing elective colorectal surgery at Vancouver General Hospital.

Disclosure Statement We do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.

Our Site The implementation of the Enhanced Recovery after surgery project was undertaken at Vancouver General Hospital, a tertiary/quaternary academic centre with >500 beds. VGH has been a member of NSQIP since May 2011. The benefit of being a NSQIP member is the ability to look at your outcomes (morbidity and mortality) and compare it to other like sites. It was through this process that we identified that we had a problem with the colorectal patient population.

Background The risk-adjusted reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) demonstrated that patients at Vancouver General Hospital undergoing colorectal surgery had a high odds ratio of postoperative morbidity (1.49). Odds ratio >1.0 indicates hospital is performing worse than expected Morbidity impacts patients safety and experience, increases length of stay and health care costs.

True North Goals As an organization, we are guided by our True North Goals. Analysis of the NSQIP data for the colorectal patient population highlighted to us that we were not achieving the best care for our patients and we needed to take action..

Enhanced Recovery After Surgery Key Components Active Patient Involvement Pre-operative Intra-operative Post-operative Pre-admission counselling Active warming Early oral nutrition Early discharge planning Use of multi-modal pain management Early ambulation Reduced fasting duration Surgical techniques Early catheter removal Carbohydrate loading Avoidance of prophylactic NG tubes & drains Use of chewing gum No/selective bowel prep Defined discharge criteria Venous thromboembolism prophylaxis Use of multi-modal anti-emetic prophylaxis Antibiotic prophylaxis Use of goal directed peri-operative fluid therapy Pre-warming Audit of compliance & outcomes Enhanced Recovery After Surgery is a multimodal, evidence based perioperative care pathway. It has been used in Europe for more than 10 years, and has been validated to achieve early recovery after major surgeries by maintaining preoperative organ function and reducing the profound stress response following surgery. Key Points: Active Patient Involvement Involvement of the whole care team throughout the pt journey Auditing the compliance & patient outcomes Whole Team Involvement

Methods A multidisciplinary team (anesthesiologists, surgeons, frontline staff, organizational leaders and quality improvement staff) was formed in February 2013. Goal: To decrease the morbidity rate for general surgery patients undergoing elective colorectal surgery at Vancouver General Hospital by 50 % by November 2014. Implementation: The ERAS protocol was implemented in two phases.

Implementation Phase 1 February-October 2013 June 2013-Ongoing Phase 2 Provided ongoing education for surgical staff on the ERAS protocol. Developed ERAS documents: Standardized order sets. Clinical pathway & kardex. Patient teaching booklet. Poster highlighting changes in practice. Automation of ERAS on OR Slate. Implemented intra-operative components by a core group of anesthesiologists. Audited compliance with intra-operative components. Measured patient outcomes in post- anesthesia care unit (PACU). Phase 2 November 2013-Ongoing Implemented pre-operative and post-operative components. Audited compliance with all ERAS components. Measured patient outcomes within 30 days after surgery on 100% of ERAS cases. Key Points: Identify unit champions Continual engagement with stakeholders as well as patients and families PDSA cycles on each phase of work Reach out to others who have already gone there and learn from them Through the process of developing the patient teaching booklet, we sought out individual pt’s to trial it on and sought their input. We also include the pt in our audit process ongoing. Some of the feedback has been: “ The ERAS patient teaching booklet was good information ; I really knew what to expect” ….patient “I found the booklet very, very useful and I read it several times; I noticed things that I missed with the first reading.  I am pretty much implementing all the things …both before surgery and now that I have had my surgery!” ….patient

ERAS Audit Summary for November 2014 (n=18) 80% A snapshot of December compliance. Pink is the pre-op components, Blue is iintra-op and green is post-op components, The goal is to achieve minimized 80% of compliance Pre-op The compliance of pre-op visit and use of SAGE wipes the nite before OR and morning of OR were 100%. 1/11 pt did not has the CHO drink, even the ERAS was completed. Reasons not noted in audit form Teaching booklet was only 44.4% , all time low, 5 cases were given in PAC, 1 pt was d/c already and 1 pt did not remember. Intra-op VTE prophylaxis: 90% highest rate since Feb 2014. Normathermia 100% Prophylaxis abx within 60min has been 100% since Sept (4 months in a row) Abx redosing: the denominator varied every month, 2 cases in Dec, all got the redosing. 4 cases in Nov, 1 case did not get the redosing, as the denominator was small, the rate dropped to 75%. The length of OR for the Nov case was 4hr. 7min. Oct had 6 cases longer than 4 hr, with 3 cases got redoing (4h10m, 4h 15m & 4hr 57m) The results for PONV prophylaxis, opoid sparing and GDFT are still pending. Post-op Overall improvement Cases with both PPO and absence of NV after 48hr up were 100% for the first time! Well done!! And strategies for improvement ? First walk: 91-100% consistently for Oct-Dec Absence of NV: around 50-59 % for Oct-Dec FF: Dec 54.5%, Nov 47.1% and Oct 75%. DAT: Dec 27.3%, Nov 6.3.% and Oct 25% Pre-operative Intra-operative Post-operative

Components sustained >80% compliance Pre-operative components: Pre-admission counselling Use of Chlorhexidine wipes Antibiotic prophylaxis within 60 minutes of skin cut Intra-operative components: Normothermia (36-38ºC) Use of multi-modal anti-emetic prophylaxis Post-operative components: Gum chewing Tolerated high protein drink (Boost) Here are the components that met and sustained our >80% compliance goal. E.g. Prophylaxis antibiotics given within 60 minutes of surgery: Achieved 100% for the past 4 months. Normothermia (36-38 º C) achieved at end of surgery: Achieved 88-100% since implementation in July 2013

Areas of Opportunity Use of goal directed fluid therapy Early mobilization Appropriate use of anti-emetics post-operatively Appropriate removal of urinary catheter Advancement of the patient diet For those areas that need improvement, we have modified our process based on the team feedback. For example, a protocol for the goal directed fluid management is readily available for all anesthesiologists to review when they are assigned to the ERAS cases. Ongoing education re: appropriate use of anti-emetics and early mobilization was provided. The unit Champions had developed a Patient Checklist that has facilitated auditing of the components and has been received positively by the patients. Delegation of auditing back to unit champions has lead to increased compliance with the post-operative components.

% of Components with Compliance > 80% (n=21) Components with compliance > 80% started to trending up.

Aggregation of Marginal Gains to Provide Large Benefit From “The Slight Edge” by Jeff Olsen

Aggregation of Marginal Gains to Provide Large Benefit SUCCESS Discharge Post-operative Management Recovery Room Intraoperative Management Preoperative counselling Preoperative preparation Admission FAILURE From “The Slight Edge” by Jeff Olsen

General Surgery Elective Colorectal Surgery NSQIP Non Risk Adjusted Data Pre ERAS Implementation Post ERAS July 2011-June 2013 n=101 Nov 2013-Aug 2014 n=174 % Change Overall Morbidity 37.6% 21%  44.1% Median Length of Stay (day) 7 5  28.6%

Lessons Learned The Power of Real Time Auditing It Takes Time to Change Culture Communication is Vital Value of Patient Partnerships As ERAS involves all in pre-op, intra-op and post-op who care for the patient. It is important to involve the key stakeholders in all stages of planning in order to ensure project success and sustainment. Educate the staff regarding the evidence of the ERAS protocol, the experience in other countries and other facilities in BC and Canada, and the benefits beyond helping the patients, such as reduce workload and job satisfaction. Engage the senior leaders to provide support and remove barriers. Actively involve the clinical leaders for support and collaboration. Communication is vital. Use both formal and informal ways of communication, such as email, meeting or 2-min conversation in the hallway. Disseminate findings to all staff frequently. And continually gather feedback to modify the processes. Educate and provide staff with the tools to be actively involved in the process.

Sustainment Plan Transition of auditing back to unit champions Revise documents (PPO, Pathway, etc.) Full implementation of the Patient Checklist Continue ongoing education of staff Continue to engage patients and family Continue to audit 100% of ERAS patients Disseminate audit results to Steering Committee and stakeholders monthly Celebrate the team’s accomplishments These are our strategies to sustain the project. Key Points: Continue 100% auditing, and ongoing feedback to the teams, which we have been doing for the past 2 weeks.

Acknowledgments VGH Perioperative Teams VCH NSQIP Team ERAS Patients and Families ERAS Steering Committee Finally, I would like to share with you a quote from Dr. Garth Warnock, one of our physician leads: “ERAS implementation is bringing together some of the most significant changes to improve recovery after colorectal surgery that I have observed in our hospital for years. The moderate to high evidence base for ERAS interventions translates science into care and makes a tremendous base for teaching our students, residents, nurses and colleagues. Patients and families are more empowered when they enter a pathway for enhanced recovery and even when deviating from the plan they are still emboldened to seek quicker return to their homes. I think we have a great opportunity to improve our NSQIP outcomes in colorectal surgery at our hospital and look forward to seeing improvements in this data in the post-ERAS era. It’s exciting to be part of such an important advance in the care of the surgical patient.” Thank You and we will now open it to questions.

Contact Information Andrea Bisaillon, RN BscN Operations Director - Surgical Services andrea.bisaillon@vch.ca Tracey Hong, RN BscN Quality and Patient Safety Coordinator tracey.hong@vch.ca