SUSP Surgeon call February 26, 2014 Enhanced Recovery (ERAS) SUSP Surgeon call February 26, 2014

What is ERAS? First proposed by Dr. Henrik Kehlet, British Anesthesiologist Multimodal approach to control postoperative pathophysiology and rehabilitation. Br. J. Anaesth. 1997;78:606-617. “The hypothesis that a combination of unimodal evidence based care interventions to enhance recovery will subsequently decrease need for hospitalization, convalescence and morbidity.” Kehlet H. Langenbecks Arch Surg (2011) 396:585–559 Supported by large body of evidence in virtually every field from vascular to bariatrics to Whipple to colorectal

Supporting DATA Dis Colon Rectum 2013 – Meta-analysis of 13 studies demonstrating significantly decreased LOS, complication rate, similar readmit and mortality Typically all studies demonstrate a 50 – 60% reduction in LOS Duke experience (abstract ASA 2011) Before/after design demonstrated significant reduction in LOS, surgical site infection, urinary tract infection, hypotension requiring treatment Mayo experience (Lovely J, et al. Br J Surg. 2011;99:120-126.) Before/after design demonstrated 44% of patients discharged on POD 2, opiod requirements less without increased pain scores, complication rate similar, hospital costs were reduced by an average of $1,039/pt

Goal of ERAS Implement a standardized, patient centered protocol Integrate the pre-operative, intra-operative, post-operative and post-discharges phases of care to reduce LOS Improve patient experience and satisfaction and decrease variability

Basic Principles of ERAS Enhanced Recovery is a multidisciplinary and collaborative approach focusing on: -Patient education and participation -Optimization of perioperative nutrition -Standardization of perioperative anesthetic plan to minimize narcotics, intravenous fluids and post operative nausea and vomiting -Stress relief -Early mobilization and oral intake

Main shifts in mentality Pain management Goal is to diminish narcotic intake Fluid management Goal is to avoid volume overload – bowel edema Activity Goal is to induce early mobility and get the bowels moving!

Develop Clinical Specifics and Standardization of care Prep Inpatient and ICU unit PACU (pain control and mobilization) Post-op pain control plan

Financial Analysis

Example of ERAS Pathway at Johns Hopkins Hospital Preoperative Clinic Identify ERAS patients Bowel prep and CHG washclothes administered Targeted pre-operative multimodal (electronic, in person and paper) education to set expectations and engage patient in their care Anesthesia clinic appointment Introduce epidural anesthesia option Instruction about day of surgery Prep Area Operating Room Recovery Room Carbohydrate drink 2 hrs before surgery Celebrex, neurontin, tylenol, scopolamine patch pre-op Standard SSI and DVT prevention Epidural placed by APS Heplock placed Standard Intra-op TIVA by dedicated team of anesthesia providers Goal directed IV hydration to minimize fluid overload Early mobilization in recovery room Post-operative Standard post-operative ordersets All patients (with and without epidurals) followed by APS with standard practice and maximal non-narcotic pain regimen Coordinated DC planning by case manager PAL line f/u calls

Monthly reports and feedback to optimize implementation ERAS Evaluation Audit of processes (pain regimen, fluid in OR and post-op, education, mobility, diet etc.) Length of Stay Pain scores post-operative HCAPS 30 day Morbidity Readmission Monthly reports and feedback to optimize implementation

Our Model Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate Reducing Surgical Site Infections Emerging Evidence Local Opportunities to Improve Collaborative learning First round notes: Add to the ‘reducing SSIs’ block “Emerging evidence, local opportunities to improve, collaborative learning NOTE: emphasize that we are coupling technical and adaptive work Think about color coding pieces (should Trip & CUSP be the same) Technical Work Adaptive Work

Discussion