Enhanced Recovery: Train-the-Trainer ERAS Collaborative Enhanced Recovery: Train-the-Trainer Feb 2015 Garth Vatkin, RN, MHA – ERAS Collaborative Nursing Co-Chair Nancy Garrett-Petts, RN – Clinical Nurse Educator, Royal Inland Hospital Role considerations vs. responsibilities because practice may very between sites depending on processes for each department as selected by your team. Disclosures = nil

ERAS® stands for Enhanced Recovery After Surgery     ERAS® stands for Enhanced Recovery After Surgery. ERAS is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. It is teamwork in action – with the patient at the centre! It helps reduce postoperative complications by up to 50% The ERAS Protocol is the evidence-based care protocol developed by the ERAS Society.  The protocol describes the perioperative care pathway with recommendations for patient care at various steps in the perioperative process.  There are around 20 care elements that have been shown to influence care time and postoperative complications. The following graph illustrates the components of the ERAS multimodal care pathway While each patients Pathway may slightly differ, depending on the clinical setting and surgical approach, several elements are applied to all patients: Note that this isn’t a new thing – Enhanced Recovery has been around since 1995. Applies to a many surgical procedures. Not just colorectal. That is the future… that is what is coming. We are starting with colorectal, but it will soon be across the board. We didn’t invent this. Internationally recognized experts. Developed as a set of recommendations and guidelines.

Now lets talk… Enhanced Recovery of the Colorectal Surgery Patient!

What is it? Enhanced Recovery after Colorectal Surgery is… - Evidence based - Patient centered - Outcome directed - Teamwork and multidisciplinary driven …pathway to decrease complications and speed up recovery

WHY COLORECTAL??? 1. Established program 2. Bang for our $$$ 3. What the data shows Why do ERACS at all?? Why was colorectal surgery picked? Why are we bringing the program regional? ERACS was one of the 1st programs established by the ERAS Society, it has tried and true and continues to show positive results for patients. IH is focusing on surgery that all of our surgical sites offer – there are other ERAS programs like surgeries related urinary system but not all IH surgical sites offer these services. Collectively, NSQUIP – which is a program where a person manually audits patient’s charts looking for a variety of elements like complications,etc. – colorectal surgeries resulted in the most complications post op. Therefore we want to tackle the biggest problem at the most number of sites!!

Who is Involved? Others include: nurse navigator, GP

Pre-Operative Phase

Surgeon Office & GI Lab Surgeon considerations: Start patient/family teaching Discuss ERAS - Provide Patient and Family Information booklet Reinforce patient participation & expected length of stay Indicate to booking office that patient will follow ERAS pathway ERAS protocol (i.e. note on booking form, use a pre-op PPO) Order bowel prep (surgeon preference) Order prophylactic antibiotic (surgeon preference) Order VTE prophylaxis

Booking Office Indicate ERAS on slate Schedule patients for the morning (when possible)

Pre-Surgical Screening (PSS) / Pre-Admission Clinic (PAC) Nurse considerations: Reinforce education to patient and family: Patient and Family Information Pre-Operative Instructions Patient Log (if used) Discharge Booklet Anaesthesiologist considerations (where applicable): Discuss anaesthetic options with patients NURSE: Site specific – ET visit in PSS; carb beverage dispensed in PSS; chart is identified in PSS ANES.: Depending if phone call or not

Carbohydrate Loading Beverage What is it? Complex carbohydrate supplement Rationale Patient can undergo surgery in a metabolically fed state When & How 12 hours and 1-3 hours (org. specific) prior to surgery time Self administered prior to surgery time Options: Juice, Sports Drink – Gatorade, Nestle SOS, Solace SolCarb When & How: St. Paul’s juice 1 hr prior to surgery, IH we say 3 hours before surgery start time

Day Care Surgery Nurse considerations: Confirm carbohydrate beverage taken Flag patients record as ERAS Attach chewing gum to chart Start IV and put on an infusion pump Administer prophylactic antibiotic Pre-warm & maintain normothermia Administer VTE prophylaxis

Intraoperative Phase

Operating Room Anaesthesia responsibilities: Intraoperative fluid management Narcotic sparing analgesia Prophylactic antibiotic Double check if it has been administered Re-dose as required Prophylactic anti-emetic Maintain normothermia VTE Prophylaxis (site specific)

Post-Operative Phase

Recovery Room Nurse considerations: Minimize narcotic use while optimizing patient comfort through multi-modal orders Encourage sugar free chewing gum Encourage deep breathing, ankle exercises Continue prophylactic anti-emetic Maintain normothermia VTE prophylaxis (mechanical) Full Fluids IV fluids provided on infusion pump Further considerations: high flow O2 for one hour

Surgical Ward Nurse considerations: Review and follow Pre-Printed Orders Early return to diet – Enterstomal Therapy & Dietician support Encourage chewing gum Support early ambulation = Group effort (physio & nursing) Monitor urinary output, apply protocol Remove urinary catheter as soon as possible Early discontinuation of IV fluids Use narcotic sparing analgesia Continued…

Surgical Ward Continued… Patient and Family Teaching: Reinforce the elements of the patient pathway Review and encourage use of patient log book (if applicable) Identify and address barriers for discharge Reinforce discharge instructions and provide the Discharge Booklet

Outcomes – Quantitative & Qualitative

Sustainability How do we tell the people who are doing the work how they are doing?

*No one falls off the pathway* - Complications are avoidable Take Away Points *No one falls off the pathway* - Complications are avoidable - Improved ‘processes of care’ = improved results - Change is possible and sustainable - We are all accountable for our patients outcomes - Patients are willing partners in their recovery

Last Point…..MAKE IT FUN 