1. TOOLKIT PERMISSIONS
The supplied PowerPoint presentation and Word documents may be modified for customization, and reproduced for use and distribution in starting ERP at your site. These documents have been made available with the sole intent of assisting sites with the initiation and development of an enhanced recovery program. In the interest of improving surgical care, favorably affecting patient outcomes, and wide promotion of best practices, MSQC has made these documents accessible with minimal restriction. Please be respectful of their use, and refrain from reproducing or using these documents outside of their intended purpose.
Created by MSQC for the purpose of initiating and maintaining ERP Quality Improvement Projects by hospitals in the Collaborative.

2. Agenda
Objectives:
Introduce Enhanced Recovery Program (ERP) Principles & Elements
Define ERP Benefits
Offer Strategy for Successful Initiation of ERP at (YOUR HOSPITAL)

3. Enhanced Recovery Program
MSQC Enhanced Recovery Program provides a framework for sites to use in establishing and implementing standardized protocols directed at optimizing patient recovery during the preoperative, intraoperative and postoperative periods of care
A multimodal optimization of surgical care that began to get attention in the 1990s, with the aim of decreasing the surgical stress response in order to improve surgical patient care, reduce complication rates, and shorten hospital stays . Eskicioglu et al. (2009)

4. MSQC-ERP Guidelines Origins:
-SYSTEMATIC REVIEW of existing guidelines
-EXPERT COUNSEL of active clinicians
Recommendations for ERP interventions aimed at optimizing perioperative recovery proceed from a systematic review of existing guidelines for Enhanced Recovery After Surgery and Fast Track Recovery, and from the expert counsel of active clinicians engaged in the application of Enhanced Recovery principles to their current and respective practices.

5. Enhanced Recovery Program Elements
Presurgical Counseling and Education
Presurgical Conditioning and Readiness
Presurgical Preparation
Intraoperative Efficiency
Targeted Postoperative Interventions
Patient Feedback and Outcomes Reporting and Analysis
There are six basic elements to an Enhanced Recovery Program: Presurgical Counseling and Education; Presurgical Conditioning and Readiness; Presurgical Preparation, Intraoperative Efficiency, Targeted Postoperative Interventions and Patient Feedback and Outcomes Reporting and Analysis.
Within these six elements, are a suggested list of evidence-based practices that result in improved outcomes for surgical patients. Initiating an Enhanced Recovery Program does not require the adoption of all practices, and is a dynamic process that evolves with each turn in the PDSA cycle. An efficient and effective Enhanced Recovery Program will require repeated and regular evaluation of each component for efficacy and improvement.
ERP isn’t “all or nothing”…there’s something for everyone, resulting in improvement in outcomes for each participant.
Preadmission counseling:
ERP Education: procedure, ERP elements, why
Anticipatory Guidance: who, when, what will happen, why
Patient-centered : goal setting, responsibilities, expected outcomes
Pre-Surgical Conditioning and Readiness
Surgical Optimization
Smoking cessation
Optimize nutrition
Optimize mobility
Eliminate alcohol intake
Patient Readiness
Identification of a patient-centered support network (provider)
Surgery “buddy” (patient-chosen)—accompanies patient: second set of eyes and ears
Anxiety assessment and short-term intervention strategies
Presurgical Preparation
Bowel Preparation
-mechanical bowel prep
-antimicrobial prophylaxis
Presurgical Carbohydrate Loading and Hydration:
clear (12.5%) carbohydrate drink (800mL) before midnight.
clear (12.5%) carbohydrate drink (400mL) 2-3 hours prior to induction.
patient freely consumed clear fluids until 2h before anesthesia for surgery
Intraoperative Efficiency:
Standardized Anesthetic Protocols
-Minimal Use of Opioids
-Measures to Optimally Sedate and Anesthetize Patients
Standardized Thromboembolism and Antibiotic Prophylaxis Protocols
Minimally Invasive Surgery
Targeted Post Operative Interventions
Early Postop Feeding
Early Removal of Catheters/Drains
Early Mobilization
Pain Management
Preop: administration of pain modulating medications
Post-op: early assessment and intervention
Discharge: good pain control with oral analgesia
Patient Feedback and Outcomes Reporting and Analysis
MSQC data collection and analysis allows for benchmarking of quality measure(s) performance specific to ERP

6. Impact on Patient Outcomes
Enhanced Recovery vs. Conventional Recovery Strategies
Global Outcomes Data (colorectal surgery)
Enhanced Recovery
Conventional
Mortality¹
0.4%
1.3%
Complications¹
28.5%
56.8%
Readmissions²
9.7%
18.2%
Length of Stay¹
by 3 days (on average)
Post Surgical Pain³
Reduced
In a literature review by Spanjersberg et al. (2011), which compared enhanced recovery (ER) versus conventional recovery strategies for colorectal surgeries, the mortality rate in enhanced recovery patients was 0.4% compared with 1.3% in conventional patients. Complications were sustained by 28.5% of ER patients versus 56.8% in conventionally treated patients. LOS (on average) was reduced by 3 days.
A comparative study of enhanced recovered patients vs. traditional postop recovered patients undergoing laparotomy for colon resection (Delaney et al. 2003) demonstrated a average reduction in readmission rates from 18.2% to 9.7%.
A meta-analysis of randomized controlled trials in colorectal surgery by Adamina et al. (2011), demonstrated similar findings: a reduction in LOS by an average of 2.5 days, morbidity reduced by half, and readmissions decreased.
And finally, Anderson et al.(2003) reported that patients’ postsurgical pain was reduced when with ER pathway interventions compared to patients treated by conventional analgesia.
In summary, the data from studies comparing enhanced recovery surgical patients and conventional recovery surgical patients has clearly and consistently evidenced better outcomes for enhanced recovery patients with notable reductions in morbidity, mortality and length of stays without increases in hospital readmission occurrences.
1. Spanjersberg et al.(2011)
2. Delaney et al. (2003)
3. Anderson et al.(2003)

7. Impact on Patient Outcomes
Enhanced Recovery Michigan Project:
St. Joseph Mercy Hospital Enhanced Recovery Initiative
2/2010
Study Commenced
2/2012
ERP
Initiated
2/2014
Study Conclusion
Headed by Robert Cleary, MD
St. Joseph Mercy Hospital, Ann Arbor, MI
In February 2012, St. Joseph Mercy Hospital Ann Arbor (537-bed teaching hospital) initiated a 16-component system as the standard of care for patients undergoing colon and rectal surgery.
The study population includes patients who underwent elective procedures: open, laparoscopic or robotic colon and rectal surgery from February 2010 through February Approximately 300 cases will be examined per year = 1200 reviewed cases for the duration of the study.
Goal of study: compare parameters of clinical interest: hospital length of stay, readmission and clinical outcomes before and after implementation.
1200 reviewed cases
Study Population: patients who
underwent elective procedures of
open, laparoscopic or robotic colon
and rectal surgery

8. Preliminary Outcomes Analysis Data For ERP Michigan Project:
Impact on Patient Outcomes
Preliminary Outcomes Analysis Data
For ERP Michigan Project:
Preliminary Conclusion:
ERP initiatives reduce length of
stay without increasing readmission
DRGs: and
Enhanced Recovery Patients
Conventional Recovery
Patients
Data analysis timeframe
Feb-Aug 2012
2011 n
114
345
ALOS (days)
4.7
6.0
30d readmission
by 1.3%
Preliminary data for the 6-month period following implementation of the ER Initiative was studied. Post-initiative cases (n=114) were compared to cases in calendar year 2011 (n=345) In diagnosis related groups (DRG) and
The preliminary results from Dr. Cleary’s study have already evidenced improved outcomes for enhanced recovery patients in comparison to patients who followed conventional post-surgical recovery with reductions in average length of stay without increase to the hospital readmission rate following discharge.
Study Forecast based on preliminary data:
-decreased complications
-improved patient outcomes
Data provided by Robert Cleary, MD (2013)
Department of General Surgery
St. Joseph Mercy Hospital, Ann Arbor, MI

9. Non-Colorectal Enhanced Recovery Programs
Enhanced Recovery Programs have a role in non-colorectal surgeries:
Principles can be tailored to improve the patient’s clinical
condition for which they have presented for surgery.
Targeted interventions:
Promote postoperative recovery
Reduce the perioperative stress response
Attenuate organ impairment
results :
- Shortened length of stays
- NO increases in readmissions
- Accelerated return to normal activities
- Decreased morbidities
Gynecologic Surgery
Orthopedic Surgery
Liver Surgery
Vascular Surgery
Enhanced Recovery Principles and Protocols, which have their origins in colorectal procedures, have since been broadly applied across multiple surgical disciplines. Basic principles for Enhanced Recovery have relevance, regardless of surgery type, in preparing the patient for surgery and maximizing his/her potential for complete and early recovery.
The differences between Enhanced Recovery Programs within surgical specialties are often noticed in the intervention “specifications” related to a given Enhanced Recovery Program Element, i.e., Early Ambulation/Mobilization: orthopedic patients may follow post-surgical protocols for ambulation that differ from those recommended for post-CABG patients, but both patient types benefit from specified ambulation/mobility protocols.
Enhanced Recovery Programs that have expanded beyond colorectal surgery have demonstrated in preliminary data for outcomes that length of stays have been shortened, without increases in readmissions, with faster return to normal function and lower incidences of complications.
Gastric and Esophageal Surgery
Radical Cystectomies
Plastic Surgery

10. Enhanced Recovery Orthopedic Programs: Reductions in Length of Stay
Enhanced Recovery for Non-Colorectal Surgery
Enhanced Recovery Orthopedic Programs:
Reductions in Length of Stay
Traditional Recovery
Enhanced Recovery
p value n
3000
1571
Median age (yrs.) 69 68
Total Hip
1368
657
Total Knee
1632
914
Mean LOS (days)
8.5
4.8
<0.001
Median LOS (days) 6 3
Reductions in LOS by approximately 3 days.
Houlihan-Burne (2009) Enhanced Recovery Hillingdon & Mount Vernon Hospitals, NHS Trust

11. Impact on Patient Engagement and Satisfaction
Patients Participating in Enhanced Recovery Programs
Reported the Following:
They felt better-prepared for surgery
Their anxiety was reduced with better confidence in good outcomes
The surgery and hospitalization went according to plan
They were ready for discharge
They were likely to recommend (97.8%)
Survey results were obtained from 538 patients who had participated in an Enhanced Recovery Program. Patients reported feeling better-prepared for surgery: the procedure, in-patient stay, and recovery—88% felt either excellently prepared or well-prepared (vs. 8% who felt adequately prepared and 4% who didn’t respond). Patients also reported a reduction in anxiety or apprehension regarding the hospital admission, as well as confidence about going home due to participation in an Enhanced Recovery Program. Over 95% of the patients felt that they consistently received the message to mobilize early and get back to normal quickly.
Akhtar and Houlihan-Burne (2010)

12. Impact on Hospital Reimbursement
Enhanced Recovery Program
(ERP)
Accountable Care Organization (ACO)
ERP positively impacts measures in 3 domains of the quality performance standard:
Patient/Caregiver Experience
Care Coordination
Preventive Health
Increased
Shared Savings
Hospital Value-Based Purchasing (VBP)
ERP positively impacts Patient Care Domain:
30% of Total Performance Score for VBP
ERP can positively affect dimensions in this domain
Increased Reimbursement
Hospital Compare
ERP positively impacts measures reported for:
HCAHPS
Timely and Effective Care
Readmissions, Complications, and Deaths
Improved
Public Reporting
ACO:
Increased quality of care = increased shared savings for ACO
ERP also increases patient engagement
According to American Hospital Association (AHA), engaging patients can improve outcomes and reduce costs
Can increase workflow efficiencies
ERP encompasses focus areas seen as necessary to increase patient activation
Highly activated patients report better care experiences (HCAHPS)
Patients with lowest activation levels had higher predicted average costs than those with highest activation levels
Activation can increase likelihood of normal clinical indicators (BP, LDL, Hgb A1c) (which hits the 4th domain of the quality performance standard: At Risk)
Domains and specific measures addressed by ERP
Patient/Caregiver Experience Domain
Getting Timely Care, Appointments, and Information
How Well Providers Communicate
Health Promotion and Education
Shared Decision Making
Health Status/Functional Status
Care Coordination Domain
All Condition Readmission
Preventive Health Domain
Tobacco Use: Screening and Cessation Intervention
At Risk Domain (affected by ERP through patient engagement)
Measures related to BP, LDL, Hgb A1c
VBP:
HCAHPS is basis for Patient Care Domain
Pay for Performance Medicare payment adjustments
Hospital Compare:
Public display of quality measures
HCAHPS measures
Communication with nurses and physicians
Pain management
Discharge information
Timely and Effective Care
Surgical Care Improvement Project
Readmissions, Complications, and Deaths
Readmissions: 30-day hospital-wide, all-cause unplanned readmissions
Surgical complications: Death among surgical patients with serious, treatable complications
Hospital-acquired conditions (HAC): Catheter-associated urinary tract infection (CAUTI)
Healthcare-associated infections (HAI): Surgical Site Infections (SSIs) from colon surgery and abdominal hysterectomy
In January 2013, CMS added 3 new items on transition to post-hospital care to HCAHPS
Care Transition Composite measure
Planned for public reporting October 2014

13. Value and Cost-Savings
Costs of 2 types of Health Care-Associated Infections seen in surgical patients
Infection Type
Cost Per Case
Surgical Site Infection (SSI)
$20, 785
Catheter-Associated Urinary Tract Infection
$896
Potential Savings with LOS Reductions
Average Reduction in LOS for Enhanced Recovery Patients
Median Savings per Day
Potential Savings per Patient (conservative estimate)
3 days
$358*
$1074
Two examples of postoperative morbidity occurrences that can be reduced through Enhanced Recovery Initiatives are SSI and UTI. While there is wide variance in impact to attributable costs and length of stay between occurrences, there is opportunity for cost-savings in each instance. The potential cost savings of an Enhanced Recovery Program is compelling when considering the combined and compounding effect ERP initiatives have on reducing LOS and preventing postoperative complications across a population of patients.
*figure based on cost analysis data from 1998
Taheri et al. (2000)
Zimlichman et al. (2013)

14. Consider Developing a Perioperative Surgical Home
Structure and Components
of a Perioperative Surgical Home
TEAM
Care that is accessible, accountable, comprehensive,
integrated, patient-centered, safe, scientifically valid,
and satisfying to both patients and their physicians.
PATIENT-PROVIDER
PARTNERSHIP
CARE MANAGMENT
INDIVIDUAL
SERVICE LINKS
CARE COORDINATION
The Perioperative Surgical Home (PSH) is an innovative model for managing the care of surgical patients. It involves the engagement of an entire perioperative care team in the service of the surgical patient. Central to the Perioperative Surgical Home is the patient, around whom the care is centered, with health care value at its foundation. Care delivered through the PSH is accessible, accountable, comprehensive, patient-centered, safe, scientifically valid, and satisfying to the patient and provider.
Reduce Cost and Improve Health Care Quality & Efficiency
Future of Family Medicine Project (2002)

15. ERP and the Perioperative Surgical Home (PSH)
ERP principles work in tandem with PSH concepts to create a context for physicians, service providers and hospitals to jointly participate in optimizing: -health system strategy -operations management -payer contract negotiations -health system finance While providing care that is: -standardized and continuous -comprehensive and patient-centered -value added for the patient, physician(s) and service providers e
PSH
The Old Way
ERP
The Perioperative Surgical Home’s approach to improving the quality and cost of surgical care considers efforts beyond the traditional approaches to increasing value. An Enhanced Recovery Program fosters an integrated approach, through the engagement of patient, physician, hospital, and other service providers, in managing the needs of surgical patients.
An Enhanced Recovery Program encompasses the concepts of the Perioperative Surgical Home to deliver care that is coordinated and managed throughout the surgical continuum using standardized processes where applicable, that are patient-centered and rooted in evidence-based best practices.
VALUE

16. Actions to Achieve Success
Commitment from Leadership
Formation of Steering Committee
Effective communication of plan
Protocol, integrated into order sets
Action Plan
with clear expectations
Education of staff
Mechanisms to hold staff accountable
Continuous evaluation of efforts and outcomes
Critical to the success of an Enhanced Recovery Program is a strong commitment from Leadership. Many of the initiatives will challenge dogma as it relates to clinical practice—inspired and positive leadership will help to ensure staff that change will be supported.
Forming a Steering Committee made up of multidisciplinary team members will provide the clinical expertise and diversity necessary in developing comprehensive and clear action plans to develop a fully engaging Enhanced Recovery Program
Finally, the development of clear, concise and effective communication plans, clinical protocols, educational support, and feedback mechanisms by the Steering Committee will provide the structure and means to fully implement a successful Enhanced Recovery Program.

17. ERP at [your hospital] Steering Committee Outcomes Morbidity Mortality
LOS
Readmissions
Postop ED visits
Presurgical Preparation
& Intervention
 Intraoperative
Efficiency
 Targeted Post-op
Intervention
Outcomes
MSQC Enhanced Recovery Protocols provide the framework for hospitals to develop an site-specific Enhanced Recovery Program.
The establishment of a Steering Committee ensures direction and clinical leadership in developing and executing initiatives to optimize patients for surgery with the specific goal of enhancing recovery after surgery.
The Steering Committee has oversight and delegates responsibility for the development of clinical practice pathways, utilizing best practices from evidence-based medicine.
Quality Improvement Initiatives are developed with specific objectives directed at securing best outcomes for the surgical patient.
Outcomes are then studied against clinical pathways and quality initiatives for effectiveness, through evaluation of MSQC data, for dynamic, continuous and meaningful process improvement.
Adapted from IHI Process Improvement Model

18. How Can MSQC Help?
Provides opportunities for on-site consultation with multidisciplinary team members
Provides opportunities to collaborate with 67 other hospitals in the state
Provides 24/7 reporting platform for measuring and evaluating outcomes
Provides expertise and knowledge to build the program

19. Summary
Enhanced Recovery Program (ERP) Principles & Elements Introduction: a flexible program that can be customized
Define ERP Benefits: improved quality of care, patient experience and outcomes, and reduced cost
Offer Strategy and Support for Successful Initiation of ERP at (YOUR HOSPITAL): MSQC-ERP and [your hospital]: partnership for improved patient care and outcomes.   
PROGRAM: ERP is a menu of best practices relevant to colon and non colon surgery, with interventions that can be tailored to target specific patient types.
BENEFITS: ERP utilizes a systematic and comprehensive approach to providing high-quality surgical care, with proven benefit to the patient experience and outcomes, and notable reductions in health care costs.
STRATEGY and SUPPORT: MSQC-ERP offers support for implementation of an enhanced recovery program through toolkits, consultation, data collection and analysis, and collaborative opportunities.
MSQC-ERP is an opportunity for regional collaboration in an effort to improve surgical patient care and outcomes,
while realizing value for patients, providers, and hospitals. Thank you for your time.

20. Questions? Thank you
Created by MSQC for the purpose of initiating and maintaining ERP Quality Improvement Projects by hospitals in the Collaborative.