1. The pathways to improve patient care Enhanced Recovery After Surgery (ERAS) Presented by Deborah Bachand Manger of Surgical Service Project & Implementation for VIHA

2. “Would you tell me, please, which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat. “ I don’t much care where–” said Alice. “Then it doesn’t matter which way you go,” said the Cat.

3. ERAS programs follow well trodden paths… Evidence based, internationally proven to improve outcomes and patient satisfaction…

4.  Medication  Cognition  Pain  Mobility  Bowel/bladder  Nutrition/hydration 48/6

5.  Elderly-friendly/ patient-centered care  Collaborative inter-professional team  Care-related communication CDMR

6. Promoting self management and care through education and prehabilitation Optimizing preoperative nutrition Normalizing GI/GU function Minimizing pain Early feeding postoperatively – as soon as appropriate Optimizing early ambulation Discontinuing attached lines, drains, tubes as soon as appropriate Optimizing respiratory function Pathway Principles The Travel Guide

7. Surgery is a Journey Think of ENHANCED SURGICAL PATHWAYS as the GPS to help our patients navigate the system…

8. Your name: _____________________ Before, During and After Colon (Bowel) Resection Surgery A guide for adults having a colon (bowel) resection at Victoria General or Royal Jubilee Hospitals. Please:  Read this booklet the day you get it.  Keep it beside your phone to write down any further instructions.  Bring it to all your appointments before and after your surgery and to the hospital the day of your surgery.

9. Changing traditional practice can be a tall order… Most of us are firmly rooted in our practice norms…

10. Operating Room Before Now  Inconsistent practice  Consistent Practice  Anesthesia Protocol Developed. Key points:  Consider Spinal for all minimally invasive surgery  Consider Epidural for all open cases unless contraindicated  All patients to receive antiemetics  Perioperative heparin to be administered to all patients  Lactated Ringers is solution of choice, and restrict maintenance fluid to 15ml/kg/hr  Active warming of the patient  Use of Fi02 of 0.8  Timely antibiotic administration

11. Care Post Operatively BeforeNow  Diet ◦ Slow progression of ice chips to fluids  Activity ◦ Slow to mobilize  Investigations ◦ Different depending on surgeon  Foley ◦ Stayed in until epidural removed  Pain Control ◦ variable  Diet ◦ Full Fluids POD 0, Light diet by POD 1  Activity ◦ Dangle POD 0  5hours or more of activity by POD 4  Investigations ◦ Standardized bw on POD 1 & 3  Foley ◦ Removed on POD 2  Pain Control ◦ Goal: 3 or less on pain scale ◦ Around the clock tylenol

12. Care Post Operatively BeforeNow  Wound Care ◦ At the discretion of nurses  DVT prophylaxis ◦ Varied by surgeon  Epidural ◦ Removed approx day 4 or 5  IV ◦ inconsistent  Discharge ◦ Varied by surgeon  Wound Care ◦ No change  DVT prophylasis ◦ Standardized (SC Heparin)  Epidural ◦ Stopped Day 2, removed day 3  IV o SL when intake is 1200 cc/day or until no longer needed  Discharge ◦ Standing criteria ◦ Target: Discharge on POD 4

13. There will be obstacles…

14. And some pitfalls…

15. Mean LOS for Colorectal Surgery

16. Some patients will ‘fall off the pathway’ The challenge for the care team is to reassess the needs for each individual and optimize the recovery within the changed care journey.

17. Patient satisfaction increases with improved outcomes. Complications and risk of infections are decreased Hospital length of stay is shortened Access is improved for all surgical patients. The Outcome…Everyone’s a Winner!

18. Thank you