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

2. What is ERAS?
First proposed by Dr. Henrik Kehlet, British Anesthesiologist
Multimodal approach to control postoperative pathophysiology and rehabilitation. Br. J. Anaesth. 1997;78:
“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

3. 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: )
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

4. 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

5. 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

6. 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!

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

9. Financial Analysis

10. 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

12. 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

13. 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

14. Discussion