1. Enhanced Recovery Processes Ron Collins, MD FRCP(C) Medical Director, Surgical Services Project Lead, Enhanced Recovery Interior Health Authority Staff Anesthesiologist, KGH

2. Relative Contributions to Adverse Events and Excess Length of Stay adapted from Fry et al, J Am Coll Surg 2008;207:698-704 Proceduren% totalAdverse event % Prop. Adv. Events % Avg.  LOS Prop. All  LOS Colectomy12,7679.928.924.39.823.5 Sm Bowel resection 3,5762.832.97.713.910.6 Inpt. Chole.11,7189.17.55.78.74.9 Ventral Hernia 7,4775.810.14.96.33.1 Pancreat.1,9271.534.94.46.83.0

3. “Ultimately, improving quality will require efforts that go beyond outcomes assessment alone. Future work should aim to improve our current understanding of processes of care associated with superior surgical outcomes.” Fry et al., J. Am Coll Surg 2008;207:698-704

4. Quality Improvement Efforts to improve quality of care generally depend on assessing three dimensions: Structure: the system in which health care is delivered. Process: the care received. Outcomes: the results of the above (mortality, morbidity including LOS). Cohen ME et al, Ann Surg 2009;250:901-907

5. Variability in LOS After Colorectal Surgery Cohen et al, Ann Surg 2009;250:901-907 NSQIP data from 182 hospitals from Jan/06 to Dec/07: 23,098 patients eLOS > 75 th percentile of distribution, role of complications (19 defined), O/E ratios No complications: LOS 6.1 days, but eLOS > 8 days Complications: LOS 16.1 days, but eLOS > 20 days “…hospitals with lower risk-adjusted morbidity had shorter risk-adjusted LOS.” “For efficiency measures to be widely accepted in the market, they should be feasible to implement, credible and reliable for patients, and fair and actionable for healthcare providers.”

6. Enhanced Recovery After Colorectal Surgery  Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery Kehlet, H. and Wilmore, D.; Ann Surg 2008;248:189-98  Consensus Review of Optimal Peri-operative Care in Colorectal Surgery ERAS Group; Arch Surg. 2009;144(10):961-969

7. Implementation of a Fast-track perioperative care Program: what are the difficulties? Polle, sw et al, Dig surg 2007;24:441-449 ERAS program: 13 elements but only 7.4 implemented per patient Compliance did not improve with the experience of the team Attributed to bad collaboration of the three different disciplines in daily practice No impact on clinical outcomes: LOS, morbidity, patient satisfaction

8. Implementing new routines Are we using ”Best practice”? The German ”Prevalence”Study in ICU M M Levy, ASPEN 2007 92%

9. It is not like we think it is…. The German ”Prevalence”Study M M Levy, ASPEN 2007 92% 4%

10. Enhanced Recovery After Surgery “The profession has placed high value on developing the basic science of medicine: it has not emphasized the process by which the science is translated into practice…” Eddy, DM. N Engl J Med 1982;307:343-7

11. Adherence to the ERAS protocol and outcomes after colorectal cancer surgery ERAS group, Arch Surg 2011;146:571-77  27% improvement in adherence (47% to 74%)  27% reduction in any 30 day morbidity  In fact: dose-response curve for adherence: 70% adherence: LOS 7.4 days; OR morbidity: 0.62 80% adherence: LOS 7.0 days; OR morbidity: 0.57 90% adherence: LOS 6.0 days; OR morbidity: 0.33  Elements most predictive of good outcome: GD fluid management, Pre-operative CHO beverage

12. Adherence to the ERAS protocol and outcomes after colorectal cancer surgery ERAS group, Arch Surg 2011;146:571-77  Prospective Cohort Study: 464 controls (2002-04), 489 study (2005-07)  Second cohort higher risk, more difficult surgery  12 ERAS elements, unchanged  Staffing, infrastructure unchanged  Study compared outcomes and adherence for two periods  MLRA examined the importance of each element in the pathway

13. Interior Health Authority Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia IH Overall Intra-operative Fluid Management

14. Interior Health Authority Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia IH Overall Length Of Stay

17. 17 Length of stay reduced from 12.8 to 4.0 days. RIW reduced from 3.41 to 1.76 Benefit/cost ratio: 2.18 ROI: 118% CIHI estimated cost reduction of 48.4%.

18. CMG: Open Colorectal Resection Length of StayR.I.W. Traditional11.42.5 ERAS5.11.7 CIHI: cost of care reduced by 33%

19. CMG: Colorectal Resection with Stoma Length of StayR.I.W. Traditional11.93.5 ERAS6.02.1 CIHI: cost of care reduced by 40%

20. What is the role of GDT? CardioQ N = 23 No CardioQ N = 55 CMG 2234.15.8 CMG 2275.07.4 Complications07

21. PURPOSE MASTERY

22. Enhanced Recovery Society of Canada Mission: “To support the development and implementation of processes of care that result in outcome benefits for surgical patients.” Sister Society in Canada of ERAS Society Website: www.enhancedrecovery.cawww.enhancedrecovery.ca Inaugural Chairperson: Prof. F. Carli: MUHC Website development courtesy of: Fresenius- Kabi and Deltex Medical.