1. 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

3. 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.

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

5. 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

6. 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!!

7. Who is Involved?
Others include: nurse navigator, GP

9. Pre-Operative Phase

10. 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

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

12. 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

13. 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

14. 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

15. Intraoperative Phase

16. 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)

17. Post-Operative Phase

18. 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

19. 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…

20. 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

22. Outcomes – Quantitative & Qualitative

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

24. *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

25. Last Point…..MAKE IT FUN 