1. Ron Collins, MD FRCP(C) Clinical Assistant Professor, APT, University of British Columbia Medical Director, Surgical Services Project Lead, Enhanced Recovery Interior Health Authority Staff Anesthesiologist, KGH

2. Disclaimer Member of Advisory Panel to Fresenius-Kabi (FLOW: Fluidop.com) None of the content or ideas relate to papers from Dr. Joachim Boldt

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

4. Enhanced Recovery Is…. Evidence-based clinical pathways Multidisciplinary in scope Outcome driven Better for patients Better for healthcare organizations “Complex” task to implement Up to 20 elements or milestones

5. Relative Contributions to Adverse Events and Excess Length of Stay adapted from Fry et al, J Am Coll Surg 2008;207:698-704 Proceduren% total Adverse 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

6. “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

7. 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

8. Colorectal Clinical Pathway Discreet steps Evidence-Based Pre-operative Intra-operative Post-operative Challenges traditional processes

9. Pre-Operative Elements Overview of pathway Establish expectations No mechanical bowel preparation Carbohydrate beverage (2 ½ hrs) No sedative premedication

10. Intra-Operative Elements TEA T9 or T10 Narcotic sparing anesthetic Goal Directed Fluids with CardioQ Active warming Routine anti-emetics No NGs, no drains

11. Post-Operative Elements: PAR Optimize epidural analgesia Narcotic sparing High-flow O2 for 1 hour May chew gum in PAR Full fluids in PAR

12. Post-Operative Elements: Surgical Ward Full fluids Day 0, DAT Day 1 Out of bed 6 hours Day 1 Activity specified May chew gum in PAR Full fluids in PAR

13. The KGH ERACS Pilot Project: Results! Numbe r ProcedureeLOSaLOS 1Transverse Colectomy9 days3 days 2Resection Terminal Ileum16 days14 days 3Anterior Resection (*)9 days4 days 4Low Anterior Resection9 days5 days 5Sigmoid Resection9 days4 days 6Hemicolectomy9 days4 days

14. Specific Measureable Actionable Realistic Timeframe Reaction Learning Application Business Impact ROI Intangible Measures

15. ROI Methodology ERACS evaluation based on first 16 pts. Interviews with 5 individuals Surveys from 33 individuals KGH records ERACS records CIHI data for RIW Cost estimates for ERACS start-up

16. Enhanced Recovery After Colorectal Surgery 16 88% of staff feel ERACS is vital to the success of IH. 87% of staff feel that ERACS provides better patient care. Opportunities to improve infrastructure and demonstrate adaptability. “The ERACS process is better for patients, and that is what my life’s work is about.” Surgical Ward Nurse

17. ROI Methodology Return on Investment: ERACS Cost Summary: $56,413.45 ($21,500 for ROI) Mostly one time costs Traditional cost (RIW 3.42): $15,884.81 ERACS cost (RIW 1.76): $8,194.42 Savings: $7,690.39 ($123,046.24)

18. Enhanced Recovery After Colorectal Surgery 18 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%.

19. CMG: Open Colorectal Resection Length of StayR.I.W. Traditional11.42.5 ERAS5.11.7

20. CMG: Colorectal Resection with Stoma Length of StayR.I.W. Traditional11.93.5 ERAS6.02.1

21. How do you measure success? CIHI assigned RIW decreased >90% of colorectal patients enrolled Fewer complications overall Fewer complications in high-risk groups Caregiver satisfaction This is the ‘new normal’ There are opportunities….. Requests from additional surgical groups!