1. Outcome-Based Medicine? Ron Collins, MD FRCP(C) Medical Director, Enhanced Recovery Interior Health Anesthesiologist, KGH

2. 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 “The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice.” Urbach DR, Baxter NN, BMJ 2005

3. 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

4. Evidence! Quality Initiative

5. “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

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. 7 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%.

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. 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

11. 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

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

13. Outcome Measurement…. Is the anticipated benefit happening? Are there unanticipated benefits? Are there unanticipated harms emerging? Is perception matched by reality? Are objective benefits matched by subjective benefits?