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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
ERAS Collaborative
Enhanced Recovery of the
Colorectal Surgery Patient!
Now lets talk…
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
WHY COLORECTAL???
1. Established program
2. Bang for our $$$
3. What the data shows
Who is Involved?
Pre-Operative Phase
Surgeon Office & GI LabSurgeon 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
Booking OfficeIndicate ERAS on slate
Schedule patients for the morning (when possible)
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
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
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
Intraoperative Phase
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)
Post-Operative Phase
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
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…
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
Outcomes – Quantitative & Qualitative
Sustainability
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
Last Point…..MAKE IT FUN