DRAFT – final pending AHRQ approval

Enhanced Recovery (ERAS)

SUSP Surgeon callFebruary 26, 2014

DRAFT – final pending AHRQ approval

What is ERAS?

First proposed by Dr. Henrik Kehlet, British Anesthesiologist

– Multimodal approach to control postoperative pathophysiology and

rehabilitation. Br. J. Anaesth. 1997;78:606-617.

“The hypothesis that a combination of unimodal evidence based care

interventions to enhance recovery will subsequently decrease need

for hospitalization, convalescence and morbidity.” Kehlet H.

Langenbecks Arch Surg (2011) 396:585–559

Supported by large body of evidence in virtually every field from

vascular to bariatrics to Whipple to colorectal

DRAFT – final pending AHRQ approval

Supporting DATADis Colon Rectum 2013 – Meta-analysis of 13 studies demonstrating significantly decreased LOS, complication rate, similar readmit and mortality– Typically all studies demonstrate a 50 – 60% reduction in LOS

Duke experience (abstract ASA 2011)– Before/after design demonstrated significant reduction in

LOS, surgical site infection, urinary tract infection, hypotension requiring treatment

Mayo experience (Lovely J, et al. Br J Surg. 2011;99:120-126.)– Before/after design demonstrated 44% of patients discharged

on POD 2, opiod requirements less without increased pain scores, complication rate similar, hospital costs were reduced by an average of $1,039/pt

DRAFT – final pending AHRQ approval

Goal of ERAS

Implement a standardized, patient centered protocol

Integrate the pre-operative, intra-operative, post-operative and

post-discharges phases of care to reduce LOS

Improve patient experience and satisfaction and decrease

variability

DRAFT – final pending AHRQ approval

Basic Principles of ERAS

Enhanced Recovery is a multidisciplinary and collaborative approach

focusing on:

-Patient education and participation

-Optimization of perioperative nutrition

-Standardization of perioperative anesthetic plan to minimize

narcotics, intravenous fluids and post operative nausea and vomiting

-Stress relief

-Early mobilization and oral intake

DRAFT – final pending AHRQ approval

Main shifts in mentality

Pain management

– Goal is to diminish narcotic intake

Fluid management

– Goal is to avoid volume overload – bowel edema

Activity

– Goal is to induce early mobility and get the bowels moving!

DRAFT – final pending AHRQ approval

Develop Clinical Specifics and Standardization of care

Clinic

Prep

Inpatient and ICU unit

PACU (pain control and mobilization)

Post-op pain control plan

DRAFT – final pending AHRQ approval

DRAFT – final pending AHRQ approval

Financial Analysis

DRAFT – final pending AHRQ approval

Example of ERAS Pathway at Johns Hopkins Hospital

• Identify ERAS patients• Bowel prep and CHG washclothes administered• Targeted pre-operative multimodal (electronic, in person and paper) education to set expectations and

engage patient in their care

PreoperativeClinic

DRAFT – final pending AHRQ approval

DRAFT – final pending AHRQ approval

ERAS Evaluation

Audit of processes (pain regimen, fluid in OR and post-op, education,

mobility, diet etc.)

Length of Stay

Pain scores post-operative

HCAPS

30 day Morbidity

Readmission

Monthly reports and feedback to optimize implementation

DRAFT – final pending AHRQ approval

Our ModelComprehensive Unit

based Safety Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Translating Evidence Into

Practice(TRiP)

1. Summarize the evidence in a checklist

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients get the evidence

• Engage• Educate• Execute• Evaluate

Reducing Surgical Site Infections

• Emerging Evidence

• Local Opportunities to Improve

• Collaborative learning

Technical Work Adaptive Work

DRAFT – final pending AHRQ approval

Discussion