Enhanced Recovery for Enhanced Outcomes: The Mayo … · Enhanced Recovery for Enhanced Outcomes:...
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Enhanced Recovery for Enhanced Outcomes: The Mayo Clinic in Arizona Experience Objective Given current literature, Mayo Clinic in Arizona used the following intervention in the enhanced recovery pathway: Pre-operative intervention • Surgeon properly educates patient on what enhanced recovery is including review of expectations. • Patients may not take a bowel cleansing prep prior to surgery. This is due to the fact that bowel cleansing preps can cause dehydration and delay in return to normal bowel function. • Patients do not fast for a prolonged period of time before surgery Intra-operative intervention • A minimalist approach to fluid replacement is done intra-operatively. Multimodal preemptive analgesia is administered to patients at the discretion of anesthesiology. • Maintenance of normothermia Post-operative intervention • Patients follow a low residual diet 4 hours after surgery, including nutritional supplements • Patients are encouraged to get out of bed the evening of surgery and as much as possible during their hospital stay Enhanced Recovery Pathway • Successful operational implementation of the pathway involved tailored communication and buy-in from key stakeholders • Surgeon champions were involved in every step of implementation and delivered education to staff • Patient education was key to ensure understanding of the protocol • Investing time into creating tools is critical to success, including patient education materials, order sets and workflows • Based on the successful reduction in LOS and cost while maintaining high quality of care, the ERAS pathway will be extended to other abdominal surgical procedures. Lessons Learned Hypothesis: Reduction in LOS would also reduce costs per patient encounter (prior analyses have shown these two metrics to be proportional) Data Collection: Included all patient encounters for three colorectal surgeons and one gynecological surgeon who participated in the initial ERAS rollout. The protocol was implemented on July 1, 2013 and patient data was collected from July 1 through September 30, 2013 and compared to patient data during the same time period the year prior. There were 99 patient encounters analyzed from 2012 and 129 patient encounters from 2013. Analysis: Analysis showed reductions in LOS and cost per case for laparoscopic and open cases. Significant reductions in cost were seen in pharmacy, inpatient, and operating room expenses, as well as laboratory and inpatient consultations from other services. Readmission rates showed no increase in re-admissions within 30 days between the control and the pilot groups. Results Fig. 1: Length of Stay Reduction in Days • Tonia Young-Fadok, MD • Paul Magtibay, MD • Andrew Gorlin, MD • Terrance Trentman, MD • Susan Hagstrom, MD • Eric Nelson, RPh • Bob Graber • Charles Oligmueller, CRNA • Patricia Whitten, RN • Steve Reimer, RN • Anna Marie Hunsaker, RN • Irene Lewis, RN • Sheryl Castaneda, RN • Joanne Schultz Contributors 1. Krishna K. Varadhan, Keith R. Neal, Cornelius H.C. Dejong, Kenneth C.H. Fearon, Olle Ljungqvist, Dileep N. Lobo, The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clinical Nutrition, Volume 29, Issue 4, August 2010, 434– 440 2. Michel Adamina, MD, PD, MSc, Henrik Kehlet, MD, PhD, George A. Tomlinson, Anthony J. Senagore, MD, MS, MBA, Conor P. Delaney, MD, MCh, PhD. Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery. Surgery, Volume 149, Issue 6, June 2011, 830-840. References © 2014 Mayo Foundation for Medical Education and Research Planning • In early 2013, the colorectal and gynecology surgical practices at Mayo Clinic in Arizona set out to reduce LOS and improve quality of care through implementation of “Enhanced Recovery After Surgery” (ERAS). • ERAS is a standardized, evidence-based clinical pathway for pre, peri and post-operative care designed to minimize stress on the body and return the patient back to normal function as quickly as possible. • Studies have shown ERAS to decrease LOS and result in fewer complications with no difference in readmission rates as compared to control groups (Varadhan et al 2010, Adamina et al 2011). • Despite the growing body of research supporting ERAS, there are significant barriers to operationalizing the components of the pathway, which are divergent from what surgeons, anesthesiologists, and nurses have been traditionally trained to do, and what patients have typically experienced before and after surgery. Kripa Krishnan, MPH; Roshanak Didehban, MHS, FACHE; T’Nita Waters, MHS; Andrew Horton, MHSA Mayo Clinic, Phoenix, Arizona In the midst of a rapidly changing healthcare market, organizations are focusing on strategies to improve value by delivering the highest quality care for the lowest possible cost. One area of high expense is the surgical episode of care, particularly complex cases that typically require more resources and longer lengths of stay (LOS). Typically, the average Medicare DRG payment for these procedures does not cover the high cost of complex care. Implementation required involvement from a range of areas that “touch” the patient along the surgical care continuum. Implementation included: • Meeting with stakeholders involved in the clinical pathway to discuss the pathway, educate on expected benefits, and gain acceptance • Tailored education to residents, fellows, OR and inpatient nursing delivered by surgeon champions • Creation of patient education materials to ensure understanding of surgical preparation and expectations during recovery • Additional awareness education to scheduling services, registration, pre- admission, and administrative support staff Implementation Patient Departments of Surgery Department of Anesthesiology Patient Education Scheduling Services Registration/ Pre- admission Information Technology Department of Nursing Pharmacy Patient Education Materials Training/Education Plan Fig. 2: Cost Reductions by Service Area 11% 12% 14% 19% 20% 20% 40% 60% 80% 100% Inpa.ent consulta.ons Laboratory Opera.ng Room Inpa.ent Pharmacy Fig. 3: Cost Per Case Reductions Patient education brochure sample, Colorectal Surgery Patient education brochure sample, Gynecology Surgery Sample patient instruction sheet 2.6 1.2 3 2.5 2 1.5 1 0.5 0 Open Laparoscopic 16% 7% 20% 40% 60% 80% 100% Open Laparoscopic
Transcript of Enhanced Recovery for Enhanced Outcomes: The Mayo … · Enhanced Recovery for Enhanced Outcomes:...
Enhanced Recovery for Enhanced Outcomes: The Mayo Clinic in Arizona Experience
Objective
Given current literature, Mayo Clinic in Arizona used the following intervention in the enhanced recovery pathway: Pre-operative intervention
• Surgeon properly educates patient on what enhanced recovery is including review of expectations.
• Patients may not take a bowel cleansing prep prior to surgery. This is due to the fact that bowel cleansing preps can cause dehydration and delay in return to normal bowel function.
• Patients do not fast for a prolonged period of time before surgery Intra-operative intervention
• A minimalist approach to fluid replacement is done intra-operatively. Multimodal preemptive analgesia is administered to patients at the discretion of anesthesiology.
• Maintenance of normothermia Post-operative intervention
• Patients follow a low residual diet 4 hours after surgery, including nutritional supplements
• Patients are encouraged to get out of bed the evening of surgery and as much as possible during their hospital stay
Enhanced Recovery Pathway • Successful operational implementation of the pathway involved tailored
communication and buy-in from key stakeholders
• Surgeon champions were involved in every step of implementation and delivered education to staff
• Patient education was key to ensure understanding of the protocol
• Investing time into creating tools is critical to success, including patient education materials, order sets and workflows
• Based on the successful reduction in LOS and cost while maintaining high quality of care, the ERAS pathway will be extended to other abdominal surgical procedures.
Lessons Learned
Hypothesis: Reduction in LOS would also reduce costs per patient encounter (prior analyses have shown these two metrics to be proportional) Data Collection: Included all patient encounters for three colorectal surgeons and one gynecological surgeon who participated in the initial ERAS rollout. The protocol was implemented on July 1, 2013 and patient data was collected from July 1 through September 30, 2013 and compared to patient data during the same time period the year prior. There were 99 patient encounters analyzed from 2012 and 129 patient encounters from 2013. Analysis: Analysis showed reductions in LOS and cost per case for laparoscopic and open cases. Significant reductions in cost were seen in pharmacy, inpatient, and operating room expenses, as well as laboratory and inpatient consultations from other services. Readmission rates showed no increase in re-admissions within 30 days between the control and the pilot groups.
Results Fig. 1: Length of Stay Reduction in Days
• Tonia Young-Fadok, MD • Paul Magtibay, MD • Andrew Gorlin, MD • Terrance Trentman, MD • Susan Hagstrom, MD • Eric Nelson, RPh • Bob Graber
• Charles Oligmueller, CRNA • Patricia Whitten, RN • Steve Reimer, RN • Anna Marie Hunsaker, RN • Irene Lewis, RN • Sheryl Castaneda, RN • Joanne Schultz
Contributors
1. Krishna K. Varadhan, Keith R. Neal, Cornelius H.C. Dejong, Kenneth C.H. Fearon, Olle Ljungqvist, Dileep N. Lobo, The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clinical Nutrition, Volume 29, Issue 4, August 2010, 434–440
2. Michel Adamina, MD, PD, MSc, Henrik Kehlet, MD, PhD, George A. Tomlinson, Anthony J. Senagore, MD, MS, MBA, Conor P. Delaney, MD, MCh, PhD. Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery. Surgery, Volume 149, Issue 6, June 2011, 830-840.
References
© 2014 Mayo Foundation for Medical Education and Research
Planning
• In early 2013, the colorectal and gynecology surgical practices at Mayo Clinic in Arizona set out to reduce LOS and improve quality of care through implementation of “Enhanced Recovery After Surgery” (ERAS).
• ERAS is a standardized, evidence-based clinical pathway for pre, peri and post-operative care designed to minimize stress on the body and return the patient back to normal function as quickly as possible.
• Studies have shown ERAS to decrease LOS and result in fewer complications with no difference in readmission rates as compared to control groups (Varadhan et al 2010, Adamina et al 2011).
• Despite the growing body of research supporting ERAS, there are significant barriers to operationalizing the components of the pathway, which are divergent from what surgeons, anesthesiologists, and nurses have been traditionally trained to do, and what patients have typically experienced before and after surgery.
Kripa Krishnan, MPH; Roshanak Didehban, MHS, FACHE; T’Nita Waters, MHS; Andrew Horton, MHSA Mayo Clinic, Phoenix, Arizona
In the midst of a rapidly changing healthcare market, organizations are focusing on strategies to improve value by delivering the highest quality care for the lowest possible cost. One area of high expense is the surgical episode of care, particularly complex cases that typically require more resources and longer lengths of stay (LOS). Typically, the average Medicare DRG payment for these procedures does not cover the high cost of complex care.
Implementation required involvement from a range of areas that “touch” the patient along the surgical care continuum. Implementation included: • Meeting with stakeholders involved in the clinical pathway to discuss the pathway,
educate on expected benefits, and gain acceptance • Tailored education to residents, fellows, OR and inpatient nursing delivered by
surgeon champions • Creation of patient education materials to ensure understanding of surgical
preparation and expectations during recovery • Additional awareness education to scheduling services, registration, pre-
admission, and administrative support staff
Implementation
Patient
Departments of Surgery
Department of Anesthesiology
Patient Education
Scheduling Services
Registration/Pre-
admission
Information Technology
Department of Nursing
Pharmacy
Patient Education Materials
Training/Education Plan
Fig. 2: Cost Reductions by Service Area
11%
12%
14%
19%
20%
20% 40% 60% 80% 100%
Inpa.ent consulta.ons
Laboratory
Opera.ng Room
Inpa.ent
Pharmacy
Fig. 3: Cost Per Case Reductions
Patient education brochure sample, Colorectal Surgery Patient education brochure sample, Gynecology Surgery Sample patient instruction sheet
-‐2.6
-‐1.2
-‐3
-‐2.5
-‐2
-‐1.5
-‐1
-‐0.5
0 Open Laparoscopic
16%
7%
20% 40% 60% 80% 100%
Open
Laparoscopic
