ERAS Key Components

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Enhanced Recovery After Surgery (ERAS) for Elective Colorectal Surgery at Vancouver General Hospital Quality Forum 2015

Transcript of ERAS Key Components

Enhanced Recovery After Surgery (ERAS)for Elective Colorectal Surgery at

Vancouver General Hospital

Quality Forum 2015

Disclosure Statement

We do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.

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Background

• The risk-adjusted reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) demonstrated that patients at Vancouver General Hospital undergoing colorectal surgery had a high odds ratio of postoperative morbidity (1.49).

o Odds ratio >1.0 indicates hospital is performing worse than expected

• Morbidity impacts patients safety and experience, increases length of stay and health care costs.

True North Goals

Enhanced Recovery After SurgeryKey Components

Pre-operative Intra-operative Post-operative

•Pre-admission counselling •Active warming •Early oral nutrition

•Early discharge planning•Use of multi-modal pain management

•Early ambulation

•Reduced fasting duration •Surgical techniques •Early catheter removal

•Carbohydrate loading •Avoidance of prophylactic NG tubes & drains

•Use of chewing gum

•No/selective bowel prep •Defined discharge criteria

•Venous thromboembolism prophylaxis

•Use of multi-modal anti-emetic prophylaxis

•Antibiotic prophylaxis •Use of goal directed peri-operative fluid therapy

•Pre-warming

Audit of compliance & outcomes

Active Patient Involvement

Whole Team Involvement

Methods

• A multidisciplinary team (anesthesiologists, surgeons, frontline staff, organizational leaders and quality improvement staff) was formed in February 2013.

Goal: • To decrease the morbidity rate for general surgery patients

undergoing elective colorectal surgery at Vancouver General Hospital by 50 % by November 2014.

Implementation: • The ERAS protocol was implemented in two phases.

Implementation

Phase 1

February-October 2013 June 2013-Ongoing

Provided ongoing education for surgical staff on the ERAS protocol.

Developed ERAS documents: o Standardized order sets.o Clinical pathway & kardex.o Patient teaching booklet. o Poster highlighting changes in practice. o Automation of ERAS on OR Slate.

Implemented intra-operative components by a core group of anesthesiologists.

Audited compliance with intra-operative components.

Measured patient outcomes in post- anesthesia care unit (PACU).

Phase 2

November 2013-Ongoing

Implemented pre-operative and post-operative components. Audited compliance with all ERAS components. Measured patient outcomes within 30 days after surgery on 100% of ERAS cases.

ERAS Audit Summary for November 2014 (n=18)80%

Pre-o

pe rative In

tra-op

erative P

ost-o

perative

Components sustained >80% compliance

Pre-operative components:• Pre-admission counselling• Use of Chlorhexidine wipes

• Antibiotic prophylaxis within 60 minutes of skin cut

Intra-operative components:• Normothermia (36-38ºC)

• Use of multi-modal anti-emetic prophylaxis

Post-operative components:• Gum chewing • Tolerated high protein drink (Boost)

Areas of Opportunity

• Use of goal directed fluid therapy • Early mobilization • Appropriate use of anti-emetics post-operatively

• Appropriate removal of urinary catheter

• Advancement of the patient diet

% of Components with Compliance > 80% (n=21)

80%

Aggregation of Marginal Gains to Provide Large Benefit

From “The Slight Edge” by Jeff Olsen

Aggregation of Marginal Gains to Provide Large Benefit

From “The Slight Edge” by Jeff Olsen

Preoperativecounselling

Preoperativepreparation Admission

IntraoperativeManagement

Recovery Room

Post-operativeManagement

Discharge

SUCCESS

FAILURE

Pre ERAS Implementation

Post ERAS Implementation

July 2011-June 2013

n=101

Nov 2013-Aug 2014

n=174% Change

Overall Morbidity 37.6% 21% 44.1%

Median Length of Stay (day)

7 5 28.6%

General Surgery Elective Colorectal SurgeryNSQIP Non Risk Adjusted Data

Lessons Learned

• The Power of Real Time Auditing

• It Takes Time to Change Culture

• Communication is Vital

• Value of Patient Partnerships

Sustainment Plan

• Transition of auditing back to unit champions

• Revise documents (PPO, Pathway, etc.)• Full implementation of the Patient Checklist• Continue ongoing education of staff• Continue to engage patients and family

• Continue to audit 100% of ERAS patients

• Disseminate audit results to Steering Committee and stakeholders monthly

• Celebrate the team’s accomplishments

Acknowledgments

• VGH Perioperative Teams

• VCH NSQIP Team• ERAS Patients and Families• ERAS Steering Committee

Contact Information

Andrea Bisaillon, RN BscN

Operations Director - Surgical Services

[email protected]

Tracey Hong, RN BscN

Quality and Patient Safety Coordinator

[email protected]