The Pathway to Improve Patient Care- Enhanced Recovery After Surgery (ERAS)Based on the Project Implemented at Al Khor Hospital

Ms. Jenine Joseph 1; Ms. Jincy Joseph Kutty 1; Mr. Jiss Thomas Babychan 1; Ms. Lilly Varghese 2; Dr. Mohamed Sheriff Poolakundan, Specialist 3; Ms. Rawia Ali Amin Sa’abneh, DONE 1; Dr. Wafik Abdel Naeem A Shehata 3, Senior Consultant; AKH ERAS Committee team

Our findings suggest that the project has resulted in improved outcomes and higher patient

satisfaction. Enhanced recovery after surgery protocols have resulted in AKH to decline the

average number of hospital stay which did not exceed four days post operatively for major cases

like TKR. 4 was the highest pain score reported on Numeric Rating Scale. So less than 20% of

patients were only prescribed opioids. Only 6% had post-operative complications like nausea

and vomiting. According to monthly statistics, half of ERAS patients consumed food and liquids

in 6 hours post operatively. 85% of the patient ambulated postoperatively with in 24 hours.

Challenges faced:

▪ Data collection from the concerned unit

▪ Drop in compliance in filling survey

▪ Follow up after discharge was not done

▪ Lack of data before 2014 because Cerner was implemented in 2014

▪ Drop in compliance in filling the compliance checklist

Enhanced recovery after surgery is a multimodal, multi-disciplinary approach that lead to a paradigm shift in

perioperative care, resulting in significant enhancements in clinical outcomes and cost savings. (1)

ERAS protocols are aimed primarily at achieving early recovery, which leads to a shorter hospital stay without

adversely affecting morbidity(6). The care changes from overnight fasting to carbohydrate drinks 2 hour

before surgery, avoid bowel preparations, initiate DVT prophylactics, single dose of prophylactic antibiotics,

short duration of action for general anesthesia, short term neuraxial and nerve block, minimally invasive

approaches instead of large incisions, management of fluids to seek balance rather than large volumes of

intravenous fluids, avoid opiates, resuming oral intake on the day of operation, avoidance of or early removal

of drain and tubes and early mobilizations.(1)

Enhanced recovery after surgery protocols started in AKH in 2014. This has resulted in decline the average

number of hospital stay post operatively for major cases like TKR. It decreased the patient reliance on

systemic Opioids in post-operative phase. Overall pain score declined on Numeric Rating Scale. Post-

operative complications reduced. According to monthly statistics, half of ERAS patients consumed food and

liquids in 6 hours post operatively. 85% of patients mobilized postoperatively within 24 hours. Patient

satisfaction is reported from good to excellent in patient satisfaction survey.

1. Shakeeb Khan, Alan Horgan, Iain Anderson, Professor John MacFie, December. (2009)..

Association of Surgeons of Great Britain and Ireland; Issues in professional practice;

Guidelines for implementation of Enhanced Recovery Protocols. London.

2. Pineda C E, Shelton A A, Hernandez-Boussard T, Morton J M, Welton M L.

(2008).Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the

literature: Centre for Reviews and Dissemination J Gastrointest SurgNov;12(11):2037-44.

3. Safiya Imtiaz Shaikh, D. Nagarekha,M. Marutheesh.(2016). Postoperative nausea and

vomiting: A simple yet complex problem: Anesthesia Essays and Researches. Retrieved

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062207/

4. Alam A, Gomes T, Zheng H, et al.(2012). Long-term analgesic use after low-risk surgery: a

retrospective cohort study: JAMA Internal Medicine. Arch Intern Med.172(5): page425–430

5. Cagla Eskicioglu, Shawn. S. Forbes, Mary-Anne Aarts, Allan Okrainec,

Robin S. McLeod.(2009). Enhanced Recovery after Surgery (ERAS) Programs for Patients

Having Colorectal Surgery: A Meta-analysis of Randomized Trials: Journal of

Gastrointestinal Surgery. Retrieved from https://link.springer.com/article/10.1007%2Fs11605-

009-0927-2

6. Gerbershagen HJ, Aduckathil S, van Wijck AJ, et al. Pain intensity on the first day after

surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology

2013;118:934-44.

7. Jennifer .M, Brian .T. Bateman, Eric Sun(2017). Chronic Opioid Use After Surgery:

Implications for Perioperative Management in the Face of the Opioid Epidemic:

Anesthesia and Analgesia. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119469/

8. Michael .T. Kassin, , Rachel .M .Owen, Sebastian. D .Perez.(2012). Risk Factors for 30-Day

Hospital Readmission among General Surgery Patients: American College of Surgeons.

Retrieved from https://www.journalacs.org/article/S1072-7515(12)00413-9/pdf

OVERVIEW

METHODOLOGY

OBJECTIVES

Data collection and evaluation

1) A compliance checklist tool was developed to measure compliance to ERAS interventions.

2) Patient satisfaction survey tool was developed

CONCLUSION

REFERENCE

0

100

200

300

400

500

600

No

. of

Pat

ien

ts

Month

Enhanced Recovery after Surgery - Patient Coverage [2017-2018]

Sum of Total No. Of Patients Sum of Patients used ERAS coverage

Graph indicates number of patients(67% in 2017 and 60% in 2018) received ERAS interventions,

monthly from Jan 2017 - Dec 2018.The decline in ERAS coverage is due to missing checklist for

analysis.

The purpose of this poster is to make a spotlight on various components of ERAS project implementation in Al

Khor Hospital, focusing on the latest report from Jan 2017 till Dec 2018 and highlight its contribution to the

improvement of peri-operative outcomes such as speedy recovery, early and safe discharge and enhanced

patient satisfaction.

• A multidisciplinary team including; anesthesiologists, surgeons, frontline staff, organizational leaders,

nurse educators, and quality improvement lead was formed in 2014.

• The interventions of ERAS were adopted From Guidelines For Implementation of Enhanced Recovery

Protocols’ December 2009, Association of Surgeons of Great Britain and Ireland, and agreed upon by the

ERAS team.

• Raising awareness and training conducted for all concerned staff.

• Monitoring tools were developed.

• KPI for the success of ERAS project were finalized and these include: Length of stay, Pain score, Opioid

use, Mobilization, Nausea and vomiting and Postoperative feeding.

1. Counseling & Training 2. A curtailed fast (6 hours to solids and 2 hours to clear liquids)

and pre-operative carbohydrate loading3. Avoid Bowel Preparation4. Deep vein thrombosis prophylaxis using low molecular weight

heparin5. A single dose of prophylactic antibiotics covering both aerobic

and anaerobic pathogens

Pre-Operative

1. High (80%) Inspired Oxygen Concentration2. Preventing Hypothermia3. Intra-operative Fluid Therapy4. Short, Transverse Incisions for Open Surgery5. Avoid Post-operative Drains and Nasogastric Tubes6. Short Duration Epidural Analgesia and Local BlocksPeri-Operative

1. Avoidance of opiates and the use of Paracetamol and non steroidal anti-inflammatory drugs (NSAIDS).

2. Continues Oxygen for at least 6 hours Post-operatively3. Early Commencement of Post-Operative Diet4. Early Post-operative mobilization5. Administration of restricted amounts of intravenous fluid6. Regular AuditPost-Operative

Three Phases of ERAS (Enhanced Recovery After Surgery) interventions

• Graph illustrates, only fewer number(3.8% in 2017 and 3.2% in 2018) of patients used Opioids

post operatively during the year Jan 2017 till Dec 2018. Most of them was in the form of oral

Tramadol .

• Over 80% of patients receive opioids after low-risk surgery, such as oxycodone or hydrocodone

(8). Patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk

of long-term opioid use(Alam A. Gomes)

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-18

Dec

-18

Perc

enta

ge o

f p

atie

nts

Month

Percentage Of Patients Used Post Operative Opioids

Graph illustrates, very few patients (2.4% in 2017 and 1.8% in 2018) only reported post-operative nausea

or vomiting. Every 30 min increase in surgery time increase risk of post operative nausea and vomiting

by 60% ( Chatterjee s, Rudra a)

Percentage of Patients with Post Operative Nausea/Vomiting

0%

1%

2%

3%

4%

5%

6%

7%

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-18

Dec

-18

Perc

enta

ge o

f p

atie

nts

Month

Graph illustrates, maximum number of patients (92% in 2017 and 93% in 2018) mobilized within 24

hours post-operatively without adverse outcome contradicting the misconceptions of early

postoperative mobilization.

78%80%82%84%86%88%90%92%94%96%98%

100%

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-18

Dec

-18

Perc

enta

ge o

f p

atie

nts

Month

Post Operative Mobilization

Graph illustrates, on all 6 surgeries, highest post-operative pain reported is less than 4 in Numeric

Rating Scale. According to studies the maximum postoperative pain score 4.1+-2.6(Winfred Misner)

with traditional approaches. German study of more than 50,000 patients, procedures such as open

appendectomy, tonsillectomy and cholecystectomy produced worst Numerical Rating Scale (NRS)pain

scores of 6.0, 5.9 and 5.8, respectively(7)

02468

10

NU

MER

IC R

ATI

NG

SC

OR

E

MONTH

ENT General SurgeryObstetrics Oral and Maxillofacial SurgeryOrthopedics Plastic and Reconstuctive SurgeryUrology

Average Pain Score Recorded During Movement

0%

10%

20%

30%

40%

50%

60%

70%

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-18

Dec

-18Pe

rcen

tage

of

pat

ien

ts

Month

Percentage of Patients received Post Operative Oral Feeding within 24 Hours

Graph illustrates, 39% in 2017 and 44% in 2018 commenced post-operative oral feeding within 24 hours

post-operatively. A meta analysis shows that 45% reduction of post operative complications was seen in

patients receiving early post operative feeding.(Emma.J.Osland)

2.5 1.7 2.2 1.3 1.53.0

1.3 1.7 1.0 1.0

2.92.3 2.2

2.0 2.2

2.4

2.2 2.2 2.72.5

2.7

2.0

1.62.4 1.8

2.5 1.5 1.3

3.52.0

1.0

1.6

1.7

3.3 3.72.9 2.6 3.1 2.8

3.1

3.7

10.0

3.1

2.23.2

1.6 1.52.0

1.7 1.1 1.5 2.2

1.6

1.8

1.81.4 2.0

0123456789

1011121314151617181920

J A N - 1 8 F E B - 1 8 M A R - 1 8 A P R - 1 8 M A Y - 1 8 J U N - 1 8 J U L - 1 8 A U G - 1 8 S E P - 1 8 O C T - 1 8 N O V - 1 8 D E C - 1 8

NO

.OF

DA

YS

MONTH

ENT General Surgery Obstetrics

Oral and Maxillofacial Surgery Orthopedics Plastic and Reconstuctive Surgery

Graph shows overall reduction in hospital length of stay for all surgeries

Above picture shows the ERAS Compliance Check list

RESULTS

Graph illustrates, only few patients were re-admitted during the year 2017 till 2018. Several

studies shows 1/5th of postoperative patients are readmitted within 30 days of surgery due to

post operative pain, surgical site infections(8).

4.8%5.1%

4.8%

2.8%

3.7%

3.1%

5.2%

3.6%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Per

cen

tage

of

un

pla

nn

ed r

e-a

dm

issi

on

Month

Unplanned Re-admission within 28 Days

1. Department of Nursing & Midwifery Education

2. Discharge Lounge

3. Department of Anesthesia

Average Post-operative Length of Stay