Susp surgeon call february 26 2014
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Enhanced Recovery (ERAS) . SUSP Surgeon call February 26, 2014. 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.

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SUSP Surgeon call February 26, 2014

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Enhanced Recovery (ERAS)

SUSP Surgeon call

February 26, 2014


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. LangenbecksArchSurg (2011) 396:585–559

  • Supportedby large bodyofevidence in virtuallyeveryfieldfromvasculartobariatricsto Whipple tocolorectal


Supporting DATA

  • Dis 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


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


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


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!


Develop Clinical Specifics and Standardization of care

Clinic

Prep

Inpatient and ICU unit

PACU (pain control and mobilization)

Post-op pain control plan


Financial Analysis


Example of ERAS Pathway at Johns Hopkins Hospital


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


Our Model

Reducing Surgical Site Infections

Translating Evidence Into Practice

(TRiP)

Comprehensive Unit based Safety Program (CUSP)

  • Emerging Evidence

  • Local Opportunities to Improve

  • Collaborative learning

  • Summarize the evidence in a checklist

  • Identify local barriers to implementation

  • Measure performance

  • Ensure all patients get the evidence

    • Engage

    • Educate

    • Execute

    • Evaluate

Educate staff on science of safety

Identify defects

Assign executive to adopt unit

Learn from one defect per quarter

Implement teamwork tools

Technical Work

Adaptive Work


Discussion


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