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Enhanced Recovery Processes. Ron Collins, MD FRCP(C) Medical Director, Surgical Services Project Lead, Enhanced Recovery Interior Health Authority Staff Anesthesiologist, KGH.

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Enhanced recovery processes

Enhanced Recovery Processes

Ron Collins, MD FRCP(C)

Medical Director, Surgical Services

Project Lead, Enhanced Recovery

Interior Health Authority

Staff Anesthesiologist, KGH


Relative Contributions to Adverse Events and Excess Length of Stayadapted from Fry et al, J Am CollSurg 2008;207:698-704


of StayUltimately, improving quality will require efforts that go beyond outcomes assessment alone. Future work should aim to improve our current understanding of processes of care associated with superior surgical outcomes.”Fry et al., J. Am CollSurg 2008;207:698-704


Quality improvement
Quality Improvement of Stay

  • Efforts to improve quality of care generally depend on assessing three dimensions:

  • Structure: the system in which health care is delivered.

  • Process: the care received.

  • Outcomes: the results of the above (mortality, morbidity including LOS).

    • Cohen ME et al, Ann Surg 2009;250:901-907


Variability in los after colorectal surgery cohen et al ann surg 2009 250 901 907
Variability in LOS After Colorectal Surgery of StayCohen et al, Ann Surg 2009;250:901-907

NSQIP data from 182 hospitals from Jan/06 to Dec/07: 23,098 patients

eLOS > 75th percentile of distribution, role of complications (19 defined), O/E ratios

No complications: LOS 6.1 days, but eLOS > 8 days

Complications: LOS 16.1 days, but eLOS > 20 days

“…hospitals with lower risk-adjusted morbidity had shorter risk-adjusted LOS.”

“For efficiency measures to be widely accepted in the market, they should be feasible to implement, credible and reliable for patients, and fair and actionable for healthcare providers.”


Enhanced recovery after colorectal surgery
Enhanced Recovery After Colorectal Surgery of Stay

  • Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery

  • Kehlet, H. and Wilmore, D.; Ann Surg 2008;248:189-98

  • Consensus Review of Optimal Peri-operative Care in Colorectal Surgery

  • ERAS Group; Arch Surg. 2009;144(10):961-969


Implementation of a Fast-track of Stayperioperative care Program: what are the difficulties?Polle, sw et al, Dig surg 2007;24:441-449

ERAS program: 13 elements but only 7.4 implemented per patient

Compliance did not improve with the experience of the team

Attributed to bad collaboration of the three different disciplines in daily practice

No impact on clinical outcomes: LOS, morbidity, patient satisfaction


Implementing new routines are we using best practice
Implementing new routines of StayAre we using ”Best practice”?

The German ”Prevalence”Study in ICU

92%

M M Levy, ASPEN 2007


It is not like we think it is
It is not like we think it is…. of Stay

The German ”Prevalence”Study

92%

4%

M M Levy, ASPEN 2007


Enhanced recovery after surgery
Enhanced Recovery After Surgery of Stay

“The profession has placed high value on developing the basic science of medicine: it has not emphasized the process by which the science is translated into practice…”

Eddy, DM. N Engl J Med 1982;307:343-7


Adherence to the ERAS protocol and outcomes after colorectal cancer surgeryERAS group, Arch Surg 2011;146:571-77

  • 27% improvement in adherence (47% to 74%)

  • 27% reduction in any 30 day morbidity

  • In fact: dose-response curve for adherence:

  • 70% adherence: LOS 7.4 days; OR morbidity: 0.62

  • 80% adherence: LOS 7.0 days; OR morbidity: 0.57

  • 90% adherence: LOS 6.0 days; OR morbidity: 0.33

  • Elements most predictive of good outcome:

  • GD fluid management, Pre-operative CHO beverage


Adherence to the ERAS protocol and outcomes after colorectal cancer surgery ERAS group, Arch Surg 2011;146:571-77

  • Prospective Cohort Study: 464 controls (2002-04), 489 study (2005-07)

  • Second cohort higher risk, more difficult surgery

  • 12 ERAS elements, unchanged

  • Staffing, infrastructure unchanged

  • Study compared outcomes and adherence for two periods

  • MLRA examined the importance of each element in the pathway


Interior Health Authority cancer surgery

IH Overall

Intra-operative Fluid Management

Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia


Interior Health Authority cancer surgery

IH Overall

Length Of Stay

Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia


Length of stay reduced from 12.8 to 4.0 days. cancer surgery

RIW reduced from 3.41 to 1.76

Benefit/cost ratio: 2.18

ROI: 118%

CIHI estimated cost reduction of 48.4%.


Cmg open colorectal resection
CMG: Open Colorectal Resection cancer surgery

CIHI: cost of care reduced by 33%


Cmg colorectal resection with stoma
CMG: Colorectal Resection with Stoma cancer surgery

CIHI: cost of care reduced by 40%


What is the role of gdt
What is the role of GDT? cancer surgery


AUTONOMY cancer surgery

PURPOSE

MASTERY


Enhanced recovery society of canada
Enhanced Recovery Society of Canada cancer surgery

  • Mission: “To support the development and implementation of processes of care that result in outcome benefits for surgical patients.”

  • Sister Society in Canada of ERAS Society

  • Website: www.enhancedrecovery.ca

  • Inaugural Chairperson: Prof. F. Carli: MUHC

  • Website development courtesy of: Fresenius-Kabi and Deltex Medical.


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