Does Enhanced Recovery Improve Outcomes? Click to edit ...
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Click to edit Master subtitle style Does Enhanced Recovery Improve Outcomes? Kaare Weber, MD Director of Surgery Associate Medical Director, Surgery A MEMBER OF THE MONTEFIORE HEALTH SYSTEM
Transcript of Does Enhanced Recovery Improve Outcomes? Click to edit ...
ClicktoeditMastersubtitlestyleDoes Enhanced Recovery Improve Outcomes?Kaare Weber, MD
Director of SurgeryAssociate Medical Director, Surgery
A M E M B E R O F T H E M O N T E F I O R E H E A L T H S Y S T E M
ClicktoeditMastersubtitlestylemes?
Kaare Weber, MDDirector of Surgery
Associate Medical Director, Surgery
A M E M B E R O F T H E M O N T E F I O R E H E A L T H S Y S T E M
NoDisclosures
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EnhancedRecoveryAfterSurgery(ERAS)
• ERASmultimodalapproachtoperioperativecaredesignedtoreducesurgicalstress,organdysfunction,andpostoperativecomplications
• ERASfocusesonstandardizationofpreoperative,intraoperativeandpostoperativecarepathwaystoincludeallteammembers– includingthepatient
• EuropecreatedtheInternationalERASSociety2010• AmericanCollegeofSurgeonsNationalSurgicalQualityImprovementProgram
(ACSNSQIP)endorsesERASprograms• In2017,ImprovingSurgicalCareandRecovery(ISCR)programcreatedbyACS
andJohnsHopkinsMedicineArmstrongInstituteforPatientSafetyandQualityandfundedbytheAgencyforHealthcareResearchandQuality(AHRQ)o GoalaidhospitalsacrossthecountrytoadoptERASpathways
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ERASStudies:Europe
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ERASStudies:USExperience
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ERASStudies:Community&LayPress
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BenefitsofEnhancedRecoveryProgram
ImprovedPatient
Outcomes
ImprovedPain
ManagementReducedLOS
ReducedReadmission
Rates
ReducedVTE
ReducedBlood
TransfusionsReducedUTI
ReducedSurgicalSiteInfections
ReducedHospitalAcquiredPneumonia
ImprovedPatient
Satisfaction
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MultidisciplinaryTeam
PatientNurse
PhysicalTherapyPhysician Assistant
Pharmacy
SurgeonNutritionCareManagement Respiratory
Anesthesia
Wound Care
Office Staff InformaticsTeamMedical SubspecialtiesInfectionControl
House Staff
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StandardizedProgramsforEachPhaseofCare
••PatientEducation••Limitfasting••CarbBeverage••IncentiveSpirometer••StandardizedBowelPrep••NasalSwab••OralCare••CHGBathx3••GlucoseControl••MultimodalPainPlan
Pre-op
••Chloraprep SkinPrep••AppropriateAntibiotics••Normothermia••VTEProphylaxis••FluidOptimization••AntiemeticProphylaxis••GlucoseControl••MultimodalPainPlan••Woundprotector••BowelIsolationTech.
Intra-op••ClearLiquidsPOD#0••Hep-lockafterPOtolerated
••FoleyRemoval••Earlyaggressiveambulation
••AntiemeticProphylaxis••GlucoseControl••MultimodalPainPlan
Post-op
MultimodalPain• NeurontinPOx1
dose MultimodalPain• IVOfirmev• IVToradolifnot
contraindicated• ExparelFieldBlock
Infiltration• IVKetamine• Limitnarcotics• IVLidocaine(soon)
MultimodalPain• IVOfirmevx24
hoursthenPOTylenol
• Toradol ifnotcontraindicated
• Neurontin• Narcoticsfor
breakthrough
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ERASWPHOutcomesFirst12months– IntestinalSurgery
Indicator Pre-ERAS Post-ERAS Source
PainManagement 45%ile 99%ile HCAHPS
LengthofStay 7.61 5.78 Meditech
SurgicalSiteInfections 1.30SIR 0.78SIR NHSN
VTEEvents 26% 23% Midas
Pneumonia 6.29 (8) 4.07(4) NSQIP
RenalFailure 2.06 (5) 1.3 (0) NSQIP
UrinaryTractInfection 2.05 (4) 1.73 (0) NSQIP
Morbidity 17.68 (19) 14.43 (11) NSQIP
Mortality 3.33(4) 2.83(2) NSQIP
ReturntoOR 4.9 (5) 5.23 (6) NSQIP
Readmissions 9.96 (7) 10.13 (7) NSQIPHCAHPS– HospitalConsumerAssessmentofHealthcareProvidersandSystemsNHSN– NationalHealthcareSafetyNetworkNSQIP– NationalSurgicalQualityImprovementProgram(SmoothedRate)2015vs.2016YTDSept
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ColorectalPatientSatisfactionScores- Pain
53
99 99
27
99 99
60
99 99
0
10
20
30
40
50
60
70
80
90
100
2015 2016 2017(MayYTD)
Percen
tileRa
nking
PainSatisfactionScoresPre&PostERASMPPImplementation
PainManagementOverall PainWellControlled StaffdoEverythingtoHelpwithPain Linear(PainManagementOverall)
ERASImplementedNovember2015
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ElectiveColorectalSurgery– AverageLengthofStay
0
20
40
60
80
100
120
140
160
180
0
2
4
6
8
10
12
2014 2015 2016 2017
CountofUnitNumber AverageofLengthOfStay
ERASImplementedNovember2015
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ColorectalSSI
ERASImplementedNovember2015
1.3
0.73
1.41
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
2015 2016 2017(SeptYTD)
WhitePlainsHospitalColorectalStandardizedInfectionRatio(SIR)
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ColorectalVTE
ERASImplementedNovember2015
0%
5%
10%
15%
20%
25%
30%
2015 2016 2017(NovYTD)
WhitePlainsHospital%ColorectalVTEfromallPeriopVTEs
2/11
6/23
3/13
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NSQIPColorectalPneumonia
ERASImplementedNovember2015
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NSQIPColorectalUTI
ERASImplementedNovember2015
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NSQIPColorectalMorbidity
ERASImplementedNovember2015
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NSQIPColorectalMortality
ERASImplementedNovember2015
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NSQIPColorectalReturntoOR
ERASImplementedNovember2015
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NSQIPColorectalReadmissions
ERASImplementedNovember2015
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ERASSummary
• ERASisbecomingastandardprotocolforsurgerypatients• Evidencedemonstratesimprovedoutcomeswithoutabilitytopinpointmostimportant
components• ManybelievemultimodalpainplaniskeytothesuccessofanERASprotocol• Requiresculturalchange,persistenceandpatience
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A M E M B E R O F T H E M O N T E F I O R E H E A L T H S Y S T E M
Thankyou!
