Enhanced Recovery After Surgery - Advocate Health Care · Enhanced Recovery After Surgery Thomas...
Transcript of Enhanced Recovery After Surgery - Advocate Health Care · Enhanced Recovery After Surgery Thomas...
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Enhanced Recovery After SurgeryThomas Aloia, MD, FACS and Vijaya Gottumukkala, MB, BS, MD (Anes), FRCA
The University of Texas MD Anderson Cancer Center
March 7 – 8, 2017
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Welcome
• Ask a question using the Skype Q&A box at the top right
• To see all questions click on “all”An orange dot next to “all” means a new question has been asked
• As many questions as possible will be answered at the end of the presentation
• A list of Q&A’s from all sessions will be sent after March 8th
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Confirm Your AttendancePhysicians and Non-Physicians
• All Skype participantsEnter your name in the Skype Q&A box at the top right and click “ask”
• All Telepresence participantsSend an email to Carol Rizzie at [email protected]
This is to confirm your attendance
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Education Credit for Tue, Mar 7
• Physicians Only– Go to activity.credit (www or http not necessary)
– Input code “BXCRHB” into the box
– Sign in, verify profile, choose password and click Save
– Follow remaining steps
– CODE EXPIRES IN 30 DAYS
– BEING LOGGED ON OR IN ATTENDANCE DOES NOT TRACK CME
• Non-physicians– Certificate of attendance will be sent after March 8th
Contact Carol Rizzie with questions [email protected]
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Disclosures
• Thomas Aloia, Faculty – Nothing to disclose
• Charles Derus, Planner / Faculty – Nothing to disclose
• Vijaya Gottumukkala, Faculty – Pacira: Consultant
• Carol Rizzie, Planner – Nothing to disclose
• Michelle Ruther, Planner – Nothing to disclose
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Vijaya Gottumukkala M.B;B.S, M.D (Anes), F.R.C.A
ProfessorDeputy Chairman & Clinical Director
Director, Cancer Anesthesia Fellowship ProgramDepartment of Anesthesiology & Perioperative Medicine
The University of Texas MD Anderson Cancer CenterHouston, Texas- U.S.A
Enhanced Surgical Recovery Program
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• PACIRA
• MEDTRONIC INC.
Enhanced Surgical Recovery Program
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online-metrics.com
Objectives:
Enhanced Surgical Recovery Program
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FUNCTIONAL AND DISABILITY FREE SURVIVAL
Enhanced Surgical Recovery Program
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RISING HEALTH CARE COSTS IN THE US
2015: $ 9,990.00 PP; 17.8% GDP
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JAMA 2012; 307:1513-1516
Value Proposition in Health Care
Safe Surgery AndAnesthetic Care
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ACUTE SURGICAL CARE IN THE USA
https://www.hcup-us.ahrq.gov/reports/statbriefs/sb186-Operating-Room-Procedures-United-States-2012.pdf.
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Transforming health care delivery in the US
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What do Consumers Want from Surgical Care?
Source: Market Innovation Center 2015 Surgical Care Consumer Choice Survey.©2016 The Advisory Board Company
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Bending the cost curveImproving surgical outcomes
Traditional Care Models are not conducive for delivery of value based
surgical care and helping bend the cost curve
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Transforming Perioperative Care of the surgical patient
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Enhanced Surgical Recovery Program
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TRANSFORMING PERIOPERATIVE CAREBuilding Blocks - MDACC ESRP
Patient Factors: Disease burden, Medical Optimization, functional status
Surgeon factors: Approach, surgical skill, extent of resectionIm
pro
ve S
urg
ical
Ou
tco
mes
Deliver High Value Care
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• Not a technique• Philosophy of care• Perioperative continuum• Multidisciplinary• Minimize symptom burden and complications• Enhance Functional Recovery• Effective care transitions• Reduce/minimize readmissions• Track outcomes and HRQoL measures• Improve population health• Reduce cost of care delivery
Enhanced Surgical Recovery Program
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MINIMIZING VARIATION IN PROCESSES OF CARE DELIVERY
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Setting up an Enhanced Recovery Program
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Fearon KCH, et al. Clinical Nutrition 2005; 24: 466-477
Setting up an Enhanced Recovery Program
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Setting up an Enhanced Recovery Program
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• Choose Wisely Campaign
• Optimize patients condition
• Patient and care-giver education and engagement
• MINIMIZE SURGICAL STRESS (MIS)
• Procedure specific opioid sparing analgesia strategies
• Minimize oxygen debt (fluids therapy-hemodynamic optimization-blood management)
• Optimal Anesthetic Care
• Pathway based postoperative care
• Early DRinking Eating AMbulating
• Early diagnosis and rapid response to manage postop complications
• Post discharge care (transitions)
FUNCTIONAL AND DISABILITY FREE SURVIVAL
MDACC Enhanced Recovery Pathway
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PATIENT EDUCATION, ENGAGEMENT AND EMPOWERMENT
MDACC Enhanced Recovery Pathway
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MDACC Enhanced Recovery Pathway Preoperative Maneuvers
• Clear liquids up to 2 hours prior to reporting for surgery
• Preventive analgesia
Celecoxib
X
XPregabalin/Gabapentin
Oral Acetaminophen
Image modified from aafp.org
Tramadol ER
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Enhanced Recovery PathwayIntraoperative Opioid Sparing Strategies
X X
x IV Acetaminophen
Ketamine Or N2O
Dexmedetomidine
Lidocaine infusion
Epidural
XTAP Block
PVB
Wound Infiltration
PIC Block
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Immediate Postoperative care: PACU and POD 0 Rapid Emergence from Anesthesia
Dynamic Pain Control
Opioid Sparing Strategies
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• Choose Wisely Campaign
• Optimize patients condition
• Patient and care-giver education and engagement
• MINIMIZE SURGICAL STRESS (MIS)
• Procedure specific opioid sparing analgesia strategies
• Minimize oxygen debt (fluids therapy-hemodynamic optimization-blood management)
• Optimal Anesthetic Care
• Pathway based postoperative care
• Early DRinking Eating AMbulating
• Early diagnosis and rapid response to manage postop complications
FUNCTIONAL AND DISABILITY FREE SURVIVAL
MDACC Enhanced Recovery Pathway
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GDT vs. Conventional
A= PNEUMONIA; B= RENAL COMPLICATIONS
MORTALITY
Anesth Analg 2012;114:640–51
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Variability in practice and factors predictive of total crystalloidadministration during abdominal surgery: retrospective
two-centre analysis
BJA 114 (5): 767–76 (2015)
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Monitoring Needs and Goal-directed Fluid Therapy Within an Enhanced Recovery Program Anesthesiology Clin 33 (2015) 35–49
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Monitoring Needs and Goal-directed Fluid Therapy Within an Enhanced Recovery Program Anesthesiology Clin 33 (2015) 35–49
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ANESTHESIOLOGY 2015; 123:307-19
MAINTAINING TISSUE PERFUSIONAVOIDING OXYGEN DEBT
AVOIDING DEEP ANESTHESIA
PERIOPERATIVE ANESTHETIC STRATEGIES AT MDACC
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Meta-analysis of RCT assessing use of intraoperative BIS and risk for POD
Avidan MS. IARS 2013 REVIEW COURSE LECTURES
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Atelectasis and perioperative pulmonary complications in high-risk patients
Curr Opin Anesthesiol 2012, 25:1-10
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Atelectasis and perioperative pulmonarycomplications in high-risk patients
Curr Opin Anesthesiol 2012, 25:1-10
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Neuromuscular Reversal and Monitoring
Anesthesiology 2017; 126 (1): 1-4
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Postoperative Care In The Hospital“ Get Back on Track “
Ambulation Pulmonary Rehab Balanced Enteral Diet
Opioids: Good, Bad and The Ugly Optimal Fluid TherapyDynamic Pain Control
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Improving Postoperative Care
Need Rapid Diagnosis, Response And Rescue
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Burden of Postoperative Complications After Major Surgery
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Burden of Postoperative Complications After Major Surgery
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Am J Med Qual. 2012; 27:383-390
Effect of Postoperative Complications
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Discharge Planning and Post discharge Care
Improving Postoperative Care
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Preoperative: Preventive Analgesia (Oral Pregabalin, Celecoxib, Tramadol ER) and PONV prophylaxis
Intraoperative: Regional Block: PVB/Epidural/TAP Block/Wound infiltration, Opioid sparing strategiesSteroids, IV Tylenol,Dexmedetomidine, IV Lidocaine and Ketamine infusionsTIVA Propofol
Optimal anesthetic plan: Normothermia, Euglycemia, Goal directed Fluid therapy, Hemodynamic optimization, Permissive hypercapnia, LPV strategies, Blood management protocol, Avoid deep anesthesiaComplete rversal of NMB
ostoperative: Opioid sparing strategies
Early DRinking Eating AMbulatingEarly diagnosis and rapid responseTransition of care planningTracking measures and outcomes (RIOT)
PERIOPERATIVE CARE OF THE CANCER PATIENTIMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
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Enhanced Surgical Recovery Program
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MDACC ENHANCED SURGICAL RECOVERY PROGRAM
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MDASI Life Interference Scores
*Aloia/Gottumukkala, JACS, 2015
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MDACC Liver SurgeryTraditional vs. ERLS
0
10
20
30
40
50
60
70
80
Early paincontrol
Complications Mortality LOS
Traditional Recovery-43 Enhanced Recovery-75
*Aloia/Gottumukkala, JACS, 2015
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Enhanced Recovery In Liver Surgery
Factors for Recovery
Factor No RTB Int RTB Int Uni p-value
Multi p-value OR (95% CI)
Age >=65 22 (32) 17 (35) 0.749
Male 35 (51) 30 (61) 0.259
Preop Chemotherapy 51 (74) 39 (80) 0.475
Minimally Invasive 14 (20) 17 (34) 0.080 0.530
Major Hepatectomy 26 (38) 11 (22) 0.079 0.069
Operation Time >= 300 m 30 (45) 16 (33) 0.235
Epidural 35 (51) 28 (57) 0.491
ERLS 38 (55) 37 (76) 0.023 0.021 2.62 (1.15 – 5.94)
LOS > 5 Days 34 (49) 19 (39) 0.259
Any Complication 35 (51) 19 (39) 0.199
Major Complication 9 (13) 7 (14) 0.846
*Aloia/Gottumukkala, JACS, 2015
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Variable Pre-ERP Post-ERP p-value
Length of Stay 4 days (2-27) 3 days (1-11) 0.001
Readmissions 11.7% 12% 1.00
GI complications 24% 15% 0.26
GU
Complications
6% 13% 0.22
Neurologic
Complications
0.01% 0.02% 1.00
Hematologic
Complications
6% 14% 0.13
RIOT* 30 (15-52) 22 (20-41) 0.08
ESRP- GYN
Preliminary Impact on LOS/Complications and RIOT
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Enhanced Recovery In Liver SurgeryApproach Over Incision
0
1
2
3
4
5
6
7
8
Open MIS
LOS
Day
s
Trad
ERAS
p<0.01
*Aloia/Gottumukkala, JACS, 2015
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ERILS Readmissions
0
5
10
15
20
25
30
% High Risk Patients Readmitted
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Time to Return to Intended
Oncologic Therapy
0 10 20 30 40
Baseline
ERILS
Postop Days
Next Step:Can Surgical
Recovery Impact Cancer-
Specific Survivals?
95%
87%
Enhance
RecoveryRIOT
Decrease
Recurrence
Improve Survivals
*Aloia/Gottumukkala, JSO, 2014
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OSJ Prevents “Poor Recovery”
• Primary outcome: “Poor Recovery”
– Composite endpoint (LOS > 7 or readmission w/in 30 days)
• Predictors of poor recovery
– Every 1 complication increases risk of poor recovery 2.4-fold
– Use of the OSJ decreases risk of poor recovery 8-fold
Odds Ratio 95% CI P-value
Diversion type 2.28 0.45 – 11.70 0.32
Operation length 1.00 0.997 – 1.011 0.27
Opioid use 1.01 0.991 – 1.025 0.37
# Complications 2.43 1.645 – 3.596 < 0.001
OSJ (yes vs. no) 0.12 0.031 – 0.459 0.002
Shah & Cata et al- Unpublished data
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Impact on PRO’s, Opioid Consumption,
PACU pain scores
• MDASI-OC: Significant decrease in severity of nausea,
sleep disturbance, constipation, urinary urgency and
difficulty with memory during the hospitalization period
• 70% reduction in intra-operative morphine equivalents
(P<0.001)
– Pre-ERP median 151 mg (25-263)
– Post-ERP median 45 mg (5-137.5)
• 34% reduction in PACU pain scores (p=0.01)
– Pre-ERP mean 6.04
– Post-ERP mean 3.98
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Enhanced Recovery After Thoracic
Surgery
Ann Thorac Surg 2015;99:1953–60
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MDACC ERP Teams – 2012 to 2017
Anesthesiology
Surgery
Nursing
Pharmacy
Nutrition
H&N
Surgery
GYN
Surgery
HIPEC
Surgery
Spine
Surgery
Neuro
Surgery
Colorectal
Surgery
Liver
Surgery
Bladder
Surgery
Breast
Surgery
Thoracic
Surgery
GIM
SCT
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Understanding Process- Measuring Outcomes
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planzsolutions.com
Enhanced Surgical Recovery Program
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• What elements should be
routine care ?
• What are core elements of
ERP?
• How do we define core elements ?
• How do we track compliance ?
• What outcomes do we measure ?
• What tools do we use to measure outcomes ?
• How do we normalize elements of care ?
Enhanced Surgical Recovery Program
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Patient Reported Outcomes Frequency/Definition
Procedure specific perioperative symptom
burden
MDASI Symptom Severity
(validated 13 core items, plus procedure specific module
items) Pre-op; Daily until discharge; Weekly for up to 3
months postop
Postoperative morbidity (symptom burden and
functional interference)
Postop days 1,3,5,7 and at discharge and first
postoperative follow-up
Return to baseline functional status Days from surgery to return to baseline functional
status
Clinical Outcomes Frequency/Definition
Post operative complications Count, frequency, grade
Medical readiness for discharge (MRD) and
Return to Intended oncological therapy (RIOT)
Days from surgery to MRD and RIOT
All Readmissions 30, 60 and 90 Day
Business Outcomes Frequency/Definition
Length of hospital stay Days from surgery to discharge
Episode or total TDABC cost for patient Total true MDACC costs / total patient costs
Modified from John Calhoun- ICCI, MDACC
Enhanced Surgical Recovery Program
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5.1d
4.7 d
7.2 d
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CHANGE ISHARD AT THE BEGINNING
MESSY IN THE MIDDLE
GORGEOUS AT THE ENDMarlosneoldeous.com
Enhanced Surgical Recovery Program
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PERIOPERATIVE CARE OF THE CANCER PATIENTIMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
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How to Build the ERAS Team
Thomas A. Aloia, MDAssociate Professor of Surgical Oncology
Division Director of Quality and Outcomes
Deputy Department Chair for Education
Associate Head, Institute for Cancer Care Innovation
Advocate MDs 02.2017
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Disclosures
• Financial: None
• Personal: Recovering Transplant Surgeon
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
• Teamwork
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I can’t tell you how to
build an ER program
unless you tell me why
you want to do ER
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Why Do You Want to Do ER?
What Is Your Vision/Goal??
ERP
Elements
??
Anesthesia-Surgery-Nursing
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What is the Goal?
More Than LOS?
0 50 100
Physical Performance Tests
Cost
Patient Satisfaction
Immunologic Factors
Pain Med Usage
Quality of Life
Bowel Function
Readmission
Mortality
LOS
Morbidity
% of Papers
MD Centric
Patient Centric
*Day & Aloia, BJS, 2015
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What Is Your ER Goal?
A. Reduce complications– Enhanced Safety Program
B. Save the hospital money– Enhanced Finance Program
C. Lower length of stay– Enhanced Discharge Program
D. Make them to poop faster (see answer C.)– Enhanced BM Program
E. Help patients recover faster– Enhanced Recovery Program
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
• Teamwork
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Surgeon/Trainee Issues
• Single largest impediment to LOS reduction is unwillingness to advance diet– Eliminate from ordersets and vocabulary
• Sips of Clears
• ADAT
• Full Liquid Diet
– POD0-1 Clears ad lib
– POD2 Regular or ADA Diet
• Second largest impediment to LOS is excessive fluid administration post op– SL at 600 mL PO intake
– UO 50cc/2 hrs acceptable
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Mayo Clinic Colectomy LOS
0
1
2
3
4
5
LO
S in
Days
Inte
rve
ntion
Inte
rve
ntion
Inte
rve
ntion
Inte
rve
ntion
Intervention #4:
No fluid bolus
without attending
approval
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
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Patient Recovery is the GoalCrossing the Quality Chasm
Health Care Goals
• Aim 1: Safe
• Aim 2: Effective
• Aim 3: Patient-Centered
• Aim 4: Timely
• Aim 5: Efficient
• Aim 6: Equitable
Patient Goals
• Don’t Hurt me
• Cure me
• Recover me
• See me quickly
• Avoid unnecessary tests
• Don’t Bankrupt me
The Institute of Medicine. Crossing the Quality Chasm:
A New Health System for the 21st Century, 2001
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
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People don't resist change. They resist
being changed
-Peter Senge
Setting up an Enhanced Recovery ProgramElements, Buy-in, Hurdles, and Conflict Resolution
Lesson 1:It’s Not Personal,
So Don’t Make It Personal
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Non-Narcotic AnalgesiaControl: Surgeon Surg/Anesth Anesthesia
MIS
• Preop
– (Limited bowel prep)
• Intraop
– Antiemetics
– Small Incisions
– Local Analgesia
• Postop
– Minimized Tubes and Drains
– Early Feeding
– Early Mobilization
MIS + ER
• Preop– Education
– Prehabilitation
– Premedication
– Diet
• Intraop– Steroids
– PROMPT Anesthesia
– Regional Blocks
– Fluid Limitation
• Postop– Non-Narcotic Analgesia
– Immediate Feeding
– SL IVF
-Many more elements
-Much more
collaboration
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Communication Keys• Long before the case
– Premeds
– Regional blocks
– Fluids
– Narcotics
• Night before case– Next day’s plan
• After the case– Share successes
• If the metric of success is patient recovery and surgeons never show anesthesiology providers an early recovered patient they should not expect buy-in
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The Best Part of ERAS
Implementation
• Bringing Together Surgery and Anesthesia
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
• Teamwork
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Nursing Concerns
• Patients are moving too fast– Diet intolerance
– Foley removal failures
– Discharge planning
• Concern for inadequate pain control– Stairstep prn regimen
• Mild pain (1-4)=Tylenol
• Moderate pain (5-7)=Tramadol
• Severe pain (8-10) (low dose dilaudid and call)
– Very low dose Dilaudid PCARemember the Goal:
Patient Experience
NOT Patient Torture in
A Quest to Reduce LOS
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Epidurals and Foleys
• Women
– foley out when independent to the bathroom
• Men
– <30 no help
– 30-50 ambulate to bathroom=foley removal
– >50 premed with Flomax and removeAutomatic foley
removal orders
are associated
with a 17%
replacement rate
“Anyone who
advocates for Foley
removal on a set
day or time has not
had one replaced
while awake” ~TAA
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
• Teamwork
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To the C-Suite:
1. Join the Team
2. Resource the Team
3. Let doctors be doctors and
nurses be nurses
4. The ROI will come
LOS reduction is
the residue of a
high-quality ERP
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ESRP Annual $ Impact
7.2 d
4.7 dTHE FORMULA
(Total OR/1000) X days reduced LOS
=$millions to margin per yr
(13,000 inpt operations/1000 x 2.5 days LOS)
13 x 2.5=$32.5 million per year
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Agenda/Challenges
• Why do you want to do ER?
• Issues
– Trainee
– Patient
– Anesthesia/Surgery
– Nursing
– Hospital Administration
• Teamwork
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ER Team Set-up Plan
1. Determine the Why
2. Form the Team– Punch tickets
– Meet weekly
3. Revise/Develop ordersets and pathways
4. Develop compliance metrics– Measure and Report
5. Develop outcome metrics (PRO)– Measure and Report
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ER Team Set-up Plan
1. Determine the Why
2. Form the Team– Punch tickets
– Meet weekly
3. Revise/Develop ordersets and pathways
4. Develop compliance metrics– Measure and Report
5. Develop outcome metrics (PRO)– Measure and Report
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Simon Sinek: Start with Why
“People do not buy WHAT you do,
they buy WHY you do it.”
Team members don’t buy-in to the
product or change they are working
on, they buy-in to why the team is
making the product or change.
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Setting up an Enhanced Recovery ProgramElements, Buy-in, Hurdles, and Conflict Resolution
There are only two ways to
influence human behavior:
you can manipulate it or
you can inspire it.
Patient-centered care is
inspirational.
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Catherinescareercorner.com
Setting up an Enhanced Recovery ProgramElements, Buy-in, Hurdles, and Conflict Resolution
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ER Team Set-up Plan
1. Determine the Why
2. Form the Team– Punch tickets
– Meet weekly
3. Revise/Develop ordersets and pathways
4. Develop compliance metrics– Measure and Report
5. Develop outcome metrics (PRO)– Measure and Report
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Early vs. Late Adopters
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The Team
• Anesthesia/Surgery
• Nursing
– Clinic
– Periop
– Inpatient
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The (Super) Team
• Anesthesia/Surgery
• Nursing
– Clinic
– Periop
– Inpatient
• Pharmacy
• Nutrition
• Patient Education
• PMNR
• Coordinator
• IT
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ER Team Set-up Plan
1. Determine the Why
2. Form the Team– Punch tickets
– Meet weekly
3. Revise/Develop ordersets and pathways
4. Develop compliance metrics– Measure and Report
5. Develop outcome metrics (PRO)– Measure and Report
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Brent James
“It’s more important that you do it the
same way than what you think is the
right way.”
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Brent James
“It’s more important that you
[organization] do it the same way
than what you [individual] think is the
right way.”
Think globally (patient-centric),
then act locally
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Ordersets and Pathways
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www.sages.org/smart-enhanced-
recovery-program
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ER Team Set-up Plan
1. Determine the Why
2. Form the Team– Punch tickets
– Meet weekly
3. Revise/Develop ordersets and pathways
4. Develop compliance metrics– Measure and Report
5. Develop outcome metrics (PRO)– Measure and Report
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0
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Colorectal ERAS Studies Elements Reporting
Named Element Explained Element Compliance Reported
*Day, Gottumukkala & Aloia, BJS, 2015
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ER Team Set-up Plan
1. Determine the Why
2. Form the Team– Punch tickets
– Meet weekly
3. Revise/Develop ordersets and pathways
4. Develop compliance metrics– Measure and Report
5. Develop outcome metrics (PRO)– Measure and Report
![Page 117: Enhanced Recovery After Surgery - Advocate Health Care · Enhanced Recovery After Surgery Thomas Aloia, MD, FACS and Vijaya Gottumukkala, MB, BS, MD (Anes), FRCA ... Blood management](https://reader030.fdocuments.net/reader030/viewer/2022041003/5ea637d9f0211f18233ea53d/html5/thumbnails/117.jpg)
windsonline.com
Setting up an Enhanced Recovery ProgramElements, Buy-in, Hurdles, and Conflict Resolution
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ERAS Plan
PROs: Symptom Interference
ERP
ElementsReduce Anxiety,
Narcotics, and
Fluids
Return to Normal
Function ASAP
Anesthesia-Surgery-Nursing
If your focus is
the patient’s
recovery
experience, your
program will be
successful.
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VM-Many Thanks
Thomas A. Aloia, M.D., F.A.C.S.MD Anderson Cancer Center
Thank You!ER @ MDACC
Steven Swisher/Thomas Feeley
Vijay Gottumukkala/Thomas Rahlfs/Carin Hagberg
John Calhoun
Clinical TeamsHPB Anesthesia/CRNAs
Surgical Oncology and HPB Surgery Fellows
Sharon Fielder/Whitney Dewhurst/Leigh Samp
Research TeamsCharles Cleeland/Shelley Wang
Ryan Day, MD, Bradford Kim, MD, MPH, Catherine Hambleton, MD
Pharmacy/Nutrition Support
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Patient Education and Engagement
Early F
eedin
g
Goal D
irecte
d
Flu
id T
he
rap
y
Non-n
arc
otic
analg
esia
Am
bula
tion
Enhanced Recovery
What Areas
Need Most
Work?
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