Ron Collins, MD FRCP(C)Clinical Assistant Professor, APT, University of British ColumbiaMedical Director, Surgical ServicesProject Lead, Enhanced RecoveryInterior Health AuthorityStaff Anesthesiologist, KGH

•Member of Advisory Panel to Fresenius-Kabi (FLOW: Fluidop.com)

•None of the content or ideas relate to papers from Dr. Joachim Boldt

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

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

• Evidence-based clinical pathways• Multidisciplinary in scope• Outcome driven• Better for patients• Better for healthcare organizations• “Complex” task to implement• Up to 20 elements or milestones

Procedure

n % total

Adverse event %

Prop. Adv. Events %

Avg. LOS

Prop. All LOS

Colectomy

12,767

9.9 28.9 24.3 9.8 23.5

Sm Bowel resection

3,576 2.8 32.9 7.7 13.9 10.6

Inpt. Chole.

11,718

9.1 7.5 5.7 8.7 4.9

Ventral Hernia

7,477 5.8 10.1 4.9 6.3 3.1

Pancreat.

1,927 1.5 34.9 4.4 6.8 3.0

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

• Discreet steps• Evidence-Based• Pre-operative• Intra-operative• Post-operative• Challenges traditional processes

• Overview of pathway• Establish expectations• No mechanical bowel preparation• Carbohydrate beverage (2 ½ hrs)• No sedative premedication

• TEA T9 or T10• Narcotic sparing anesthetic• Goal Directed Fluids with CardioQ• Active warming• Routine anti-emetics• No NGs, no drains

•Optimize epidural analgesia•Narcotic sparing •High-flow O2 for 1 hour•May chew gum in PAR•Full fluids in PAR

•Full fluids Day 0, DAT Day 1•Out of bed 6 hours Day 1•Activity specified•May chew gum in PAR•Full fluids in PAR

Number

Procedure eLOS aLOS

1 Transverse Colectomy

9 days 3 days

2 Resection Terminal Ileum

16 days 14 days

3 Anterior Resection (*) 9 days 4 days4 Low Anterior

Resection9 days 5 days

5 Sigmoid Resection 9 days 4 days6 Hemicolectomy 9 days 4 days

SpecificMeasureable

ActionableRealistic

Timeframe

Reaction LearningApplicationBusiness ImpactROIIntangible Measures

ROI Methodology

• ERACS evaluation based on first 16 pts.• Interviews with 5 individuals • Surveys from 33 individuals • KGH records• ERACS records• CIHI data for RIW• Cost estimates for ERACS start-up

Enhanced Recovery After Colorectal Surgery

16

88% of staff feel ERACS is vital to the success of IH.87% of staff feel that ERACS provides better patient care.Opportunities to improve infrastructure and demonstrate

adaptability.

“The ERACS process is better for patients, and that is what my life’s work is about.”Surgical Ward Nurse

ROI Methodology

• Return on Investment:

• ERACS Cost Summary: $56,413.45

• ($21,500 for ROI)• Mostly one time costs• Traditional cost (RIW 3.42):

$15,884.81• ERACS cost (RIW 1.76): $8,194.42• Savings: $7,690.39 ($123,046.24)

Enhanced Recovery After Colorectal Surgery

18

Length of stay reduced from 12.8 to 4.0 days.RIW reduced from 3.41 to 1.76

Benefit/cost ratio: 2.18ROI: 118%

CIHI estimated cost reduction of 48.4%.

Length of Stay

R.I.W.

Traditional 11.4 2.5

ERAS 5.1 1.7

Length of Stay

R.I.W.

Traditional 11.9 3.5

ERAS 6.0 2.1

• CIHI assigned RIW decreased• >90% of colorectal patients enrolled• Fewer complications overall• Fewer complications in high-risk groups• Caregiver satisfaction• This is the ‘new normal’• There are opportunities…..• Requests from additional surgical groups!