Guidance on the Enhanced Recovery Programme in Colorectal ...
Reduce Overall Colorectal Morbidity through the Implementation of Enhanced Recovery After Surgery...
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Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at
Vancouver General Hospital
Quality Forum 2014
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Disclosure Statement
We do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.
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Our Site
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Background
• The risk-adjusted reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) demonstrate that patients at Vancouver General Hospital undergoing colorectal surgery have a high odds ratio of postoperative morbidity (1.50-1.54).
o Odds ratio >1.0 indicates hospital is performing worse than expected
• Morbidity impacts patients safety and experience,
increases length of stay and health care costs.
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True North Goals
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Enhanced Recovery After Surgery
Pre-operative Intra-operative Post-operative
•Pre-admission education •Active warming •Early oral nutrition
•Early discharge planning •Opioid-sparing technique •Early ambulation
•Reduced fasting duration •Surgical techniques •Early catheter removal
•Carbohydrate loading •Avoidance of prophylactic NG tubes & drains
•Use of chewing gum
•No/selective bowel prep •Defined discharge criteria
•Venous thromboembolism prophylaxis •Goal directed peri-operative fluid management
•Antibiotic prophylaxis •Pain & nausea management
•Pre-warming
Audit of compliance & outcomes
Active Patient Involvement
Whole Team Involvement
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Methods • A multidisciplinary team (anesthesiologists, surgeons, frontline staff,
organizational leaders and quality improvement staff) was formed in February 2013.
Goal: • To decrease the morbidity rate for general surgery patients
undergoing elective colorectal surgery at Vancouver General Hospital by 50 % by June 2014.
Implementation: • The ERAS protocol was implemented in two phases.
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Implementation
Phase 1
February-October 2013 June 2013-Ongoing
Provided ongoing education for surgical staff on the ERAS protocol Developed ERAS documents:
o Standardized order sets o Clinical pathway & kardex o Patient teaching booklet o Poster highlighting changes in practice
Implemented intra-operative components by a core group of anesthesiologists Audited compliance with intra-operative components Measured patient outcomes in post- anesthesia care unit (PACU)
Phase 2
November 2013-Ongoing
Implemented pre-operative and post-operative components Audited compliance with all ERAS components Measured patient outcomes within 30 days after surgery
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Progress so far…..
• June-December 2013 Audited103 cases for intra-operative components
• Compliance 80-100%: Normothermia Prophylaxis antibiotics within 60min of skin cut Appropriate prophylaxis anti-emetics
• Areas of opportunity: Goal directed fluid management Antibiotics re-dosing
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Progress so far….. • November-December 2013
Audited 31 cases for all components • Compliance 80-100%: Pre-admission education Use of chewing gum
• Areas of opportunity: Use of ERAS order set Early mobilization Appropriate use of anti-emetics Appropriate removal of urinary catheter
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Mean Length of Stay* in Post Anesthesia Care Unit (PACU)
*Times patient enters PACU to times when PACU discharge criteria is met
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Complications in Post Anesthesia Care Unit
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Mean Hospital Length of Stay (days)
7.3 7.2
4.8
October November December
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Lessons Learned
• Process mapping • Team building • Communication • Culture of quality and patient safety
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Sustainment Plan • Continue ongoing education of staff • Continue to engage patients and family • Continue to audit 100% of ERAS patients • Disseminate audit results to Steering Committee
and stakeholders monthly • Celebrate the team’s accomplishments
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Acknowledgments
• VGH Perioperative Teams • VCH NSQIP Team • ERAS Steering Committee • Numerous Patients and Families • Stephen Parker: Clinical Nurse Specialist, PHC • Deborah Bachand: Projects Manager, Surgical Services, VIHA
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Contact Information
Andrea Bisaillon, RN BscN Operations Director - Surgical Services [email protected] Tracey Hong, RN BscN Quality and Patient Safety Coordinator [email protected]