Spreading ERAS Beyond Colorectal Surgery · Solids within 48 hrs Mobilized BID POD 2 Mobilized POD...
Transcript of Spreading ERAS Beyond Colorectal Surgery · Solids within 48 hrs Mobilized BID POD 2 Mobilized POD...
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Spreading ERAS Beyond
Colorectal SurgeryMaking it Happen
Dr. Tom Wallace MD FRCSC FACS
General Surgeon
Royal Inland Hospital
Kamloops, BC
Please Log On To:PollEV.com/tomwallace540
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What is Enhanced Recovery?
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Traditional Care
Enhanced Recovery
What is Enhanced Recovery?Functional Perspective
Function
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What is Enhanced Recovery?Patient Perspective
Partner in their care
Condition optimized preoperatively
Best evidence-based care processes
American Society of Enhanced Recovery
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What is Enhanced Recovery?System Perspective
Evidence-based perioperative care processes
Multi-modal and multi-professional teamwork
Continuous audit
Enhanced Recovery Society
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What is Enhanced Recovery?System Perspective
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Royal Inland Hospital254 Acute Care Beds
Kamloops 100,000 population120 Elective Colon Resections per year
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ERAS timeline at RIH
2/20/2019 9
September 2013: Start of the RIH ERAS Program
May 21, 2014: First Colorectal ERAS Patient
November 2014: RIH joined BC ERACS Collaborative
April 2017: First Urology ERAS patient
May 2018: First Gyne ERAS patient
October 2018: 442 Colorectal, 12 Urology and 16 Gynecology patients through program
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Making it Happen!
1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability
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The Case for Change
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The Case for Change
• “Go, Look, See”
• Process, Value Stream Mapping
Systems
Processes
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The Case for Change
35%
17%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Morbidity SSI
Colorectal Pre Intervention
April 2011 – May 2013
Outcomes
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The Case for Change System
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The Case for Change Process
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The Case for Change
35%
17%
27%
10%
20%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Morbidity SSI
Pre Intervention (n=94) Post SSI Bundle (n=95) Post ERACS (n=165)
Outcomes
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Making it Happen
1. The Case for Change
2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability
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Building the Team
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Building the Team
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Build the Team
Nursing
Surgery
Enterostomal Therapy
Administration
Physiotherapy
Project Manager Patient
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Department of Anesthesia
Pre Surgical Screening
NSQIP
Operating Room
Wound/Ostomy Nurses
Daycare Surgery
PARPhysio
Surgical Ward
Surgeons
Patients
Build the Team
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Systems Leadership Approach
• Influence and motivate
• Build relationships and networks
• Shared vision
• Work across disciplines
• Lead without direct managerial control of resources
Build the Team
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Making it Happen
1. The Case for Change2. Build the Team
3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability
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Communicate the Vision
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Communicate the Vision
Values driven strong belief
ERAS is the right thing to do for patients, staff and organization
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Communicate the VisionDifferent message for different stakeholders
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Making it Happen
1. The Case for Change2. Build the Team3. Communicate the Vision
4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability
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Meeting ResistanceI don’t get it!I don’t like it!I don’t like you!
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I already do ‘best
practices’
My patients already have great
outcomes.
I don’t get it!
• Lack of information
• Disagreement with data
• Skeptical of purported benefits
• Lack of engagement
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1. Denial: My patients do
well already
2. Anger: #%$&*
3. Bargaining: Ok, let me
look at that data, its clearly
flawed
4. Sadness: Do we really
Suck?
5. Acceptance: What
should we do now?
5 Phases of ‘I don’t get it!’
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‘I don’t get it!’Supportive Response
• Make ‘the case for change’
• Patience through the 5 phases
• Benefits for patients, staff, organization
• Lay out the cost of inaction
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‘I don’t like it!’
• Emotional, physiological reaction to change
• Perceived threat to job, status, autonomy
• Time – competing priorities
• Traditional ways of working
• Complacency
• Lack of resources / managerial support
• Scope creep
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‘I don’t like it!’Supportive Response
• Be sympathetic• Acknowledge Change is
Hard• Ensure support available
to learn new skills, new ways of working
• Address positive aspects of change: ‘What’s in it for me?’ Explain opportunities for staff, patients
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Lack of trust or confidence in leadership
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‘I don’t like you!’Supportive Response
• Dispel distrust• Take responsibility,
admit when you have been wrong
• Develop relationships
• Listen!• Incorporate ideas
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Making it Happen!
1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance
5. Action Planning6. Measurement7. Celebrate Success8. Sustainability
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Action Planning
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Action Planning
Driver Diagrams
PDSA CyclesPriority Matrix
QI Toolbox
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828477 Jan 10-17 Adapted with permission of Fraser Health Authority
Enhanced Recovery
After Surgery (ERAS) For
Radical Cystectomy Patients
Patient and Family InformationFor more information on Enhanced Recovery please visit
www.interiorhealth.ca/YourCare/HospitalCare/Surgery/PreparingforSurgery/Pages/ERAS.aspx
PROOF
100% of cystectomy patients on ERAS pathway by May 2018
Increase compliance with
preoperative elements
Driver Diagram
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Action Planning
Priority Matrix
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Action Planning
Quick Wins
• Big Impact, little effort
Major Project
• Big Impact, complex to implement
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Action Planning
Fill Ins
• Little impact, little effort
Hard Slogs
• Are they worth it?
• Crowding out effect
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Timeline of Urology ERAS at RIH
December 2015 – March 2016Documentation developed
Staff Education
October 2015Urology baseline data collection April 2016
First Urology ERAS patient
September 2015Initial discussions
November 201812 Urology ERAS
patients
Action Planning
7 months
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Making it Happen!
1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning
6. Measurement7. Celebrate Success8. Sustainability
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Measurement
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Measurement
• What to measure?
• Frequency and duration of data collection?
• How will you collect data
• Reporting and sharing mechanisms for data?
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2/20/2019 520% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No IV/IM Analgesia given after PCA D/C
PCA D/C POD 2
Foley out by POD 2
Solids within 48 hrs
Mobilized BID POD 2
Mobilized POD 0 or 1
Prophylactic given as prescribed (x 24 hrs)
IV discontinued POD 0 or 1
Clear Fluids started POD 0 or 1
Chewed gum POD 0 or 1
No abdominal/pelvic drains
Multimodal antiemetic
Normal temp on arrival in PAR
Multimodal pain management
Pre Op Analgesia Ordered
Prophylactic abx 0-60 min of cut time
Pre op VTE Prophylaxis
Both doses of Carbohydrate Drink
Pre-admission Councelling
Gyne ERAS Compliance16 patients
Post Op
Pre Op
Intra Op
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Results:Gynecology ERAS Outcomes
Pre-ERAS(April 2011 – October 2017)
ERAS (May - October 2018)
# of Elective ERAS Pts 310 16
Morbidity* 10 % 19 %
# of patients with at least 1 complications*
32 3
Average Length of Stay 2.7 days (Median 3) 3 days ( Median 3)
Surgical Site Infection (All Wound) 5.4 % (17) 12.5 % (2)
Urinary Tract Infection 3.8 % (12) 12.5 % (2)
Re-admission 4.1 % (13) 6 % (1)
Return to the OR 2.0 % (6) 0 % (0)
Intra / Post Op Transfusion w/i 72 hrs
of surgery
4.5 % (14) 6 % (1)
Complications / Morbidity includes: Superficial Incisional SSI, Deep Incisional SSI, Organ/Space SSI, Wound Disruption, Pneumonia, Unplanned Intubation, on Ventilator > 48 hours, Progressive Renal Insufficiency, Acute Renal Failure, Urinary Tract Infection, Stroke/Cerebral Vascular Accident, Cardiac Arrest, Myocardial Infarction, Systemic Sepsis (Sepsis or Septic Shock)
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Making it Happen!
1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement
7. Celebrate Success8. Sustainability
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Celebrate Success
And the Oscar for best ERAS program goes to…
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Celebrate SuccessPatients Treated on Pathway
October 2018: 442 Colorectal, 12 Urology and 16 Gynecology patients through program
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Celebrate Success
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35%
17%
27%
10%
20%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Morbidity SSI
Pre Intervention (n=94) Post SSI Bundle (n=95) Post ERACS (n=165)
Celebrate SuccessImproved Outcomes
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Celebrate SuccessPublications
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Pre Surgical ScreeningOperating Room
Daycare Surgery / PARSurgical Ward
The Team
Celebrate SuccessAwards
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Making it Happen!
1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success
8. Sustainability
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Sustainability
• Regular interdisciplinary meetings
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Sustainability
ProcessOutcomesSystem
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Share Data
2/20/2019 64
Sustainability
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Sustainability
• Seek out training / mentorship from other hospitals
• Look for networking opportunities
• Celebrate successes and milestones
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Thank You!
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AcknowledgementsDr. Lee Jonat – UrologistDr. Paula Lott - GynecologistDr. James Baughan – General SurgeonDr. Bruce Kilpatrick - AnaesthesiologistJulie Wootton – Quality Improvement ConsultantCheryl Sibbelee – NSQIP SCRKerry Cardwell – NSQIP SCRSue Gardner-Clark– Administration SponsorNancy Garrett-Petts – Educator DCS/PAR