Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

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Enhanced Recovery After Surgery (ERAS) To Improve Recovery Francesco Carli MD, MPhil Professor of Anesthesia McGill University [email protected]

Transcript of Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

Page 1: Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

Enhanced Recovery After Surgery (ERAS) To Improve Recovery

Francesco Carli MD, MPhil Professor of Anesthesia

McGill University

[email protected]

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Disclosures

None

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Improving Patient’s Recovery What if surgery could be done without:

Metabolic stress response

Catabolism

Organ dysfunction Complications

Pain Fatigue…

…length of stay and costs will decrease too

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We’re not there yet

• Complications: 21-45% of patients have complications after cancer surgery and 1-4% die.

• Variations: Significant differences between and within centers in perioperative processes, complications and hospital stay

• Patient centered outcomes: Full recovery takes longer than we think.

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Colectomy outcomes remain poor

Schilling, Dimick, Birkmeyer JACS 2008. 207(5):698-704

Prioritizing quality improvement in general surgery

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Cohen ME Ann Surg 2009

Variability in long length of stay after uncomplicated colorectal surgery in NSQIP hospitals

87% had no complications: 6.1(3.8) days, median 5 days 13% had complications: 16.1(14.2) days, median 12 days

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Variability in Processes of Care: Responses (%) to questionnaire on perioperative care in colonic resection in 5 northern European countries

Response Scotland Netherlands Sweden Norway Denmark Range

NG is removed in OR 75% 22% 83% 82% 85% 22-85%

Epidural analgesia is used routinely on ward

11% 83% 93% 89% 96% 11-96%

Clear fluids day of surgery 38% 58% 71% 82% 96% 38-96%

Oral intake at will by POD1 27% 46% 44% 53% 85% 27-85%

Lassen K, BMJ, 2005

Based on traditions

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Patients (n=17)

Clinicians (n=15)

Energy Level 88% 67%

Carrying out daily routine 76% 60%

General physical endurance 53% 53%

Sensation of pain 47% 87%

Recreational activities 47% 33%

Walking 41% 47%

Sleep functions 41% -

Appetite 35% 40%

Moving around 35% 47%

Defecation functions 18% 47%

Quality of consciousness - 60%

Doing housework - 47%

Family relationships - 40%

Informal social relationships - 40%

Lee L, Dumitra T, Fiore J Jr, Mayo NE, Feldman LS. How well are we measuring postoperative “recovery”? Qual Life Res, 2015

Outcomes that matter to patients recovering from GI surgery

Patients emphasized energy level, functional status (daily routine, recreational activities, endurance) and sleep

Compared to patients, clinicians put more emphasis on symptoms (pain, cognition, bowel function)

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Patient Expectations: What day do you tell patients to expect to be

discharged after uncomplicated colon resection?

0

10

20

30

40

50

60

70

POD 1 POD 2 POD 3 POD 4 POD 5 POD 6 POD 7

Res

po

nse

s

Keller DS, Delaney CP, Senagore AJ, Feldman LS. Surg Endosc 2016

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Trajectory of functional ability throughout the perioperative period

Level of F

unctional

abili

ty

Preop Recovery

Recovery = time to recovery to baseline

Surgery

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Decrease trauma of surgery improve recovery

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• How long does it take to recover after a lap chole?

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How long to full recovery? longer than we think >1 month to recover higher intensity physical activities after ambulatory laparoscopic cholecystectomy

19

0 6

20

14

19

0

10

20

30

40

50

Baseline 1 week 1 month

kcal.kg

-1.w

k-1

higher intensity lower intensity

Feldman LS, Kaneva P, Demyttenaere S, Carli F, Fried GM, Mayo NE. Validation of a physical activity questionnaire (CHAMPS) as an indicator of postoperative recovery after laparoscopic cholecystectomy. Surgery, 146 (1): 31-9, 2009.

p<0.05

p=0.68

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Surgical stress: pain, catabolism, fluid/salt

retention, immune dysfunction, nausea/vomiting, ileus, impaired pulmonary function, increased

cardiac demands, hypercoaguability, sleep

disturbances, fatigue

Kehlet and Wilmore, Ann Surg 2008 (revised)

Approaches to reduce surgical stress and improving outcomes

Minimally Invasive Surgery

Afferent neural blockade: thoracic epidural

local infiltration anesthesia peripheral nerve blocks

Pharmacologic interventions: non-opioid, multimodal analgesia

anti-emetics glucocorticoids

systemic local anesthetics insulin

β-blockers α2-agonists

anabolic agents

Other interventions: fluid balance

normothermia preoperative carbohydrate

exercise

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Perioperative care in GI Surgery: • >20 elements

• “Strong” recommendations

• Several challenge traditions

• Multiple stakeholders

• How do we get all this into

practice?

Lots of evidence

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Cole Thompson “Three Silos – Central Colorado- 2007”

“Health care historically has been a very siloed field that’s organized around medical

specialties... The patient is the ping-pong ball that moves from service to service”

-Michael Porter

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Enhanced Recovery Pathway

• Integrated, evidence-based, multimodal, consensus on perioperative care

• Goals: – Support early return of function

– Reduce morbidity

– Improve efficiency

– Decrease variability

– Increase value (outcomes/cost)

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CHO loading

Activation

Optimization

Reduced fasting

Fast acting anesthetics

Multimodal opioid sparing analgesia

Fluid balance

Normothermia

Regional anesthesia

Periop nutrition Early mobilization

Daily care maps Discharge criteria

Early removal catheters &

drains

PONV and Ileus prophylaxis

Prehabilitation

?bowel prep

Components of an Enhanced Recovery Program

Preop

Intraop

Postop

No NG

Minimally Invasive

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Level of

Fu

nctional

abili

ty

Surgery

Surgery

ERP Traditional

Preop Recovery

Trajectory of functional ability throughout the perioperative period

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Ann Surg 2000

60 patients (74 yo) Open colon resection + “accelerated

multimodal rehabilitation program” Epidural, early feeding and mobilization Median LOS 2 days (mean 3 days) 15% readmissions

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• Lap foregut pathway • Started in 2001 • Nutrition management • Limited investigations • Excellent patient acceptance

• Colorectal fast track • Started in 2006 • Laparoscopic cases only • Surgeons selected patients • Limited patient education

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Mission: Implement multidisciplinary ERPs across department

• Initiated by clinicians, supported by Chair

• Started October 2008

• Target prevalent in-patient procedures

• Pathways would be standard of care (all start pathway)

• Full time coordinator as pilot project (1 year)

• Multidisciplinary team with clinical experts for each pathway

• Weekly meeting

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ERP Team: Steering Group

• Pathway coordinator • Surgeon lead • Anesthesia lead • Nurse manager surgery ward • Clinical nurse specialist- pain • Physiotherapist • Nutritionist • Pharmacist • Librarian

PLUS Clinical Experts for each pathway – surgical

lead, anesthesia, nursing

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Literature review- guidelines, discharge target Perioperative medical and pharmaceutical orders ADL flowsheets and nursing documentation External prescriptions

Pathway creation

Nurses: preoperative clinic and the recovery room Surgeon staff and Surgical Residents Launch date- “everyone starts the pathway”

MUHC Committees Reviews and Approvals

Personnel Training

Development of an ERP

Surgical Recovery team Review Committee Nursing Clinical Practice Review Committee (NCPRC) Pharmacy and Therapeutics (P&T) Committee Form Committee (medical archives)

Audit and Revision

New Perioperative Pathway

Surgeons & nurses: Standard orders Patient: Education & care map

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Why fasting?

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The ”evidence” behind NPO

• Mendelson paper 1946

• Textbook ”thruth” from 1964

But:

• No true scientific backing

• Few aspirations in elective surgery

• Risk: associated with concomitant disease

J R Maltby in Best Practice in Anaesthesia and Intensive Care 2006

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Well known physiology: Gastric emptying

Ljungqvist & Söreide, Br J Surg, 90: 400-406, 2003

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Gastric emptyng after 400 cc of carbohydrate

MRI Lobo et al. Clin Nutr 2009:28(6)636-41

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Why challenge NPO?

• Normal physiology

• NPO is no guarantee of an empty stomach

• The same gastric volume with/without clear fluids

• Improved well being: thirst (headaches, hunger)

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Modern fasting guidelines Elective surgery

• Clear fluids – water, coffee, tea (no milk), some juice

• 2 h before anaesthesia & surgery

• Exclusions – Emergency surgery – Upper GI symtoms, GI transit slow

Ljungqvist & Söreide Br J Surg 2003

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Cochrane review 2003

• No evidence that liberal fasting guidelines had negative impact on gastric volumes or pH

• Intake of water up to 90 mins preop resulted in lower gastric volumes

• Clinicians should …. when necessary adjust existing fasting policies

PC Stuart in Best Practice in Anaesthesia and Intensive Care 2006

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Why carbohydrate treatment?

• Animal work showed survival benefit from fed state in stress

• Short term fasting changes metabolic setting

• Un-natural way to prepare for stress

• Potential metabolic gains…..

Ljungqvist et al, Best Pract & Res Clin Anaesthiol 23 (2009) 401–409

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• Reading level of patient education materials: Grade 11.5 Smith & Haggerty, 2003

• 1 out of 5 American adults reads at the 5th grade level or below, and the average American reads at the 8th to 9th grade level, yet most health care materials are written above the 10th grade level

National Patient Safety Foundation, 2011

• Printed materials should be accurate, easily accessible, and at a 6th to 7th grade reading level National Institutes of Health, 2011

• 800 studies between 1970 and 2006 indicate most health materials exceed high-school graduate reading levels Canadian Council for Learning, 2008

Patient Education Is An Important Element

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What is Health Literacy? The degree to which individuals can obtain, process and

understand basic health information and services they need to make appropriate health decisions.

Institute of Medicine’s report Health Literacy: Prescription to End Confusion (2004) ;

The U.S. Department of Health and Human Services’ Healthy People (2010)

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How to get ready for your surgery

The evening before your surgery take a shower. The morning of your surgery take another shower. On the day of your surgery do not put any makeup, cream or lotions.

We strongly suggest you stop smoking completely before your surgery, as this will reduce the risk of lung complications afterwards and help the incision to heal. Doctors can help you stop smoking by prescribing certain medications. Please discuss these options with your doctor.

Decrease your alcohol use. Alcohol can interact with medications. Do not drink alcohol 24 hours before surgery. Please let us know if you need help decreasing your alcohol use before surgery.

If you get sick before your surgery please phone the hospital to cancel.

Some pain medications can cause constipation. If constipation becomes a problem, increase the amount of fluids you drink, add more whole grains, fruits and vegetables to your diet and continue to exercise and walk regularly.

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How to get ready for your surgery

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www.muhcpatienteducation.ca

Why a patient version of pathway? Align expectations & empower patients to “speak up!”

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www.muhcpatienteducation.ca

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www.muhcpatienteducation.ca

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www.muhcpatienteducation.ca

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Is achieved when a process or outcome, measured at least a year later, has not returned to its past state. (Parsons & Cornett 2011)

Sustainability

Share Data Visual Cues

slide: Debbie Watson

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1. Esophagectomy June 2010; revised 2014 2. Colorectal Aug 2010; RVH 2014 3. Prostatectomy Nov 2010 ; revised 2014 4. Lap chole Aug 2011; revised 2016 5. Thyroidectomy Oct 2011; revised 2014; revised 2016 6. Inguinal hernia Feb 2012 7. Lung resection Sept 2012 8. Hip and Knee Arthroplasty Sept 2013; hip revised 2016 9. Nephrectomy June 2014 10. Hepatectomy RVH June 2014 11. Spine (day surgery) Sept 2014 12. EVAR RVH march 2016 13. Cystectomy RVH Sept 2016 14. Bariatric March 2017

15. Hip fracture 16. Head and neck oncology 17. Gastrectomy 18. Video assisted Thoracic surgery 19. Kidney transplant 20. Gyne Oncology 21. Hysterectomy 22. Pancreatectomy

Implemented

In Development

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Adherence to ERP: 23 elements

Preoperative Intraoperative Postoperative

Preadmission education 347 (100) Antibiotic prophylaxis 345 (99) Multimodal analgesia 241 (98)

Selective MBP 246 (71) Epidural analgesia 253 (73) Oral liquids on POD 0 209 (89)

Carbohydrate loading 213 (61) Laparoscopic approach 250 (72) Nutritional drink POD 0 146 (42)

No long-acting sedatives 347 (100) Balanced IV fluids 90 (26) Regular food on POD 1 282 (81)

PONV prophylaxis 320 (92) Early termination of IV 201 (58)

Normothermia 223 (64) Early mobilization 275 (79)

No abdominal drainage 298 (86) Early termination of urinary drainage

298 (86)

TED prophylaxis 346 (100) Chewing-gum 217 (63)

No nasogastric tube 344 (99) Laxative 210 (61)

Transition to oral analgesia on POD 2

255 (73)

Mean overall adherence: 77% ± 11%

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Predictors of “successful hospital recovery” (LOS≤4d, no complications, no readmission)

ERP element OR 95% CI p-value

Laparoscopy 4.32 2.260 – 8.267 < 0.001

Early mobilization* 2.25 1.130 – 4.474 0.021

Early termination of IV fluids 1.99 1.158 – 3.445 0.013

Regular food on POD 1 2.37 0.952 – 4.393 0.067

Early termination of urinary drainage 2.05 0.956 – 5.854 0.063

Adjusted multivariate regression model (n=347)

*Early mobilization = out of bed at least once in first 24 hours

Pecorelli N, Fiore Jr J, Charlebois P, Liberman S, Stein B, Baldini G, Carli F, Feldman LS. Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc 2016

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Relationship between overall adherence to enhanced recovery pathway elements, successful recovery and 30-day

complications

Pecorelli N, Hershorn O, Baldini G, Fiore Jr JF, Stein BL, Liberman AS, Charlebois P, Carli F, Feldman S, Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program, Surgical Endoscopy, April 2017, 31(4), 1670-71

Ove

rall

adh

ere

nce

n=347 elective colorectal surgery

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Average LOS CUSM

2011-12 2012-13 2013-14 2014-15 2015-16

%difference 5% 2% 2% -2% -7%

-8%

-6%

-4%

-2%

0%

2%

4%

6%

Average LOS: % difference vs MSSS target for typical cases

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LOS as measure of recovery?

Fiore et al, WJS 2013 n=70 colorectal 54% lap Traditional care LOS = TRD + 1 day

No ERAS

Tolerance of oral intake 2 [1-3]

Recovery of lower GI function 1 [1-2]

Adequate pain control with oral analgesia 3 [2-3]

Ability to mobilize and self-care 3 [2-3]

No evidence of complications 2 [1-2.5]

Time to readiness for discharge 3 [2-4]

Length of hospital stay 3 [3-5]

Balvardi et al, SAGES 2017 n=100 colorectal 81% lap Enhanced Recovery Pathway LOS = TRD

+ ERAS

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Conventional Care (n=95)

Enhanced Recovery (n=95)

p

Preoperative management

Written patient education 0 (0%) 95 (100%) <0.001

Mechanical bowel prep 63 (66%) 34 (36%) <0.001

Sedative 54 (57%) 0 (0%) <0.001

Carbohydrate drink 0 (0%) 46 (48%) <0.001

Intraoperative management

Antibiotic prophylaxis 95 (100%) 95 (100%) 1.000

Mean IV crystalloid, ml (SD) 2475 (1368) 1707 (1122) <0.001

Mean IV colloid, ml (SD) 429(405) 305(385) 0.038

Abdominal drain 13(14%) 4(4%) 0.022

NG tube left in situ 5(5%) 1(1%) 0.097

Normothermia 91 (96%) 91 (96%) 0.710

Thoracic epidural 61 (64%) 56 (59%) 0.456

Laparoscopic 45(47%) 71 (75%) <0.001

New stoma 33(35%) 22 (23%) 0.056

Cost-Effectiveness of Enhanced Recovery vs Conventional Perioperative Management

Lee L, Mata J, Augustin B, Ghitulescu G, Boutros M, Charlebois P, Stein B, Liberman AS, Fried GM, Morin N, Carli F, Latimer E, Feldman LS. Cost-Effectiveness of Enhanced Recovery versus Conventional Perioperative Management for Colorectal Surgery. Ann Surg 2015 Dec; 262(6):1026-33

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Postoperative Management Conventional Care (n=95)

Enhanced Recovery (n=95)

p

Median days to mobilization > 2h/day, days [IQR]

2[1-2] 1[1-2] <0.001

Median days to discontinuation of IV fluids, days [IQR]

3[2-5] 1[1-1] <0.001

Median days passage of first flatus, days [IQR] 3[2-3] 1[1-2] <0.001

Median days to receive oral fluids, days [IQR] 2[1-3.5] 0[0-0] <0.001

Median days to tolerate solid diet, days [IQR] 4[3-5] 1[1-2] <0.001

Median days to removal of bladder catheter, days [IQR]

2[1-3] 1[1-1] <0.001

Enhanced Recovery met discharge milestones sooner and less variability

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Postoperative Management Conventional Care (n=95)

Enhanced Recovery (n=95)

p

Median days to mobilization > 2h/day, days [IQR]

2[1-2] 1[1-2] <0.001

Median days to discontinuation of IV fluids, days [IQR]

3[2-5] 1[1-1] <0.001

Median days passage of first flatus, days [IQR] 3[2-3] 1[1-2] <0.001

Median days to receive oral fluids, days [IQR] 2[1-3.5] 0[0-0] <0.001

Median days to tolerate solid diet, days [IQR] 4[3-5] 1[1-2] <0.001

Median days to removal of bladder catheter, days [IQR]

2[1-3] 1[1-1] <0.001

Median total hospital stay, days [IQR] 7 [5-9] 4 [3-7] <0.001

Results in decreased length of stay

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Clinical outcomes

Total hospitalization, mean (SD): 9.8(12) vs 6.5(6)d*

60-d readmissions: 11 vs 13%

60-d complications: 43 vs 40%

Complication severity, mean (SD): 10.7(17) vs 10.2(14)

Postdischarge outcomes

Lost days from work: 35(20) vs 26(18)*

Caregiver lost days from work: 5(12) vs 1.3(2.6)*

Postoperative CLSC visits: 3.7(9) vs 1.4 (4.6)*

No difference in HRQoL (SF-6D)

Lee L, Mata J, Augustin B, Ghitulescu G, Boutros M, Charlebois P, Stein B, Liberman AS, Fried GM, Morin N, Carli F, Latimer E, Feldman LS. Cost-Effectiveness of Enhanced Recovery versus Conventional Perioperative Management for Colorectal Surgery. Ann Surg 2015 Dec; 262(6):1026-33

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Implementation Costs Source What was included? Cost*

(2013 CAN$)

Roulin (BJS 2013) Switzerland

“Implementation costs” 19 800

Travel and lunch of multidisciplinary team

5 423

Full-time nurse coordinator (6 mos) 36 300

Total 61 523**

Sammour (NZ Med J 2010) New Zealand

Denmark visit (3 persons) 12 190

Research fellow salary (15 mos) 97 128

Total 109 318

Lee (Ann Surg 2014) Canada

Booklet development 14 320

Pathway creation 19 340

Full-time nurse coordinator 81 225

Total 108 770

*Currency conversion using purchasing power parity from OECD

• Colorectal • Esophagectomy/gastrectomy • Pulmonary resection • Thyroidectomy • Laparoscopic cholecystectomy • Inguinal hernia • Prostatectomy

708 total patients 2012-2013 = $153 per patient

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Mean difference in costs from Different Perspectives (per patient)

Institutional cost saving

-$1,150 (-3487 to 905)

Health care system cost saving

-$1,602(-4,050 to 517)

Society cost saving

-$2,985(-5,753 to -373)*

Lee et al, Ann Surg 2015

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Br J Surg 2013;100(10); 1326-34

Expected cost savings per patient: $2666 Average caseload: 50-60 per year $2666 savings/patient X 50 patients/year = $133,300 savings/year

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Economic Impact of an Enhanced

Recovery Pathway for Lung Resection

Paci et al. STS 2017 (Submitted to Ann Thor Surg, in revisions)

CC (n=58 ) ERP (n= 75 ) p-value

Clinical outcomes

Any complication 30 (52) 24 (32) 0.022

Pulmonary complication 20 (34) 12 (16) 0.013

Minor (Clavien I-II) 20 (34) 17 (23) 0.13

Urinary tract infection 8 (14) 2 (3) 0.021

Major (Clavien III-V) 10 (17) 7 (9) 0.18

Mortality 0 1 (1) 1.00

Readmission 3 (5) 3 (4) 1.00

Emergency department visit 9 (16) 0 <0.001

Length of Stay

Overall 6 [4-9] 4 [3-6] 0.002

Discharged by target (POD#4) 16 (28) 39 (52) 0.005

Prolonged LOS (>14 days) 8 (14) 1 (1) 0.01

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Adherence to elements of the standardized postoperative pathway in the conventional care (CC) and enhanced recovery pathway (ERP) groups

Paci et al. STS 2017 (Submitted to Ann Thor Surg, in revisions)

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Zaouter C, Kaneva P, Carli F. Reg Anesth Pain Med 2009; 34:542-8

Early removal (n=105)

Standard removal (n=110)

p

UTI 2% 17% 0.004

In and out catheterization 8% 2% 0.09

Reinsertion of Foley 3% 0 0.229

• Patients with continuous thoracic epidural at low risk for POUR • RCT of early removal urinary catheter POD 1 vs standard

• Bladder scan every 3 hours if no void

Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia.

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Economic Impact of an Enhanced

Recovery Pathway for Lung Resection

Mean difference in costs per patient from all perspectives

Favors ERP Favors Conventional Care

Institutional

Health care system

Societal

-8000 -4000 0 4000 8000Mean difference (95% CI), CAN$

Institutional cost saving

-$2,580 (-6,245 to 576)

Health care system cost saving

-$2,850 (-6,380 to 244)

Societal cost saving

-$4,396 (-8,674 to -618)

Paci et al. STS 2017 (Submitted to Ann Thor Surg, in revisions)

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Level of

Fu

nctional

abili

ty

Surgery

Surgery

ERP Traditional

Preop Recovery

Trajectory of functional ability throughout the perioperative period

Prehabilitation + ERP

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Shifting role for preoperative team and preoperative time

Risk stratification

Resource allocation (ICU)

“OK for OR”

Optimization

Metabolic preparation

Prehabilitation

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Prehabilitation and functional capacity before and after colorectal surgery: 5-years McGill experience

Minella et al Acta Oncol. 2017 Feb;56(2):295-300

n=185 +30(47)m*

-11(72)m*

17(84)m*

-5.8(40)m

-72(129)m

-9(74)m

* p <0.05

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Recovered to baseline walking capacity 5-9 wks post CRS

59 66 60

84

0%

20%

40%

60%

80%

100%

not recovered

recovered

1998-2000 2005-06 2009-11 2011-13

Laparosc. No 24% 93% 97%

ERP No - + +

Prehab No - - +

Moriello C Phys Med Rehab 2008;

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Recovered to baseline walking capacity 5-9 wks post CRS

59 66 60

84

0%

20%

40%

60%

80%

100%

not recovered

recovered

Moriello C Phys Med Rehab 2008; Carli F BJS, 2010;

1998-2000 2005-06 2009-11 2011-13

Laparosc. No 24% 93% 97%

ERP No No + +

Prehab No No - +

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Recovered to baseline walking capacity 5-9 wks post CRS

59 66 60

84

0%

20%

40%

60%

80%

100%

not recovered

recovered

Moriello C Phys Med Rehab 2008; Carli F BJS, 2010; Li Surg Endosc, 2013;

1998-2000 2005-06 2009-11 2011-13

Laparosc. No 24% 93% 97%

ERP No No Yes +

Prehab No No No +

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Recovered to baseline walking capacity 5-9 wks post CRS

59 66 60

84

0%

20%

40%

60%

80%

100%

not recovered

recovered

Moriello C Phys Med Rehab 2008; Carli F BJS, 2010; Li Surg Endosc, 2013; Gillis C Anesthesiology 2014;

1998-2000 2005-06 2009-11 2011-13

Laparosc. No 24% 93% 97%

ERP No No Yes Yes

Prehab No No No Yes

Page 72: Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

Summary: Pathway approach • Need to change the culture • Focus on patient’s recovery • Get evidence into practice • Improve interdisciplinary environment • Applicable across procedures • Decreases variability Increase value* of what we do

*outcomes that matter to patients/ cost

Page 73: Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

Thanks!