Enhanced Recovery: Implementation Practice for Best Care in Surgery

Transcription

1 Enhanced Recovery: Implementation Practice for Best Care in Surgery Julie K. Marosky Thacker, MD, FACS, FASCRS Medical Director for Evidence Based Perioperative Care, Duke University Hospital and Health System Founding Surgeon, American Society of Enhanced Recovery Co-Lead of ERIN, Enhanced Recovery in NSQIP Collaborative

2 iclicker Are you doing enhanced recovery? A) Yes B) No

3 What s in a name? ERAS Fast Track ERP, Enhanced Recovery Program or Practice ERIN Enhanced Recovery After Surgery

4 Enhanced Recovery-a new care paradigm Purpose improve surgical outcomes improve patient experience Method examination of current practices implementation every perioperative EBM care point multimodal, multidisciplinary, patient focused

5 Enhanced Recovery-what it ISN T fast track an order set automated medicine impersonal just the surgeon s job individual sport luck ORDER SET

6 How to do enhanced recovery Go to literature Assess current practice Create protocol Develop team Educate Audit

7 How to do enhanced recovery Go to literature 2009 Consensus, 2012 Guideline papers, meta-analyses Specialty specific, country specific Assess current practice Outcomes of interest Hospital specifics Patients of interest, surgeons of interest Current outcomes and needs Create protocol Preop intraop postop Develop team Anesthesia, nurses, administration, auditors, support staff, nutrition, physiotherapy, bed control, residents, students, travelers, OR team PATIENT Educate your patient and everyone who will be in contact with your patient Plan audit Compliance Outcomes Financial or, you could just join ERIN

8 Varandan, Crit Care Clin 2010

9 Surgeon, room LPN, preop RN educator, phone triage Surgery Clinic Night before call, front desk, check in, preop screen, preop RN, preop anesthesia, anesthesia resident, CRNA Anesth Preop Screening Preop holding OR Screening anesthesiologist, screening RN, insurance screen, random clinic staff Room RN, service coordinator, room CRNA, ANYONE GIVING a BREAK, off service anesthesia, pharmacy, anesthesia techs n/a; PACU 2hr ave ward Home, SNF Ward managers, RN s, LPN s residents, students, discharge planners, admin, PATIENTS, family, friends

10 Duke Enhanced Recovery Focus Elements Pre-Operative Intra-Operative Post-Operative Counseling and Patient Education Medical Optimization Strong for Surgery Epidural/regional blocks Monitored, Goal-Directed Fluid Administration Immediate Diet Immediate Mobilization No maintenance IVF Food until 6 hours preop Clears until 2 hours preop No long-acting sedatives or anxiolytics Minimally invasive surgery Avoidance of tubes, drains, and lines Multimodal pain regimen Multimodal prevention of PONV Defined discharge criteria and teaching Patient s Journey through Surgery

11 Benefits of Enhanced Recovery Improve outcomes Improve efficiency Decrease variability Increase value, (outcomes/cost)

12 Effects Of Secular Trends On The Impact Of An Enhanced Recovery Program For Colorectal Surgery: A Time-Series Analysis. Less variability Better outcomes Lee et al (unpublished)

13 Significant Outcome Improvements SSI UTI Sepsis LOS readmissi on Pre-ERAS 24.3% 24.2% 8.1% % ERAS 6.7% 9.4% 0.5% % SSI=surgical site infection UTI=urinary track infection LOS=length of hospital stay, average in days, (median was 7 to 4) Readmission=all cause readmission within 30d of index operation Miller, A&A, 2014 Pappas, US ERAS Symposium 10/2013 Thacker, QI review 2013

14 Duke Inpatient Colorectal Discharges LOS, Readmission Rate, and Cost Baseline THRU 6/21 ALOS MEDIAN LOS DAY READMIT 15.0% 12.8% 16.2% 12.5% 13.5% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 33% reduction in ALOS 10% drop in Readmission rate 9% drop in cost/case

15 Evidence Based Enhanced Recovery Accomplishments Patient preparation Team work Minimize perioperative trauma Optimize recovery Improve outcomes, increase value Create a change process model for perioperative best care implementation

16 Implementation change curve 10minhr.com

17 Post implementation change curve 10minhr.com

18 Beyond enhanced recovery Great results from ERP Team built, system primed NSQIP SSI rate better, not low

19 Surgical Site Infection Prevention Bundle Pre-Operative Intra-Operative Post-Operative Chlorhexidine Shower Selective bowel prep with oral antibiotics Ertapenum within one hour of incision Fascial Wound Protector Gown & glove change prior to fascial closure Dedicated wound closure tray Limited OR traffic Removal of sterile dressing within 48 hours Daily washings of incision(s) with chlorhexidine Standardized chlorhexidine prep Maintenance of euglycemia Maintenance of normothermia Patient Education and Reinforcement of SSI Preventative Measures and Objectives Keenan, 2014, unpublished

20 Enhanced Recovery-a model for perioperative care improvement 9/2006: DUMC joins ACS-NSQIP 1/2010: Introduction of ERP 7/2011: Introduction SSIB Pre-ERP/SSIB Post-ERP/Pre-SSIB Post-ERP/SSIB LOS SSI 24% 18.8% 6.3% Decreased UTI, readmissions, pneumonia Improvements ADDITIVE Keenan, 2014, unpublished

21 ER P SSI B Keenan, 2014, unpublished

22 Enhanced Recovery Directed implementation of evidence Low/no cost, value improvement strategy Model for change process